Cerebrovascular accident clinical pathway. The development of a stroke clinical pathway: an experience in a medium-sized community hospital. A model for management of patients with stroke during the acute phase. Outcome and economic implications. Effectiveness of a clinical pathway for inpatient asthma management. [Electronic clinical pathway for community acquired pneumonia (e-CP CAP)]. Clinical pathways in hip and knee arthroplasty: a prospective randomised controlled study. Prospective, randomized, controlled trial between a pathway of controlled rehabilitation with early ambulation and diet and traditional postoperative care after laparotomy and intestinal resection. Variance analysis applied to a stroke pathway: how this can improve efficiency of healthcare delivery. [Clinical significance of a standardized clinical pathway in gastrectomy patients]. Effects of a multidisciplinary, post-discharge continuance of care intervention on quality of life, discharge satisfaction, and hospital length of stay: a randomized controlled trial. Clinical pathway for fractured neck of femur: a prospective, controlled study. Improving end-of-life care: development and pilot-test of a clinical pathway. Design, implementation, and quality control in the Pathways American-Indian multicenter trial. A controlled trial of a critical pathway for treatment of community-acquired pneumonia. CAPITAL Study Investigators. Community-Acquired Pneumonia Intervention Trial Assessing Levofloxacin. Effects of counseling and implementation of clinical pathway on diabetic patients hospitalized with hypoglycemia. Striving to prevent falls in an acute care setting--action to enhance quality. The critical path method in stroke rehabilitation: lessons from an experiment in cost containment and outcome improvement. A prospective, randomized study of goal-oriented hemodynamic therapy in cardiac surgical patients. Effect of a nurse team coordinator on outcomes for hospitalized medicine patients. Nursing home-acquired pneumonia: outcomes from a clinical process improvement program. The results of a randomized trial of a quality improvement intervention in the care of patients with heart failure. The MISCHF Study Investigators. Adoption of a ventilator-associated pneumonia clinical practice guideline. Does an integrated care pathway improve processes of care in stroke rehabilitation? A randomized controlled trial. Evaluation of a critical pathway for stroke. The effect on cost of medical care for patients treated with an automated clinical audit system. Development and pilot evaluation of a complex intervention to improve experienced continuity of care in patients with cancer.
The cerebrovascular accident (CVA) clinical pathway project was selected to complement the work already underway within the West Moreton Health Services District such as the development of a continuum of care model, revision of work practices to complement the new hospital redevelopment and encouraging team and evidence-based approaches to problem solving. Specific objectives were set for the project along with a detailed evaluation plan. A steering group was convened to run the project and a full time project officer was appointed. At the end of the 12 month period all the objectives were met. Specific achievements included a reduction in the overall average length of stay for those patients who experience CVA, improved clinical outcomes and a more effective use of resources. Quality of care has been improved through the preparation of specialized clinical pathway documentation, education packages, patient surveys, focus groups, independent reviews and benchmarking. Complementing these measures has been a series of process changes and environmental modifications. Furthermore, good working relationships have been established with private sector providers of health care and other external bodies. The development of the CVA clinical pathway at the Ipswich Hospital has meant timely referrals and a streamlined assessment and referral process to get patients into rehabilitation sooner. It has promoted good communication between, and recognition of, the professional roles of various team members and has put the patient back at the centre of the care process. Patients with acute ischemic strokes were studied in a medium-sized community hospital in Mississippi. Studies were done before and after implementation of the stroke clinical care pathway with emphasis on the following clinical indicators: 1) performance of a brain CT scan, 2) the search for the etiology of the stroke, 3) whether the patient was treated emergently for hypertension, 4) the use of measures to prevent deep-vein thrombosis, and 5) prophylactic drug treatment against recurrent stroke after hospital discharge. Following application of the clinical pathway, there was a significant improvement in all the clinical indicators that were felt to require further attention and none had a setback. The length of hospital stay was decreased, and there was no significant increase in the hospital costs in the post-pathway study despite an increase in the number of diagnostic and therapeutic procedures performed. When applied properly, clinical pathways can effectively mobilize hospital resources, maximize quality of care, and at the same time minimize costs. The purpose of the study was to develop a clinical pathway for patients with nonhemorrhagic stroke during the acute hospital phase to improve the quality of care and reduce costs.
                The pathway included standard admission orders and a swallow screen on day 1 of hospitalization. Physical therapy, occupational therapy, speech therapy, and social worker assessments were done on day 2. A physiatry consult was performed on day 3 if indicated, and by day 4 a discharge target date and disposition were addressed.
                Outcomes for 121 patients during the first year of pathway implementation are reported. The average length of stay on the acute service decreased from 10.9 days to 7.3 days (P < .05), reducing the charges per patient by 14.6%. Complications in the form of urinary tract infections and aspiration pneumonia rates decreased by 63.2% (P < .05) and 38.7%, respectively.
                We conclude that the implementation of a clinical pathway for patients with acute, nonhemorrhagic stroke resulted in a significant reduction in length of stay, charges, and complications while improving the quality of care. Clinical pathways for asthma are tools that have the potential to improve compliance with nationally recognized management guidelines, but their effect on patient outcomes has not been documented.
                To determine the effect of an asthma clinical pathway on patients' length of stay, use of nebulized beta-agonist therapy while hospitalized, and use of acute care clinics for 2 weeks after discharge.
                The study was a randomized, controlled trial. Patients between the ages of 2 and 18 years admitted with an asthma exacerbation and not under the care of an asthma specialist were eligible for the study. Patients were randomized either to a conventional ward (control group) or to a ward using the clinical pathway (intervention group). For 2 weeks after discharge, we collected data to determine whether patients visited a health care provider for worsening asthma.
                One hundred ten patients (26%) were enrolled. Control and intervention groups had similar demographic and asthma severity profiles. The intervention group had an average length of stay 13 hours shorter than did the control group. In addition, at every dosing interval, the intervention group received less nebulized beta-agonist therapy. There were no deaths in either group.
                A clinical pathway for inpatient asthma decreased the length of stay and beta-agonist medication use with no adverse outcomes or increased acute-care encounters through 2 weeks after discharge. Clinical pathway is a useful strategy for the management of risk and cost for medical care. We developed an electronic clinical pathway (e-CP) for community acquired pneumonia (CAP). We programmed all medical procedures, including physical and laboratory examinations, medical care, prescriptions, diets, limitations of activities, and patient education on a computer. With e-CP, we achieved 30% cost reduction (34048 points vs. 24338 points), 25% shortening of admission duration (10.77 days vs. 8.03 days) and 21% shortening of the duration of intravenous antibiotics administration (8.22 days vs. 6.47 days). Introduction of computer-aided clinical pathway for CAP may contribute to the standardization of medical care for patients with CAP. To ascertain the effectiveness of clinical pathways for improving patient outcomes and decreasing lengths of stay after hip and knee arthroplasty.
                Twelve-month randomised prospective trial comparing patients treated through a clinical pathway with those treated by an established standard of care at a single tertiary referral university hospital.
                163 patients (56 men and 107 women; mean age, 66 years) undergoing primary hip or knee arthroplasty, and randomly allocated to the clinical pathway (92 patients) and the control group (71 patients).
                Time to sitting out of bed and walking; rates of complications and readmissions; match to planned discharge destination; and length of hospital stay.
                Clinical pathway patients had a shorter mean length of stay (P = 0.011), earlier ambulation (P = 0.001), a lower readmission rate (P = 0.06) and closer matching of discharge destination. There were beneficial effects of attending patient seminars and preadmission clinics for both pathway and control patients.
                Clinical pathway is an effective method of improving patient outcomes and decreasing length of stay following hip and knee arthroplasty. In an era of dwindling hospital resources and increasing medical costs, safe reduction in postoperative stay has become a major focus to optimize utilization of healthcare resources. Although several protocols have been reported to reduce postoperative stay, no Level I evidence exists for their use in routine clinical practice.
                Sixty-four patients undergoing laparotomy and intestinal or rectal resection were randomly assigned to a pathway of controlled rehabilitation with early ambulation and diet or to traditional postoperative care. Time to discharge from hospital, complication and readmission rates, pain level, quality of life, and patient satisfaction scores were determined at the time of discharge and at 10 and 30 days after surgery. Subgroups were defined to evaluate those who derived the optimal benefit from the protocol.
                Pathway patients spent less total time in the hospital after surgery (5.4 vs. 7.1 days; P = 0.02) and less time in the hospital during the primary admission than traditional patients. Patients younger than 70 years old had greater benefits than the overall study group (5 vs. 7.1 days; P = 0.01). Patients treated by surgeons with the most experience with the pathway spent significantly less time in the hospital than did those whose surgeons were less experienced with the pathway (P = 0.01). There was no difference between pathway and traditional patients for readmission or complication rates, pain score, quality of life after surgery, or overall satisfaction with the hospital stay.
                Patients scheduled for a laparotomy and major intestinal or rectal resection are suitable for management by a pathway of controlled rehabilitation with early ambulation and diet. Pathway patients have a shorter hospital stay, with no adverse effect on patient satisfaction, pain scores, or complication rates. Patients younger than 70 years of age derive the optimal benefit, and increased surgeon experience improves outcome. Stroke is a complicated disease that requires a multidisciplinary approach for its management. We postulated that variance analysis applied to a stroke pathway, by identifying major problem areas and encouraging timely corrective actions, would lead to more efficient healthcare delivery to hospitalised stroke patients.
                Prospectively collected variance data from consecutive stroke patients discharged from a tertiary hospital in Singapore during a 3-month period in 2000 were used to identify the major variances causing increased length of stay. These were compared and contrasted to variance data collected during the same 3-month period in the subsequent year (2001), after the implementation of stroke pathway and the availability of monthly variance analysis reports. Patient characteristics and outcome measures were also compared between the two study periods.
                The four major variances that accounted for increased length of stay were, in descending order of the number of patients affected, awaiting bed availability in step-down facilities, delay in head computed tomographic scan performance, awaiting family's decision on discharge plan and incomplete application submitted to step-down facilities. After implementation of the stroke pathway with ongoing variance analysis, all four variances showed different extent of improvements. There were no significant differences in patient characteristics between the two study periods, whereas the average length of stay significantly diminished in the late study period with a trend for decreased in-hospital mortality, compared to the early study period.
                Variance analysis applied in the context of a stroke pathway was effective in identifying major variances causing increased length of stay. This allowed targeted intervention to improve efficiency of healthcare delivery to stroke patients. In traditional practice patterns, physicians take care of all clinical decisions, such as diagnosis, treatment, and recovery. In the Nippon Medical School Hospital a clinical pathway for distal gastrectomy patients, recorded as a post-operative care map, was introduced in August 2000. In January 2001 the post-operative management was analyzed and standardization of practice was carried out with printed order sets, such as drugs and infusion solutions. The aim of this study was to evaluate the clinical significance of the clinical pathway for gastrectomy patients by employing standardized postoperative management and printed order sets.
                From January 2001 to December 2001, 87 patients underwent distal (43), total (28), proximal (7) and partial gastrectomy (9) for gastric cancer (stage IA: 47, IB: 9, II: 7, IIIA: 8, IIIB 2, IV: 10) and gastrointestinal stromal tumor (4). These patients were randomly assigned to either the main building or the east building of our hospital. In the main building 38 patients were looked after using traditional practice (control group). In the east building 47 patients were looked after according to the clinical pathway (path group) and 2 patients were excluded from the path group because of neo-adjuvant chemotherapy and severe heart failure. Aspects of the patients' outcomes, including length of stay, the first day of the diet, morbidity, and medical costs, were compared between the path group and the control group. All data were expressed as means+/-standard deviation. Statistical analyses were made using Student t-test, Mann-Whitney U-test, and chi(2) test, and the 5%level was chosen for statistical significance.
                The length of the hospital stay was 27.1+/-10.0 and 40.8+/-26.1 days (p<0.005) and the length of post-operative stay was 18.1+/-9.5 and 28.2+/-22.3 days (p<0.01) in the path group and the control group, respectively. The post-operative day when the diet was started for the path and control groups was 6.8+/-8.9 and 8.2+/-7.2, respectively; however, the length of the intravenous infusion for the two groups was 11.8+/-1.1 and 16.5+/-1.2 days (p<0.01), respectively. There was no statistically significant difference in the morbidity rate between the path group (3/47) and the control group (5/38). The total cost was 1,502,587 yen +/-41,650 in the path group and 1,932,197 yen +/-131,030 in the control (p<0.001).
                A clinical pathway for gastrectomy patients proved useful to optimize their postoperative care, including medication management and diet education. It is suggested that the implementation of a standardized clinical pathway for gastrectomy patients reduced the length of the hospital stay and the medical costs. To determine the impact of a hospital-coordinated discharge care plan, involving a multidisciplinary team of primary health care providers, on hospital length of stay, quality of life, and both patient and general practitioner inclusion in, and satisfaction with, discharge procedures.
                This investigation comprised a prospective, randomized, controlled, clinical trial.
                This multicentre and cross-jurisdictional study focused on areas of tertiary and primary health care as well as community allied health in Western Australia.
                Patients (n = 189) with chronic cardiorespiratory diagnoses were recruited from respiratory, cardiovascular, and general medical wards at two tertiary hospitals.
                Subjects were randomly assigned to one of two groups. Intervention group patients received a discharge care plan in accordance with that outlined in the Australian Enhanced Primary Care Package, completed before discharge and sent to the patient's general practitioner and other community service providers for review. Control patients were discharged under existing hospital processes. Outcome measures. Patients and general practitioners were surveyed pre-discharge and 7 days post-discharge for quality of life and opinion of discharge procedures. Hospital length of stay was also determined.
                Significant improvements in discharge planning involvement, health service access, confidence with discharge procedures, and opinion of discharge based on previous experience were seen for patients who received the discharge care plan. Further, improved perceptions of mental quality of life were observed within the first week post-discharge for intervention patients. Length of stay showed no difference between groups. Extent and speed of hospital-general practitioner communication were significantly improved via the intervention.
                Our results indicate that a multidisciplinary discharge care plan, initiated before separation, improves quality of life, involvement, and satisfaction with discharge care, and hospital-general practitioner integration. As such, it possesses benefits over current Western Australian hospital discharge procedures for the care of chronically ill populations. To assess outcomes of using a clinical pathway for managing patients with fractured neck of femur.
                Prospective, pseudorandomised, controlled trial.
                St Vincent's Hospital, Melbourne, Victoria (a tertiary referral, university teaching hospital), 1 October 1997 to 30 November 1998.
                111 patients (80 women and 31 men; mean age, 81 years) admitted via the emergency department with a primary diagnosis of fractured neck of femur.
                Management guided by a clinical pathway (55 patients) or established standard of care (control group, 56 patients).
                Timing of referrals and discharge planning; total length of stay; and complication and readmission rates within 28 days of discharge.
                Patients managed according to the clinical pathway had a shorter total stay (6.6 versus 8.0 days; P = 0.03), even if assessment for placement by the Aged Care Assessment Service was required (9.5 versus 13.6 days; P = 0.03). There were no significant differences in complication and readmission rates between pathway and control patients (complication rates, 24% versus 36%; P = 0.40; readmission rates, 4% versus 11%; P = 0.28).
                Coordinated multidisciplinary care of patients with fractured neck of femur reduces length of stay without increasing complications. Prior studies have revealed deficiencies in the care provided to patients dying from advanced medical illnesses in acute care hospitals. These deficiencies are best addressed through system change, which may include the development of clinical pathways and quality improvement models. The Palliative Care for Advanced Disease (PCAD) pathway was developed by an interdisciplinary team and includes a carepath, a daily flowsheet, and a physician order sheet with standard orders for symptom control. To evaluate the utility of PCAD, the clinical pathway was introduced on three hospital units (Oncology, Geriatrics, and an inpatient palliative care/hospice unit) as part of a quality improvement initiative and outcomes were compared to two general medical units receiving usual care. A chart audit tool (CAT) was used to review medical records of 101 patients who died on one of these five units during the year prior to implementation (baseline) and 156 who died during the nine months of the PCAD intervention. Four indices from CAT evaluated change over time: the mean number of 1) symptoms assessed, 2) problematic symptoms, 3) interventions consistent with PCAD, and 4) consultations requested. Nine of 27 (33%) patients on the Oncology/Geriatrics units and all 50 patients who died on the palliative care/hospice unit were placed on PCAD. During the PCAD intervention, dying patients who resided on Geriatrics, Oncology and palliative care/hospice units were more likely to have DNR orders than the comparison units, whereas the comparison units were more likely to use "morphine infusions" and cardiopulmonary resuscitation than the units that received the PCAD intervention. The mean number of symptoms assessed increased significantly in all units (P < 0.001 for all comparisons). The number of problematic symptoms identified (P=0.014) and the number of interventions consistent with PCAD increased only on the palliative care/hospice unit (P=0.021). The number of medical consultations declined on all units and reached significance on the Geriatrics and Oncology units (P=0.037). Although these results reflect less than one year of the PCAD intervention and must be considered preliminary, they suggest that 1) a clinical pathway such as PCAD can serve as a managerial and educational tool to improve the care of the imminently dying inpatient; 2) a PCAD clinical pathway can be implemented on hospital units as a quality improvement initiative--a "PCAD intervention;" 3) a PCAD intervention can change outcomes in a positive direction, as measured using a chart audit tool; 4) a PCAD intervention can promote aggressive symptom assessment and treatment when goals of care are aimed at comfort; and 5) changes may occur in units that do not directly receive the intervention, a phenomenon that suggests the possibility of diffusion. Further study of this systems-oriented approach to change is warranted and should include direct assessment of patient and family outcomes, as well as measures of process. Pathways was the first multicenter American-Indian school-based study to test the effectiveness of an obesity prevention program promoting healthy eating and physical activity.
                Pathways employed a nested cohort design in which 41 schools were randomized to intervention or control conditions and students within these schools were followed as a cohort (1,704 third graders at baseline). The study's primary endpoint was percent body fat. Secondary endpoints were levels of fat in school lunches; time spent in physical activity; and knowledge, attitudes, and behaviors regarding diet and exercise. Quality control (QC) included design of data management systems which provided standardization and quality assurance of data collection and processing. Data QC procedures at study centers included manuals of operation, training and certification, and monitoring of performance. Process evaluation was conducted to monitor dose and fidelity of the interventions. Registration and tracking systems were used for students and schools.
                No difference in mean percent body fat at fifth grade was found between the intervention and control schools. Percent of calories from fat and saturated fat in school lunches was significantly reduced in the intervention schools as was total energy intake from 24-hour recalls. Significant increases in self-reported physical activity levels and knowledge of healthy behaviors were found for the intervention school students.
                The Pathways study results provide evidence demonstrating the role schools can play in public health promotion. Its study design and QC systems and procedures provide useful models for other similar school based multi- or single-site studies. Large variations exist among hospitals in the use of treatment resources for community-acquired pneumonia (CAP). Lack of a common approach to the diagnosis and treatment of CAP has been cited as an explanation for these variations.
                To determine if use of a critical pathway improves the efficiency of treatment for CAP without compromising the well-being of patients.
                Multicenter controlled clinical trial with cluster randomization and up to 6 weeks of follow-up.
                Nineteen teaching and community hospitals in Canada.
                A total of 1743 patients with CAP presenting to the emergency department at 1 of the participating institutions between January 1 and July 31, 1998.
                Hospitals were assigned to continue conventional management (n = 10) or implement the critical pathway (n = 9), which consisted of a clinical prediction rule to guide the admission decision, levofloxacin therapy, and practice guidelines.
                Effectiveness of the critical pathway, as measured by health-related quality of life on the Short-Form 36 Physical Component Summary (SF-36 PCS) scale at 6 weeks; and resource utilization, as measured by the number of bed days per patient managed (BDPM).
                Quality of life and the occurrence of complications, readmission, and mortality were not different for the 2 strategies; the 1-sided 95% confidence limit of the between-group difference in the SF-36 PCS change score was 2.4 points, which was within a predefined 3-point boundary for equivalence. Pathway use was associated with a 1.7-day reduction in BDPM (4.4 vs 6.1 days; P = .04) and an 18% decrease in the admission of low-risk patients (31% vs 49%; P = .01). Although inpatients at critical pathway hospitals had more severe disease, they required 1.7 fewer days of intravenous therapy (4.6 vs 6.3 days; P = .01) and were more likely to receive treatment with a single class of antibiotic (64% vs 27%; P<.001).
                In this study, implementation of a critical pathway reduced the use of institutional resources without causing adverse effects on the well-being of patients. A prospective randomized controlled study was conducted to examine the effects of counseling and implementation of clinical pathway on type 2 diabetic patients hospitalized with hypoglycemia.
                Thirty- three cases received counseling and clinical pathway for treatment of hypoglycemia (study group) and another 32 cases received conventional treatment for hypoglycemia (control group) in Taksin Hospital between July and December 2005.
                Both groups have similar age, sex, and mean serum glucose on admission. There were also no differences between the two groups in terms of number of patients with chronic diabetic complications, acute concurrent illness and pattern of hypoglycemic drugs used for treatment. Average length of hospital stay of the study group was significantly lower than that of the control group (3.94 +/- 1.03 vs 6.38 +/- 4.05; p = 0.0005). There were also a significant decrease in the mean number of capillary blood glucose tests performed in the study group compared to the control group (10.03 +/- 5.04 vs 12.34 +/- 5.96; p = 0.048). Subsequent readmissions with recurrent hypoglycemia at 1 and 3 months interval after being discharged from the hospital decreased significantly in the study group (6.06 % vs 34.38 %; p = 0.036). While there was considerable reduction in mean medical cost in the study group, it did not reached a statistically significant difference when compared with the control group (2,743.58 +/- 1,473.04 vs 3,687 +/- 3,110.82; p = 0.06).
                Counseling and implementation of clinical pathway on type 2 diabetic patients hospitalized with hypoglycemia can reduce the length of hospital stay and decrease readmission rates of recurrent hypoglycemia. This results in considerable health and economic benefits. Although most falls do not result in serious physical injury, they can contribute to a loss of confidence and mobility which can culminate in a significant reduction in quality of life. Furthermore, the potential to fall is often increased when an individual is institutionalized because of frailty or confusion. The purpose of the study was, therefore, to establish whether a structured intervention would assist in preventing falls in an acute setting. This pre-test/post-test study was carried out over a 12-month period. Interventions included risk assessment, an alert system, reinforcing preventive actions, staff education and ongoing audits and feedback. Initial analysis of the data and comparison of fall rates indicated a significant reduction in the rate of falls between the pre- and post-intervention phases, although subsequent statistical analysis did not identify any significant relationships. It must be noted that no controls existed for extraneous variables, although patient profiles varied minimally during the period of the study. Outcomes include: a reduction in fall numbers and rates, enhanced staff morale with ownership of the programme, provision of a learning experience for staff (on which to build), and the fostering of a professional approach to improving the quality of patient care. This study tested the effects of a project network technique called the Critical Path Method (CPM) on the costs and outcomes of inpatient team stroke rehabilitation. On admission to a large, academic, inpatient rehabilitation hospital adults who had a recent (< 120 days) stroke were randomly assigned to receive rehabilitation services from a team trained in CPM (N = 53) or from usual care teams (N = 68). Results showed no significant difference between groups in length of stay, hospital charges, or functional status at discharge. CPM may be effective in patient care services that are less influenced by specialization, professional issues, and external regulation and in settings where patient outcomes are relatively fixed and predictable, and medical care is integrated across institutions. Organ dysfunction and multiple organ failure are the main causes of prolonged hospital stay after cardiac surgery, which increases resource use and health care costs. Increased levels of oxygen delivery and consumption are associated with improved outcome in different groups of postoperative patients. Cardiac surgical patients are at risk of inadequate perioperative oxygen delivery caused by extracorporeal circulation and limited cardiovascular reserves. The purpose of our study was to test whether increasing oxygen delivery immediately after cardiac surgery would shorten hospital and intensive care unit (ICU) stay. Four hundred three elective cardiac surgical patients were enrolled in the study and randomly assigned to either the control or the protocol group. Goals of the protocol group were to maintain SvO(2) >70% and lactate concentration < or =2.0 mmol/L from admission to the ICU and up to 8 h thereafter. Hemodynamics, oxygen transport data, and organ dysfunctions were recorded. The median hospital stay was shorter in the protocol group (6 vs 7 days, P < 0.05), and patients were discharged faster from the hospital than those in the control group (P < 0.05). Discharge from the ICU was similar between groups (P = 0. 8). Morbidity was less frequent at the time of hospital discharge in the protocol group (1.1% vs 6.1%, P < 0.01). Increasing oxygen delivery to achieve normal SvO(2) values and lactate concentration during the immediate postoperative period after cardiac surgery can shorten the length of hospital stay. Implications: Health care economics has challenged clinicians to reduce costs and improve resource use in cardiac surgery and anesthesia in a patient population increasing in age and in severity of disease. Optimizing cardiovascular function to maintain adequate oxygen delivery during the immediate postoperative period after cardiac surgery can decrease morbidity and reduce length of hospital stay. Several randomized trials have found that discharge planning improves outcomes for hospitalized patients. We do not know if adding a clinical nurse specialist (CNS) to physician teams in hospitals that already have discharge planning services makes a difference.
                In 2 teaching hospitals, patients were randomly assigned to regular hospital care or care with a clinical nurse specialist. The clinical nurse specialist facilitated hospital care by retrieving preadmission information, arranging in-hospital consultations and investigations, organizing postdischarge follow-up visits, and checking up on patients postdischarge with a telephone call. In-hospital outcomes included mortality and length of stay. Postdischarge outcomes included time to readmission or death, patient satisfaction, and the risk of adverse event. Adverse events were poor outcomes due to medical care rather than the natural history of disease.
                A total of 620 sequential patients were randomized (CNS n = 307, control n = 313), of which 361 were followed after discharge from hospital (CNS n = 175, control n = 186). The groups were similar for the probability of in-hospital death (CNS 9.3% vs control 9.7%) or being discharged to the community (58.0% vs 60.0%). The groups did not differ for postdischarge outcomes including readmission or death (21.6% vs 15.6%; P = 0.16) or risk of adverse event (23.6% vs 22.8%). Mean [SD] patient ratings of overall quality of care on a scale of 10 was higher in the clinical nurse specialist group (8.2 [2.2] vs 7.6 [2.4]; P = 0.052).
                The addition of a clinical nurse specialist to a medical team improved patient satisfaction but did not impact hospital efficiency or patient safety. At EHS Christ Hospital and Medical Center, an eight-step process improvement model was developed that incorporates continuous quality improvement concepts for monitoring, evaluating and improving patient care. Nursing home residents admitted with pneumonia were identified as the group having the most influence on mortality and costs associated with treatment of pneumonia at our hospital. A multidisciplinary team evaluated clinical resource use and patient care processes, and identified root causes of various influencing treatment. Clinical guidelines were created and outcomes were defined, resulting in significant improvement in the clinical management of these patients. Average length of stay decreased from 8.6 days in 1992 to 7.6 days in 1993, with a charge reduction of $1830 per patient. The methodologic framework of a process improvement program combines epidemiologic, clinical, and quality improvement sciences. This mix is essential in improving patient care and quantifying outcomes. Quality improvement and disease management programs for heart failure have improved quality of care and patient outcomes at large tertiary care hospitals. The purpose of this study was to measure the effects of a regional, multihospital, collaborative quality improvement intervention on care and outcomes in heart failure in community hospitals.
                This randomized controlled study included 10 acute care community hospitals in upstate New York. After a baseline period, 5 hospitals were randomly assigned to receive a multifaceted quality improvement intervention (n = 762 patients during the baseline period; n = 840 patients postintervention), while 5 were assigned to a "usual care" control (n = 640 patients during the baseline period; n = 664 patients postintervention). Quality of care was determined using explicit criteria by reviewing the charts of consecutive patients hospitalized with the primary diagnosis of heart failure during the baseline period and again in the postintervention period. Clinical outcomes included hospital length of stay and charges, in-hospital and 6-month mortality, hospital readmission, and quality of life measured after discharge.
                Patients had similar characteristics in the baseline and postintervention phases in the intervention and control groups. Using hospital-level analyses, the intervention had mixed effects on 5 quality-of-care markers that were not statistically significant. The mean of the average length of stay among hospitals decreased from 8.0 to 6.2 days in the intervention group, with a smaller decline in mean length of stay in the control group (7.7 to 7.0 days). The net effects of the intervention were nonsignificant changes in length of stay of -1.1 days (95% confidence interval [CI]: -2.9 to 0.7 days, P = 0.18) and in hospital charges of -$817 (95% CI: -$2560 to $926, P = 0.31). There were small and nonsignificant effects on mortality, hospital readmission, and quality of life.
                The incremental effect of regional collaboration among peer community hospitals toward the goal of quality improvement was small and limited to a slightly, but not significantly, shorter length of stay. The Academic Center for Evidence-based Practice (ACE) Star Model was used to implement an evidence-based clinical practice guideline (CPG) in order to decrease ventilator-associated pneumonia (VAP) incidence rates and ventilator days. The goal was to interrupt person-to-person transmission of bacteria and bacterial colonization using low-cost, evidence-based strategies to prevent VAP. DISCOVERY: Two geographically proximate medical centers, inclusive of five intensive care units located in the southwestern region of the United States had significant variations in their VAP rates.
                Using the U.S. Preventive Services Task Force grading criteria, the results of 69 studies were used to establish a clinical practice guideline to prevent ventilator-associated pneumonia. TRANSLATION: A clinical practice guideline was developed for the prevention of VAP and included five nursing activities: (a) head-of-bed elevation; (b) oral care; (c) ventilator tubing condensate removal; (d) hand hygiene; and (e) glove use. The effect of the CPG, inclusive of an educational intervention, was measured using an observational, prospective, quasi-experimental design. INTEGRATION: A multidisciplinary education team developed a self-learning packet, educational materials, and storyboards for the staff as dissemination strategies. Strategies also included e-mail, one-on-one teaching with clinicians, and feedback on guideline adoption and VAP rate reports.
                Observation data were collected to evaluate adoption of the CPG while caring for 106 ventilated patients. VAP rates changed at both hospitals although the change was not statistically significant. Additionally, the ICU length of stay declined at both facilities, causing cost savings.
                These results support the idea that adoption of evidence-based practices contributes to decreased VAP rates. For a successful program, ICU leaders should emphasize strategies that routinize adoption of evidence-based CPGs. to evaluate whether integrated care pathways improve the processes of care in stroke rehabilitation.
                comparison of processes of care data collected in a randomized controlled trial.
                acute stroke patients undergoing rehabilitation randomized to receive integrated care pathways management (n=76) or conventional multidisciplinary care (n=76).
                proportion of patients meeting recommended standards for processes of care using a validated stroke audit tool.
                integrated care pathways methodology was associated with higher frequency of stroke specific assessments, notably testing for inattention (84% versus 60%; P=0.015) and nutritional assessment (74% versus 22%, P<0.001). Documentation of provision of certain information to patients/carers (89% versus 70%; P=0.024) and early discharge notification to general practitioners (80% versus 45%; P<0.001) were also more common in this group. There were no significant differences in the processes of interdisciplinary co-ordination and patient management between the integrated care pathways group and the control group.
                integrated care pathways may improve assessment and communication, even in specialist stroke settings. The diagnosis of stroke, which is diagnosis-related group (DRG) 014, is the fourth most frequent discharge DRG at Macomb Hospital Center, Warren, Michigan. The length of stay for stroke was 7.52 days before intervention. Quality improvement techniques identified areas of delay that presented opportunities for improvement. After the initiation of a critical pathway that begins its interventions in the Emergency Department, the length of stay decreased to 6.33 days. Quality of care was also improved in delivery time of carotid artery ultrasound examinations, as well as in timeliness of obtaining head computed tomography scans and reports. This article describes the development, implementation, and results of a stroke critical pathway that was implemented to address excessive length of stay. An automated clinical medical record and audit system was developed to evaluate the effect of modifying physician behavior at the control points in the ambulatory care process and to determine if this change was reflected in patient care cost outcomes. This study compared clinical and cost results of patients in an experimental group, who had the automated record and audit system, to a control group, who had a traditional clinic record without chart audit. Physicians responded to the automated audit suggestions at a rate of 50.25 in the experimental group and 37.3 in the control group. No major differences were observed in clinical outcomes, with the exception of the number of days of hospitalizations and, consequently, the cost of hospitalizations. The experimental group cost for hospitalizations was one-third of the control group and accounted for a majority of the differences in the total annual cost for the two groups. High experienced continuity of care in patients with cancer is associated with lower needs for care, better quality of life and better psychological outcomes. We developed and evaluated an intervention to improve experienced continuity. The intervention, consisted of (1) a 17-item patient-completed continuity assessment; (2) feedback to clinical nurse specialists and action to address the needs identified. Multidisciplinary team meetings and oncology outpatient clinics were observed, and patients and staff were interviewed. After qualitative work and reliability testing, the intervention was evaluated in a feasibility trial. Sixty-one patients provided data for analysis. No statistically significant differences were found in patients' experienced continuity between the trial arms, but important trends were seen in measures of needs for care in favour of those receiving the intervention. Feeding back findings from the continuity assessment to clinicians reduced patients' needs for care. Our results indicate that an intervention to target patients' experiences of continuity can reduce their subsequent needs for care. However, overcoming barriers to organisational change and addressing some patients' hesitation to report their continuity difficulties must be considered when implementing such an intervention. A phase III trial targeting patients with inadequate experienced continuity of care is recommended.
Clinical pathways are associated with reduced in-hospital complications and improved documentation without negatively impacting on length of stay and hospital costs.