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Clinical Pathway (clinical + pathway)
Selected AbstractsAn Updated Interdisciplinary Clinical Pathway for CRPS: Report of an Expert PanelPAIN PRACTICE, Issue 1 2002Dr. med, Michael D. Stanton-Hicks MB Abstract: The goal of treatment in patients with complex regional pain syndrome (CRPS) is to improve function, relieve pain, and achieve remission. Current guidelines recommend interdisciplinary management, emphasizing 3 core treatment elements: pain management, rehabilitation, and psychological therapy. Although the best therapeutic regimen or the ideal progression through these modalities has not yet been established, increasing evidence suggests that some cases are refractory to conservative measures and require flexible application of the various treatments as well as earlier consideration of interventions such as spinal cord stimulation (SCS). While existing treatment guidelines have attempted to address the comprehensive management of CRPS, all fail to provide guidance for contingent management in response to a sudden change in the patient's medical status. This paper reviews the current pathophysiology as it is known, reviews the purported treatments, and provides a modified clinical pathway (guideline) that attempts to expand the scope of previous guidelines. [source] Implementation of a Clinical Pathway in Management of the Postoperative Vestibular Schwannoma Patient,THE LARYNGOSCOPE, Issue 11 2001Katrina R. Stidham MD Abstract Objective The purpose of the study was to evaluate the effectiveness of a new clinical pathway in management of patients with postoperative vestibular schwannoma. The impact on duration of hospitalization and quality of care was evaluated. Study Design The study was a retrospective review of 59 consecutive patients undergoing surgical intervention for vestibular schwannoma between January 1995 and July 1999. Methods A new clinical pathway for management of postoperative vestibular schwannoma patients was implemented at The California Ear Institute at Stanford (Palo Alto, CA) in January 1995. All patients undergoing surgical intervention subsequent to initiation of the pathway were included in the study. Data including surgical approach, patient age, sex, and tumor size were included. Duration of hospitalization and postoperative complications were recorded. During the same time period, data for patients undergoing radiation therapy for vestibular schwannomas were evaluated for length of hospital stay and in-hospital complications. Data were compared with norms recorded in the literature for duration of hospitalization and complications following surgical intervention. Results Fifty-nine patients underwent 35 middle fossa approaches and 24 translabyrinthine approaches to their tumors. The average patient age was 53 years; there were 34 female and 25 male patients. The average length of hospital stay was 3.83 days (SD = 1.4 days) with a range from 2 to 10 days. Postoperative complications were observed in 19% of patients, including eight (13%) cerebrospinal fluid (CSF) leaks, two requiring lumbar drains (3.4%); one hematoma (1.6%), one postoperative fever (1.6%), and one dural tear with associated hyponatremia (1.6%). These results compared favorably with previously recorded average hospital stays of 5.95 to 9.5 days 1,5,7 and CSF leak complication rates of 7% to 15%. 9,10 Conclusions Implementation of a clinical pathway for management of the patient with postoperative vestibular schwannoma improves efficiency of patient care, allowing decreased duration of hospitalization. This goal is achieved without increasing complication rates and, in our experience, actually improving the quality of clinical care. The cost-effectiveness of clinical pathways may become increasingly important in a managed care,driven environment. [source] Implementation of an Emergency Department,based Transient Ischemic Attack Clinical Pathway: A Pilot Study in Knowledge TranslationACADEMIC EMERGENCY MEDICINE, Issue 11 2007Michael D. Brown MD Objectives To assess the feasibility of implementing an emergency department (ED),based transient ischemic attack (TIA) clinical pathway that uses computer-based clinical support, and to evaluate measures of quality, safety, and efficiency. Methods This was a prospective cohort study of adult patients presenting to a community ED with symptoms consistent with acute TIA. Adherence to the clinical pathway served as a test of feasibility. Compliance with guideline recommendations for antithrombotic therapy and vascular imaging were used as process measures of quality. The 90-day risk of recurrent TIA, stroke, or death provided estimates of safety. Efficiency was assessed by measuring the rate of uneventful hospitalization, defined as a hospital admission that did not result in any major medical event or vascular intervention such as endarterectomy or stent placement. Results Of the 75 subjects enrolled, physician adherence to the clinical pathway was 85.3%, and 35 patients (46.7%) were discharged home from the ED. Antithrombotic agents were prescribed to 68 (90.7%), and vascular imaging was performed in 70 (93.3%). The 90-day risk of recurrent TIA was seven out of 75 (9.3%; 95% confidence interval [CI] = 4.6% to 18.0%), one patient experienced stroke (1.3%; 95% CI = 0.2% to 7.2%), and three patients died (4.0%; 95% CI = 1.4% to 11.1%). Uneventful hospitalization occurred in 38 of 40 patients (95.0%). Conclusions Implementation of a clinical pathway for the evaluation and management of TIA using computer-based clinical support is feasible in a community ED setting. This pilot study in knowledge translation provides a design framework for further studies to assess the safety and efficiency of a structured ED-based TIA clinical pathway. [source] Toward Improved Implementation of Evidence-based Clinical Algorithms: Clinical Practice Guidelines, Clinical Decision Rules, and Clinical PathwaysACADEMIC EMERGENCY MEDICINE, Issue 11 2007Gary M. Gaddis MD This is a summary of the consensus-building workshop entitled "Guideline Implementation and Clinical Pathways," convened May 15, 2007, at the Academic Emergency Medicine Consensus Conference, "Knowledge Translation in Emergency Medicine: Establishing a Research Agenda and Guide Map for Evidence Uptake." A new term, "evidence-based clinical algorithms" is suggested to encompass evidence-based information codified into clinical pathways, clinical practice guidelines, and clinical decision rules. Examples of poor knowledge translation (KT) relevant to the specialty of emergency medicine are identified, followed by brief descriptions of important research and concepts that inform the research recommendations. Four broad themes for research to improve the KT of evidence-based clinical algorithms are suggested: organizational factors, cognitive factors, social factors, and motivational factors. In all cases, research regarding optimizing KT for the subthemes identified by Glasziou and Haynes, "getting the evidence straight," and "getting the evidence used," are interwoven into the thematic research recommendations. Consensus was reached that the majority of research efforts to evaluate means to improve KT need to be centered on the factors that show promise to enhance "getting the evidence used," focused especially on organizational factors. [source] Clinical pathway for tension-free vaginal mesh procedure: Evaluation in 300 patients with pelvic organ prolapseINTERNATIONAL JOURNAL OF UROLOGY, Issue 3 2009Kumiko Kato Objectives: To evaluate a clinical pathway of discharge on postoperative day 3 for the tension-free vaginal mesh (TVM) procedure in patients with pelvic organ prolapse (POP). Methods: Between May 2006 and December 2007, 305 consecutive women with POP quantification stage 3 or 4 were planned to undergo the TVM procedure in a single general hospital. Excluding five patients with concomitant hysterectomy, a pathway (removal of the indwelling urethral catheter on the next morning, discharge on postoperative day 3) was applied to the remaining 300 patients. The perioperative complications and postoperative hospitalization were prospectively evaluated in this case series. Results: Perioperative complications were: bladder injury (11 cases, 3.7%), vaginal wall hematoma (two cases, 0.7%), rectal injury (one case, 0.3%) and temporary hydronephrosis (one case, 0.3%). None needed blood transfusion. The indwelling urethral catheters were removed on the next morning as in the pathway in 287 cases (95.6%), and none required clean intermittent catheterization at home. Postoperative hospitalization was within 3 days in 280 cases (93.3%). The six cases (2.0%) with longer hospitalization were due to complications (two cases of bladder injury, one of rectal injury, one of blood loss over 200 mL, one of temporary urinary retention, and one of hydronephrosis). Two patients were re-hospitalized within one month due to vaginal bleeding or gluteal pain. Conclusions: Patients generally accepted the pathway of discharge on postoperative day 3 in spite of the Japanese culture preferring a longer hospital stay. [source] Does the organization of care processes affect outcomes in patients undergoing total joint replacement?JOURNAL OF EVALUATION IN CLINICAL PRACTICE, Issue 1 2010Kris Vanhaecht RN MSc PhD Abstract Background, Surgeons realize that safe and efficient care processes for total joint replacement requires more than just well-performed operations. Orthopaedic teams are reorganizing care process to improve efficacy and shorten length of stay. Little is known on the impact of organizational changes on patient outcome. This paper studies the relation between the organization of care processes and patient outcomes in hip and knee. Clinical pathways are used as one of the methods to structure the care process. Although evidence is available on the effect of pathways in total joint replacement, their impact with the organization of the care process has not been studied previously. Methods, A cross-sectional multicentre study was performed on 39 care processes and 737 consecutive patients. Regression models were used to analyse the relation between the organization of the care process and risk-adjusted patient outcomes. The use of pathways and the organization of the care process, measured by the Care Process Self Evaluation Tool (CPSET), were measured at organizational level. Length of stay, pain, mobility and elapsed time to discharge were measured at patient level. Results, The use of pathways had a positive effect on four out of five subscales and the overall CPSET score. Using pathways decreased length of stay (P = 0.014), pain (P = 0.052) and elapsed time to discharge (P = 0.003). The CPSET subscale communication was related with three risk adjusted outcomes. Multivariate analysis demonstrated a significant effect by three different variables on the length of stay; (1) use of pathways; (2) coordination of care processes; and (3) communication with patients and family. Both the use of pathways and coordination of the care process were determinants for the elapsed time to discharge. A significant interaction effect was found between use of pathways and coordination of the care process. Conclusion, This large multicentre study revealed the relation between the use of pathways, organization of the care process and patient outcomes. This information is important for both clinicians and managers to understand and further improve the organization of orthopaedic care. Level of evidence, Level I prognostic study. [source] Do pathways lead to better organized care processes?JOURNAL OF EVALUATION IN CLINICAL PRACTICE, Issue 5 2009Kris Vanhaecht RN MSc PhD Abstract Aim, Clinical pathways are used worldwide to (re)organize care processes. They are used by multidisciplinary teams in their search towards excellence. The goal of this study is (1) to assess differences in the perception of health professionals in their evaluation of care processes; (2) to assess whether care processes supported by clinical pathways perform better than those not supported by clinical pathways; and (3) to assess the sensitivity and specificity of clinical pathways in predicting well-organized care processes. Methods, A cross-sectional, multi-centre study was performed comprising 309 healthcare workers, 103 care processes and 49 hospitals. The Care Process Self Evaluation Tool (CPSET) was used to score care processes according to their organization. Processes were also scored according to the level of pathway implementation. Results, (1) Significant differences between healthcare professionals were found on two of five CPSET subscales. No significant differences were found among the overall CPSET scores. (2) Care processes supported by pathways had the highest CPSET scores. Nonetheless, continuous follow-up is necessary. (3) Clinical pathways have significant impact on the coordination of care (odds ratio: 8.92), follow-up (odds ratio: 6.65) and overall CPSET score (odds ratio: 4.26). Clinical pathways have a positive impact on the organization of care processes. Not all pathways have high CPSET scores, and care processes without pathways can also be well organized. Continuous evaluation is essential. This is the first study to analyse how healthcare teams perceive the organization of care processes with respect to clinical pathways. Our findings are important for other quality improvement methods. [source] A concept for the clinical implementation of sentinel lymph node biopsy in patients with breast carcinoma with special regard to quality assurance,CANCER, Issue 3 2005Thorsten Kuehn M.D. Abstract The development of standardized and reproducible clinical pathways is an important precondition for quality assurance in medicine, especially if a new method has not yet been ultimately validated. Sentinel lymph node biopsy (SLNB) is a widely accepted new surgical procedure in the treatment of early breast carcinoma. However, numerous steps of the method and details of the technique are not standardized and, thus, hamper quality assurance for SLNB. The German Society of Senology appointed an interdisciplinary consensus committee to work out guidelines for the standardized performance and quality-assured implementation of SLNB on a nationwide, homogeneous standard. The committee consisted of surgeons, gynecologists, radiooncologists, nuclear physicians, oncologists, and pathologists. Relevant questions related to patient selection, lymphatic mapping, surgery, histopathologic work-up, further local and systemic treatment decisions, patient information, training, and follow-up were evaluated with respect to clinical evidence, objectivity, and reproducibility. Clinical pathways were developed on the basis of this analysis. Requirements to the performing institutions and surgeons were defined. Cancer 2005. © 2004 American Cancer Society. [source] Clinical pathway for tension-free vaginal mesh procedure: Evaluation in 300 patients with pelvic organ prolapseINTERNATIONAL JOURNAL OF UROLOGY, Issue 3 2009Kumiko Kato Objectives: To evaluate a clinical pathway of discharge on postoperative day 3 for the tension-free vaginal mesh (TVM) procedure in patients with pelvic organ prolapse (POP). Methods: Between May 2006 and December 2007, 305 consecutive women with POP quantification stage 3 or 4 were planned to undergo the TVM procedure in a single general hospital. Excluding five patients with concomitant hysterectomy, a pathway (removal of the indwelling urethral catheter on the next morning, discharge on postoperative day 3) was applied to the remaining 300 patients. The perioperative complications and postoperative hospitalization were prospectively evaluated in this case series. Results: Perioperative complications were: bladder injury (11 cases, 3.7%), vaginal wall hematoma (two cases, 0.7%), rectal injury (one case, 0.3%) and temporary hydronephrosis (one case, 0.3%). None needed blood transfusion. The indwelling urethral catheters were removed on the next morning as in the pathway in 287 cases (95.6%), and none required clean intermittent catheterization at home. Postoperative hospitalization was within 3 days in 280 cases (93.3%). The six cases (2.0%) with longer hospitalization were due to complications (two cases of bladder injury, one of rectal injury, one of blood loss over 200 mL, one of temporary urinary retention, and one of hydronephrosis). Two patients were re-hospitalized within one month due to vaginal bleeding or gluteal pain. Conclusions: Patients generally accepted the pathway of discharge on postoperative day 3 in spite of the Japanese culture preferring a longer hospital stay. [source] An Updated Interdisciplinary Clinical Pathway for CRPS: Report of an Expert PanelPAIN PRACTICE, Issue 1 2002Dr. med, Michael D. Stanton-Hicks MB Abstract: The goal of treatment in patients with complex regional pain syndrome (CRPS) is to improve function, relieve pain, and achieve remission. Current guidelines recommend interdisciplinary management, emphasizing 3 core treatment elements: pain management, rehabilitation, and psychological therapy. Although the best therapeutic regimen or the ideal progression through these modalities has not yet been established, increasing evidence suggests that some cases are refractory to conservative measures and require flexible application of the various treatments as well as earlier consideration of interventions such as spinal cord stimulation (SCS). While existing treatment guidelines have attempted to address the comprehensive management of CRPS, all fail to provide guidance for contingent management in response to a sudden change in the patient's medical status. This paper reviews the current pathophysiology as it is known, reviews the purported treatments, and provides a modified clinical pathway (guideline) that attempts to expand the scope of previous guidelines. [source] Does epidural analgesia delay the diagnosis of lower limb compartment syndrome in children?PEDIATRIC ANESTHESIA, Issue 2 2009DOUG J.G. JOHNSON MBChB MRCP FRCA Summary One of the cardinal symptoms of compartment syndrome is pain. A literature review was undertaken in order to assess the association of epidural analgesia and compartment syndrome in children, whether epidural analgesia delays the diagnosis, and to identify patients who might be at risk. Evidence was sought to offer recommendations in the use of epidural analgesia in patients at risk of developing compartment syndrome of the lower limb. Increasing analgesic use, increasing/breakthrough pain and pain remote to the surgical site were identified as important early warning signs of impending compartment syndrome in the lower limb of a child with a working epidural. The presence of any should trigger immediate examination of the painful site, and active management of the situation (we have proposed one clinical pathway). Avoidance of dense sensory or motor block and unnecessary sensory blockade of areas remote to the surgical site allows full assessment of the child and may prevent any delay in diagnosis of compartment syndrome. Focusing on excluding the diagnosis of compartment syndrome rather than failure of analgesic modality is vital. In the pediatric cases reviewed there was no clear evidence that the presence of an epidural had delayed the diagnosis. [source] Impact of a pediatric asthma clinical pathway on hospital cost and length of stay,PEDIATRIC PULMONOLOGY, Issue 3 2001April Wazeka MD Abstract This study sought to determine if a clinical pathway developed and executed by specialists in pediatric asthma would reduce hospital costs and length of stay (LOS). The study design was a retrospective, nonrandomized, controlled trial. Subjects were children aged 2,18 years (N,=,1,004) with a history of recurrent wheezing, hospitalized with a diagnosis of acute asthma exacerbation between 1995,1998 at the New York Hospital-Weill Cornell Medical Center and treated via the pathway, as well as a control group of 206 children ages 2,18 hospitalized for acute asthma exacerbation in 1994, the year prior to pathway implementation. Patients were treated via the pathway under the supervision of an asthma specialist. The pathway provided guidelines for: 1) frequency of patient assessment; 2) bronchodilator usage; 3) corticosteroid use; 4) laboratory evaluation; 5) vital signs, oxygen saturation, and peak flow measurements; 6) chest x-rays; 7) social work intervention; and 8) discharge planning. The main outcome measures were hospital length of stay, cost per hospitalization, nursing, medication, laboratory and radiology costs, and relapse rate. Total charges for admission and average LOS for 1995,1998 were calculated, and compared with 1994, the year preceding implementation of the pathway. LOS decreased from 4.2 days to 2.7 days (P,<,0.0001). The annual total charges for pediatric asthma admissions decreased from $2 million to $1.4 million (P,<,0.005). Nursing and laboratory costs showed a statistically significant decrease. Follow-up study at 8 months showed a readmission rate of 0.02%. The implementation of a pediatric asthma clinical pathway, directed by specialists, resulted in significantly decreased length of stay and overall cost, without an increased rate of readmission. Pediatr Pulmonol. 2001; 32:211,216. © 2001 Wiley-Liss, Inc. [source] Acute Stroke Care at Rural Hospitals in Idaho: Challenges in Expediting Stroke CareTHE JOURNAL OF RURAL HEALTH, Issue 1 2006James G. Gebhardt MD ABSTRACT:,Context: Thrombolytics are currently the most effective treatment for stroke. However, the National Institute for Neurological Disorders and Stroke criteria for initiation of thrombolytic therapy, most notably the 3-hour time limit from symptom onset, have proven challenging for many rural hospitals to achieve. Purpose: To provide a snapshot of stroke care at rural hospitals in Idaho and to investigate the experiences of these hospitals in expediting stroke care. Methods: Using a standard questionnaire, a telephone survey of hospital staff at 21 rural hospitals in Idaho was performed. The survey focused on acute stroke care practices and strategies to expedite stroke care. Findings: The median number of stroke patients treated per year was 23.3. Patient delays were reported by 77.8% of hospitals, transport delays by 66.7%, in-hospital delays by 61.1%, equipment delays by 22.2%, and ancillary services delays by 61.1%. Approximately 67% of hospitals had implemented a clinical pathway for stroke and 80.0% had provided staff with stroke-specific training. No hospitals surveyed had a designated stroke team, and only 33.3% reported engaging in quality improvement efforts to expedite stroke care. Thrombolytics (tPA) were available and indicated for stroke at 55.6% of the hospitals surveyed. Conclusions: Rural hospitals in Idaho face many difficult challenges as they endeavor to meet the 3-hour deadline for thrombolytic therapy, including limited resources and experience in acute stroke care, and many different types of prehospital and in-hospital delays. [source] Implementation of a Clinical Pathway in Management of the Postoperative Vestibular Schwannoma Patient,THE LARYNGOSCOPE, Issue 11 2001Katrina R. Stidham MD Abstract Objective The purpose of the study was to evaluate the effectiveness of a new clinical pathway in management of patients with postoperative vestibular schwannoma. The impact on duration of hospitalization and quality of care was evaluated. Study Design The study was a retrospective review of 59 consecutive patients undergoing surgical intervention for vestibular schwannoma between January 1995 and July 1999. Methods A new clinical pathway for management of postoperative vestibular schwannoma patients was implemented at The California Ear Institute at Stanford (Palo Alto, CA) in January 1995. All patients undergoing surgical intervention subsequent to initiation of the pathway were included in the study. Data including surgical approach, patient age, sex, and tumor size were included. Duration of hospitalization and postoperative complications were recorded. During the same time period, data for patients undergoing radiation therapy for vestibular schwannomas were evaluated for length of hospital stay and in-hospital complications. Data were compared with norms recorded in the literature for duration of hospitalization and complications following surgical intervention. Results Fifty-nine patients underwent 35 middle fossa approaches and 24 translabyrinthine approaches to their tumors. The average patient age was 53 years; there were 34 female and 25 male patients. The average length of hospital stay was 3.83 days (SD = 1.4 days) with a range from 2 to 10 days. Postoperative complications were observed in 19% of patients, including eight (13%) cerebrospinal fluid (CSF) leaks, two requiring lumbar drains (3.4%); one hematoma (1.6%), one postoperative fever (1.6%), and one dural tear with associated hyponatremia (1.6%). These results compared favorably with previously recorded average hospital stays of 5.95 to 9.5 days 1,5,7 and CSF leak complication rates of 7% to 15%. 9,10 Conclusions Implementation of a clinical pathway for management of the patient with postoperative vestibular schwannoma improves efficiency of patient care, allowing decreased duration of hospitalization. This goal is achieved without increasing complication rates and, in our experience, actually improving the quality of clinical care. The cost-effectiveness of clinical pathways may become increasingly important in a managed care,driven environment. [source] Laparoscopic anterior resection for rectosigmoid cancer: Patient outcomes after implementation of a clinical pathwayASIAN JOURNAL OF ENDOSCOPIC SURGERY, Issue 1 2010T.W. Hsu Abstract Introduction: A clinical pathway designed for a single type of laparoscopic colorectal surgery for cancer might be helpful in decreasing complication rates and total hospital costs. It has been reported to be effective in reducing costs and shortening length of hospital stays in many situations such as laparoscopic cholecystectomy, colon resection, total colectomy, and gastrointestinal bleeding, as well as when caring for patients in the intensive care unit. Materials and Methods: A clinical pathway, including surgical details and perioperative management, for patients undergoing laparoscopic anterior resection for rectosigmoid cancer was designed and implemented. From January 2003 to December 2006, it was applied to 80 patients. Results: The average length of a hospital stay for these patients was 9.06 d. The mean hospital stay and total cost decreased year by year. The overall complication rate was 8.75% without perioperative mortality, and 47.5% of patients with underlying diseases were treated safely. Discussion: Laparoscopic anterior resection for rectosigmoid cancer, with curative or palliative intent, was safe after standardization of surgical details and perioperative management. The total hospital costs for each patient was predictable and decreased year by year. [source] Implementation of an Emergency Department,based Transient Ischemic Attack Clinical Pathway: A Pilot Study in Knowledge TranslationACADEMIC EMERGENCY MEDICINE, Issue 11 2007Michael D. Brown MD Objectives To assess the feasibility of implementing an emergency department (ED),based transient ischemic attack (TIA) clinical pathway that uses computer-based clinical support, and to evaluate measures of quality, safety, and efficiency. Methods This was a prospective cohort study of adult patients presenting to a community ED with symptoms consistent with acute TIA. Adherence to the clinical pathway served as a test of feasibility. Compliance with guideline recommendations for antithrombotic therapy and vascular imaging were used as process measures of quality. The 90-day risk of recurrent TIA, stroke, or death provided estimates of safety. Efficiency was assessed by measuring the rate of uneventful hospitalization, defined as a hospital admission that did not result in any major medical event or vascular intervention such as endarterectomy or stent placement. Results Of the 75 subjects enrolled, physician adherence to the clinical pathway was 85.3%, and 35 patients (46.7%) were discharged home from the ED. Antithrombotic agents were prescribed to 68 (90.7%), and vascular imaging was performed in 70 (93.3%). The 90-day risk of recurrent TIA was seven out of 75 (9.3%; 95% confidence interval [CI] = 4.6% to 18.0%), one patient experienced stroke (1.3%; 95% CI = 0.2% to 7.2%), and three patients died (4.0%; 95% CI = 1.4% to 11.1%). Uneventful hospitalization occurred in 38 of 40 patients (95.0%). Conclusions Implementation of a clinical pathway for the evaluation and management of TIA using computer-based clinical support is feasible in a community ED setting. This pilot study in knowledge translation provides a design framework for further studies to assess the safety and efficiency of a structured ED-based TIA clinical pathway. [source] Guidelines for the Management of Squamous Cell Carcinoma in Organ Transplant RecipientsDERMATOLOGIC SURGERY, Issue 4p2 2004Thomas Stasko MD Background. Solid-organ transplant recipients have a high incidence of cutaneous squamous cell carcinoma (SCC) and often develop multiple and aggressive tumors. There are few published studies or reviews, which provide guidance to the clinician in the treatment of these patients. Objective. The objective was to develop useful clinical guidelines for the treatment of skin cancer in organ transplant recipients (OTRs). Methods. The members of the Guidelines Committee of the International Transplant,Skin Cancer Collaborative (ITSCC) carried out a computerized search utilizing the databases of the National Library of Medicine for reports in the literature on SCC in OTRs. These reports were collectively examined by the group and combined with experiences from the members' clinical practices in the development of the guidelines. Results. More than 300 articles relating to SCC in OTRs were reviewed. In general, reports concerning the prevention and treatment of SCC in OTRs are of individual cases or small case series. They are retrospective in nature, statistically nonrigorous, and lack the complete epidemiologic data necessary to derive definitive conclusions. Combining these studies and collective clinical experience, however, is at present the best available method for devising guidelines for the treatment of SCC in OTRs. Conclusion. Guidelines developed for the treatment of skin cancer in OTRs, supported by the best available data and collective clinical experience, may assist in the management of OTRs with SCC. The development of clinical pathways and complete documentation with rigorous prospective study is necessary to improve and refine future guideline development. [source] Stroke units: many questions, some answersINTERNATIONAL JOURNAL OF STROKE, Issue 1 2009Blanca Fuentes Background The development of specialized stroke units has been a landmark innovation in acute stroke care. However, the high scientific evidence level for the recommendation for stroke units to provide clinical attention for acute stroke patients does not correspond to the level of stroke unit implementation. A narrative, nonsystematic review on published studies on stroke units was conducted, with special emphasis on those demonstrating their efficacy and effectiveness. We also attempt to provide some answers to several open questions regarding practical issues of stroke units. Summary of review Stroke units represent the most efficacious model for care provision compared with general ward care and stroke teams. Every stroke patient can benefit from stroke unit care. These units are efficient, cost-effective and their benefits are consistent over time. Compared with other specific stroke therapies such as aspirin or intravenous thrombolytic agents, stroke units have a higher target population and higher benefit in terms of number of deaths and/or dependencies avoided. New approaches in stroke unit management such as the implementation of noninvasive monitoring or alternative clinical pathways could improve their benefit even further. Conclusion Stroke units are cost-effective and need to be considered as a priority in health-care provision for stroke patients. [source] Do pathways lead to better organized care processes?JOURNAL OF EVALUATION IN CLINICAL PRACTICE, Issue 5 2009Kris Vanhaecht RN MSc PhD Abstract Aim, Clinical pathways are used worldwide to (re)organize care processes. They are used by multidisciplinary teams in their search towards excellence. The goal of this study is (1) to assess differences in the perception of health professionals in their evaluation of care processes; (2) to assess whether care processes supported by clinical pathways perform better than those not supported by clinical pathways; and (3) to assess the sensitivity and specificity of clinical pathways in predicting well-organized care processes. Methods, A cross-sectional, multi-centre study was performed comprising 309 healthcare workers, 103 care processes and 49 hospitals. The Care Process Self Evaluation Tool (CPSET) was used to score care processes according to their organization. Processes were also scored according to the level of pathway implementation. Results, (1) Significant differences between healthcare professionals were found on two of five CPSET subscales. No significant differences were found among the overall CPSET scores. (2) Care processes supported by pathways had the highest CPSET scores. Nonetheless, continuous follow-up is necessary. (3) Clinical pathways have significant impact on the coordination of care (odds ratio: 8.92), follow-up (odds ratio: 6.65) and overall CPSET score (odds ratio: 4.26). Clinical pathways have a positive impact on the organization of care processes. Not all pathways have high CPSET scores, and care processes without pathways can also be well organized. Continuous evaluation is essential. This is the first study to analyse how healthcare teams perceive the organization of care processes with respect to clinical pathways. Our findings are important for other quality improvement methods. [source] Implementation of a Clinical Pathway in Management of the Postoperative Vestibular Schwannoma Patient,THE LARYNGOSCOPE, Issue 11 2001Katrina R. Stidham MD Abstract Objective The purpose of the study was to evaluate the effectiveness of a new clinical pathway in management of patients with postoperative vestibular schwannoma. The impact on duration of hospitalization and quality of care was evaluated. Study Design The study was a retrospective review of 59 consecutive patients undergoing surgical intervention for vestibular schwannoma between January 1995 and July 1999. Methods A new clinical pathway for management of postoperative vestibular schwannoma patients was implemented at The California Ear Institute at Stanford (Palo Alto, CA) in January 1995. All patients undergoing surgical intervention subsequent to initiation of the pathway were included in the study. Data including surgical approach, patient age, sex, and tumor size were included. Duration of hospitalization and postoperative complications were recorded. During the same time period, data for patients undergoing radiation therapy for vestibular schwannomas were evaluated for length of hospital stay and in-hospital complications. Data were compared with norms recorded in the literature for duration of hospitalization and complications following surgical intervention. Results Fifty-nine patients underwent 35 middle fossa approaches and 24 translabyrinthine approaches to their tumors. The average patient age was 53 years; there were 34 female and 25 male patients. The average length of hospital stay was 3.83 days (SD = 1.4 days) with a range from 2 to 10 days. Postoperative complications were observed in 19% of patients, including eight (13%) cerebrospinal fluid (CSF) leaks, two requiring lumbar drains (3.4%); one hematoma (1.6%), one postoperative fever (1.6%), and one dural tear with associated hyponatremia (1.6%). These results compared favorably with previously recorded average hospital stays of 5.95 to 9.5 days 1,5,7 and CSF leak complication rates of 7% to 15%. 9,10 Conclusions Implementation of a clinical pathway for management of the patient with postoperative vestibular schwannoma improves efficiency of patient care, allowing decreased duration of hospitalization. This goal is achieved without increasing complication rates and, in our experience, actually improving the quality of clinical care. The cost-effectiveness of clinical pathways may become increasingly important in a managed care,driven environment. [source] A concept for the clinical implementation of sentinel lymph node biopsy in patients with breast carcinoma with special regard to quality assurance,CANCER, Issue 3 2005Thorsten Kuehn M.D. Abstract The development of standardized and reproducible clinical pathways is an important precondition for quality assurance in medicine, especially if a new method has not yet been ultimately validated. Sentinel lymph node biopsy (SLNB) is a widely accepted new surgical procedure in the treatment of early breast carcinoma. However, numerous steps of the method and details of the technique are not standardized and, thus, hamper quality assurance for SLNB. The German Society of Senology appointed an interdisciplinary consensus committee to work out guidelines for the standardized performance and quality-assured implementation of SLNB on a nationwide, homogeneous standard. The committee consisted of surgeons, gynecologists, radiooncologists, nuclear physicians, oncologists, and pathologists. Relevant questions related to patient selection, lymphatic mapping, surgery, histopathologic work-up, further local and systemic treatment decisions, patient information, training, and follow-up were evaluated with respect to clinical evidence, objectivity, and reproducibility. Clinical pathways were developed on the basis of this analysis. Requirements to the performing institutions and surgeons were defined. Cancer 2005. © 2004 American Cancer Society. [source] Toward Improved Implementation of Evidence-based Clinical Algorithms: Clinical Practice Guidelines, Clinical Decision Rules, and Clinical PathwaysACADEMIC EMERGENCY MEDICINE, Issue 11 2007Gary M. Gaddis MD This is a summary of the consensus-building workshop entitled "Guideline Implementation and Clinical Pathways," convened May 15, 2007, at the Academic Emergency Medicine Consensus Conference, "Knowledge Translation in Emergency Medicine: Establishing a Research Agenda and Guide Map for Evidence Uptake." A new term, "evidence-based clinical algorithms" is suggested to encompass evidence-based information codified into clinical pathways, clinical practice guidelines, and clinical decision rules. Examples of poor knowledge translation (KT) relevant to the specialty of emergency medicine are identified, followed by brief descriptions of important research and concepts that inform the research recommendations. Four broad themes for research to improve the KT of evidence-based clinical algorithms are suggested: organizational factors, cognitive factors, social factors, and motivational factors. In all cases, research regarding optimizing KT for the subthemes identified by Glasziou and Haynes, "getting the evidence straight," and "getting the evidence used," are interwoven into the thematic research recommendations. Consensus was reached that the majority of research efforts to evaluate means to improve KT need to be centered on the factors that show promise to enhance "getting the evidence used," focused especially on organizational factors. [source] Effective Synthesized/preappraised Evidence Formats in Emergency Medicine and the Use of Supplemental Knowledge Translation TechniquesACADEMIC EMERGENCY MEDICINE, Issue 11 2007Brian H. Rowe MD Most clinicians, and especially emergency physicians, are increasingly faced with the need for valid and reliable evidence upon which to base practice decisions in a timely fashion. Despite the accumulation of synthesized evidence in emergency medicine over the past decade, knowledge gaps still exist between what is known and what is practiced. In many cases, this failure in knowledge uptake relates to barriers in uptake as well as the difficulty of translating evidence from research to the bedside. Preappraised evidence syntheses represent a potential partial solution to these problems by providing condensed summaries of the large volume of scientific literature in our field. The participants in this workshop examined the availability, utility, and impact of preappraised evidence and examined innovative ways to translate this knowledge into practice. In addition, the workshop participants also explored more globally all knowledge translation methods that are distinct from clinical pathways (e.g., audit and feedback, academic detailing, reminders, and local opinion leaders). These are initiatives that are instituted at the level of a particular hospital or with respect to a certain condition, and emergency physicians need to understand their definition and application. Overall, the recommendations arising from this workshop have the potential to alter future emergency care in important ways. [source] | ||||||||||