Evidence Report/Technology Assessment Number 43 - Making ...

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effect of a pathway on the treatment of acute myocardial infarction demonstrated that the improvements seen in the intervention group were likely secondary to secular trends and not an independent effect of the pathway. 6 These powerful results cast a great deal of doubt over those studies that demonstrated effectiveness of the pathways in comparison to historical controls alone. Potential for Harm There are theoretical concerns that pathways may result in adverse patient outcomes as a result of shortened length of stay and a dependence on “cookbook medicine,” although there is little support for this in the literature. Costs and Implementation Although many studies report cost savings associated with instituting pathways, very few detail the costs of developing and implementing them. One report attempted to put a dollar figure on the development of a pathway for the treatment of patients undergoing knee replacement surgery; however the reported estimate ($21,000) did not account for the time staff physicians spent on the project. 14 The expense of developing critical pathways in terms of physician time commitment and actual financial outlay is unknown. In addition, most pathways are developed on the local level and require a great deal of initiative and expertise on the part of the hospital or medical center. Whether most centers have access to these resources is unclear. Physicians and other providers are also not universally welcoming of critical pathways. They are considered intrusive by some providers and evidence of “cookbook medicine” by others. The developers of pathways must be careful to allow for clinical judgment and flexibility in the pathways or they are likely to be ignored or applied too rigidly. Comment There is conflicting evidence regarding the efficacy of critical pathways as a method to modify health care provider behavior and a means of implementing patient safety initiatives. Although a few studies suggest they may impact physician practice and, to a lesser extent, complication rates and other clinical outcomes, the data are inconsistent and more studies are needed. Additionally it is unclear whether the costly development and implementation of pathways represents an appropriate use of limited health care resources. Finally, there is very little information on the application of pathways to patient safety. 584
Table 52.1. Key features of studies of critical pathways Study Setting Design, Outcomes Children with an asthma Level 1, exacerbation admitted to an Level 1 academic medical center: patients randomized to pathway group or usual care group 22 Patients undergoing hip or knee Level 1, replacement surgery at an academic Level 1 medical center in Australia: patients randomized to pathway group or usual care group 21 Patients being treated for hip fracture Level 1, at an academic medical center in Australia 20 Level 2 Patients presenting to the emergency Level 1, department with pneumonia at 19 Level 1 medical centers across Canada: hospitals were randomized to pathway group or usual care group 23 Patients in need of supplemental Level 2, oxygen therapy: prospective beforeafter analysis with washout period 26 Level 1 Patients undergoing unilateral neck Level 2, dissection at an academic medical Level 1 center: pathway group compared to historical controls and nonrandomized concurrent controls 25 Patients admitted to a community Level 2, teaching hospital for the treatment of Level 1 an asthma exacerbation: pathway group compared to historical controls and non-randomized concurrent controls 24 Patients undergoing one of several Level 2, defined surgical procedures over a Level 2 seven year period at an academic medical center: pathway group compared to historical controls as well as to patients from other similar hospitals in the same region 27 Clinical Outcomes (p value) Shorter duration of intensive nebulizer treatment (0.02), length of stay (0.01) Shorter length of stay (0.011) and time to mobilization (0.001) and ambulation (0.02) Shorter length of stay (0.03) Lower rates of bed-days per patient (0.04), shorter length of stay (0.01) and shorter duration of IV therapy (0.01) More frequent appropriate oxygen discontinuation orders (0.001) Length of stay decreased compared to historical controls (0.001) but not concurrent controls More appropriate antibiotic use and conversion to nebulizer treatment (0.002 for historical controls, 0.05 for concurrent controls) Decreased lengths of stay for the pathway group compared to the historical controls, but not compared to the concurrent control group Non-Clinical Outcomes (p value) Lower room charges (0.001) and therapy charges (0.001) Increased costs (0.02) Total costs decreased compared to historical controls (0.001) but not concurrent controls 585
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Evidence Report/Technology Assessme
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Structured Abstract Objectives: Pat
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CONTENTS Summary...................
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Chapter 37. Pain Management........
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Summary Overview Patient safety has
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from the domains of commercial avia
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section above. The editorial team c
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Clear Opportunities for Research Un
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Evidence Report
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Chapter 1. An Introduction to the R
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The Evidence Chapter 3 describes ou
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never occur. Although some of these
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• Potential for Harm - Many pract
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• John W. Gosbee, MD, MS, Directo
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23. Brennan TA, Leape LL, Laird NM,
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As outlined in Chapter 24, signific
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21. Roberts KH, Libuser C. From Bho
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literature and were meant to be as
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Table 3.3. Hierarchy of study desig
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Table 3.5. Ten Required Abstraction
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References 1. Thurfjell E, Thurfjel
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PART II. REPORTING AND RESPONDING T
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Incident reports may target events
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Opportunities for Impact Most hospi
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incident reporting and analysis cou
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References 1. Brennan TA, Leape LL,
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41. Weingart SN, Ship AN, Aronson M
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Despite legitimate concerns about t
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Evidence for Effectiveness of the P
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17. Rasmussen J. Human error and th
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Section A. Adverse Drug Events (ADE
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Prevalence and Severity of the Targ
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egimen 27 (Level 2); another study
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few data describing reductions in A
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Table 6.2. Studies of clinical deci
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15. Bates DW, Boyle DL, Vander Vlie
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Chapter 7. The Clinical Pharmacist
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Table 7.1. Studies of clinical phar
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18. Beney J, Bero LA, Bond C. Expan
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to alert the monitoring clinician i
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Comment Computerized real-time moni
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References 1. Kellaway GS, McCrae E
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Chapter 9. Protocols for High-Risk
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egarded as a case-control study. 29
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Comment The primary purpose of hepa
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Table 9.1. Studies focused primaril
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Table 9.2. Inpatient anticoagulatio
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References 1. Bates DW, Cullen DJ,
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37. Ellis RF, Stephens MA, Sharp GB
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Chapter 10. Unit-Dose Drug Distribu
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Study Designs The 5 studies meeting
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hospitals that wish to do much of t
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When wrong time errors were omitted
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21. Barker KN, McConnell WE. The pr
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Chapter 11. Automated Medication Di
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system. 5 We classified this as a L
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Table 11.1. Six studies reviewing a
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117
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Chapter 12. Practices to Improve Ha
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interventions to assess effectivene
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Table 12.1. Fourteen studies of pra
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References 1. Haley RW, Culver DH,
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Chapter 13. Impact of Barrier Preca
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poor, 20 often below 50%. 21 Purpor
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the annual expenses due directly to
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254-bed long-term care facility in
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Table 13.2. Studies of barrier prec
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References 1. Handwerger S, Raucher
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35. Gammon J. The psychological con
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Chapter 14. Impact of Changes in An
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Table 14.1. Before-after studies of
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18. MacGowan AP, Brown I, Feeney R,
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Chapter 15. Prevention of Nosocomia
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Table 15.1.1. Studies of silver all
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9. Kunin CM. Urinary Tract Infectio
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probably appropriate to use since i
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Table 15.2.1. Prospective studies c
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6. Saint S, Veenstra DL, Sullivan S
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Chapter 16. Prevention of Intravasc
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Prevention Unnecessarily prolonged
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Table 16.1.1. Studies of vascular c
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Subchapter 16.2. Use of Central Ven
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Comment In light of the substantial
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Ramsay 41 §: 397 hospital patients
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Subchapter 16.3. Use of Chlorhexidi
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Table 16.3.1. Characteristics of st
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support the routine use of tunnelin
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32. Maki DG, Stolz SM, Wheeler S, M
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Final Comment to Chapter 16 Infecti
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Chapter 17. Prevention of Ventilato
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Potential for Harm No adverse effec
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Table 17.1.1. Patient positioning*
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Opportunities for Impact Continuous
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Table 17.2.1. Randomized trials of
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total antibiotic costs. 14-16 decre
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References 1. D'Amico R, Pifferi S,
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Table 17.4.1. Studies of stress ulc
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12. Slaughter S, Hayden MK, Nathan
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Chapter 18. Localizing Care to High
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showed an association) and physicia
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In addition to the potential use of
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References 1. Luft HS, Bunker JP, E
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Chapter 19. Learning Curves for New
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Thus, determination of a minimum nu
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References 1. Gallstones and laparo
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39. Crawford DL, Phillips EH. Lapar
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Chapter 20. Prevention of Surgical
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Costs and Implementation A number o
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• Single dose vs. multiple dose r
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All Cesarean section: RR 0.37 (0.33
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17. Vegas AA, Jodra VM, Garcia ML.
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Subchapter 20.2. Perioperative Norm
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Comment Given the evidence of effec
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Opportunities for Impact Administra
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5. Greif R, Laciny S, Rapf B, Hickl
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Table 20.4.1. Prospective, before-a
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29. Lazar HL, Chipkin S, Philippide
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Chapter 21. Ultrasound Guidance of
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after 1996 9,15,17 and one that inc
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Comment Real-time US guidance for C
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References 1. Civetta JM, Taylor RW
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38. Kaufmann C, Rhee P, Burris D. T
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Chapter 22. The Retained Surgical S
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prevalence of this error and the ef
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Chapter 23. Pre-Anesthesia Checklis
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to anesthesia providers’ own meth
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References 1. Reason JT. Human Erro
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Chapter 24. The Impact Of Intraoper
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complications. During anesthesia an
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References 1. American Society of A
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Chapter 25. Beta-blockers and Reduc
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27 Accounting for these differences
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The use of beta-blockers to reduce
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defined as systolic blood pressure
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28. Litwack R, Gilligan D, DeGrutto
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Chapter 26. Prevention of Falls in
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facilities and a 31% reduction in m
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as to whether identification bracel
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36. Mitchell A, Jones N. Striving t
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has been good. In fact, given adequ
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References 1. Health Care Financing
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Table 26.3.1. Study of bed alarms f
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Table 26.4. Study of special floori
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Costs and Implementation An Austral
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7. Lauritzen JB, Petersen MM, Lund
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Chapter 27. Prevention of Pressure
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employed, ranging from Grade 1 (dis
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5. Norton D, McLaren R, Exton-Smith
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Chapter 28. Prevention of Delirium
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aseline co-morbidities of the enrol
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References 1. Elie M, Cole MG, Prim
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Chapter 29. Multidisciplinary Geria
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Study Outcomes Ten studies reported
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experienced geriatric team in a hos
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Marcantoni 126 orthopedic patients
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19. Gayton D, Wood-Dauphinee S, de
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Chapter 30. Geriatric Evaluation an
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Cognitive function, as measured by
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Table 30.1. Randomized Controlled T
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References 1. Creditor MC. Hazards
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Section E. General Clinical Topics
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Chapter 31. Prevention of Venous Th
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patients, the incidence of DVT was
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data show that aspirin (6 studies,
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Medical Patients VTE prevention in
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LMWH was more cost-effective than L
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Table 31.1. Mechanical and pharmaco
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Table 31.3. Recommended VTE prophyl
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17. Vanek VW. Meta-analysis of effe
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Chapter 32. Prevention of Contrast-
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the studies used aminophylline, rat
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Table 32.1. Studies of strategies f
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References 1. Parfrey PS, Griffiths
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33. Tippins RB, Torres WE, Baumgart
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Chapter 33. Nutritional Support Nei
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developing major infectious complic
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Table 33.1. Studies evaluating nutr
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19. Moore FA, Moore EE, Jones TN, M
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literature during that time. 17 Ide
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Costs and Implementation One cost-e
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6. Beejay U, Wolfe M. Acute gastroi
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375
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inferior to film interpretation for
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Study Outcomes Most studies reporte
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Table 35.1. Educational interventio
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31. Herman PG, Gerson DE, Hessel SJ
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Chapter 36. Pneumococcal Vaccinatio
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andomized controlled trials (RCTs)
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All studies of the effectiveness of
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Table 36.1. 1. Pneumococcal vaccine
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9. Whitney CG, Farley MM, Hadler J,
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395
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surgeons indicate that the majority
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Table 37.1.1. Randomized controlled
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anesthesiologists, specially traine
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Table 37.2.1. Studies of acute pain
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Opportunities for Impact The degree
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Practice Description Non-pharmacolo
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Table 37.4.1. Studies of non-pharma
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Section F. Organization, Structure,
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Chapter 38. “Closed” Intensive
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pediatric multidisciplinary ICUs. I
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adjusted hospital mortality and a n
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RRR is the unadjusted mortality rel
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19. DiCosmo BFM. Addition of an int
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Chapter 39. Nurse Staffing, Models
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interventions to reduce pain, nause
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al 30 also does not find an associa
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associated with in-hospital mortali
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Table 39.3 Structural measures: ava
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8. Data from HCFA Medicare Level 3,
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Table 39.4 Structural variables: nu
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Table 39.5 Process measures: nurse
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10. Finnigan SA, Abel M, Dobler T,
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50. Kite K. Changing mouth care pra
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91. Medicare. Available at: www.sta
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138. Jones J, Rowan K. Is there a r
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Chapter 40. Promoting a Culture of
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organizational culture in high reli
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vary, depending on the type of acci
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Table 40.1. Checklist of elements t
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References 1. Roberts KH, Gargano G
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42. Helmreich RL. On error manageme
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Chapter 41. Human Factors and Medic
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Device Evaluation Prior to Purchase
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Identification of Alarm Source and
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Decreasing the Frequency of Alarms
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checklists in medicine have been li
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31. Stanford L, McIntyre J, Hogan J
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Chapter 42. Information Transfer Ha
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surveyed also wished to be provided
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Table 42.1.1. Practices to improve
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adverse medical event occurring dur
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Table 42.2.1. Computerized sign-out
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Costs and Implementation The direct
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Practice Description Our search rev
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Table 42.4.1. Randomized controlled
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Chapter 43. Prevention of Misidenti
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Medical record keeping Radiology an
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Study Outcomes Some of the studies
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References 1. Rappoport A. A hospit
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payments in 84% of cases, compared
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12. Cowell HR. Wrong-site surgery.
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Chapter 44. Crew Resource Managemen
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Representative Studies Several stud
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on Crisis Management Training in He
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practice, relatively little about t
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21. Halamek LP, Kaegi DM, Gaba DM,
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Chapter 45. Simulator-Based Trainin
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e difficult, 19 initial work has be
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factors that contribute to negative
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25. Sica GT, Barron DM, Blum R, Fre
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Chapter 46. Fatigue, Sleepiness, an
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fellowships. 34, 35 These shifts ar
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patient outcomes. Any effort to cha
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hour prophylactic nap in the evenin
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11. Cox T K, GP, ed. Stress and Sus
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53. Overland DW. Comparison of Effe
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97. Nicholson AN, Pascoe PA, Roehrs
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Page 545 and 546: eceive special training in skills n
Page 547 and 548: availability and different scoring
Page 549 and 550: Potential for Harm Inadequate maint
Page 551 and 552: Table 47.2 Manual versus mechanical
Page 553 and 554: 20. Duke G, Green J. Outcome of cri
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Page 557 and 558: Legislation governing the requireme
Page 559 and 560: obtaining informed consent often re
Page 561 and 562: patients that had been treated surg
Page 563 and 564: References 1. Edwards SJ, Lilford R
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Page 567 and 568: Failure to Document Preferences The
Page 569 and 570: Evidence for Effectiveness of the P
Page 571 and 572: have demonstrated that most medical
Page 573 and 574: Costs and Implementation Estimating
Page 575 and 576: References 1. Jonsen AR SM, Winslad
Page 577 and 578: 39. Kurent J. Death and Dying in Am
Page 579 and 580: Chapter 50. Other Practices Related
Page 581 and 582: analyzed these competing views, and
Page 583 and 584: PART IV. PROMOTING AND IMPLEMENTING
Page 585 and 586: Chapter 51. Practice Guidelines Rob
Page 587 and 588: Evidence for Effectiveness of Pract
Page 589 and 590: 4. Weingarten S. Using practice gui
Page 591 and 592: Chapter 52. Critical Pathways Rober
Page 593: not reach statistical significance)
Page 597 and 598: 19. Willis B, Kim LT, Anthony T, Be
Page 599 and 600: Chapter 53. Clinical Decision Suppo
Page 601 and 602: A final systematic review analyzed
Page 603 and 604: Costs and Implementation Very few s
Page 605 and 606: Chapter 54. Educational Techniques
Page 607 and 608: interventions with at least 3 compo
Page 609 and 610: Table 54.1. Studies of techniques f
Page 611 and 612: Chapter 55. Legislation, Accreditat
Page 613 and 614: hospitals and other health care ins
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Page 617 and 618: Table 55.2. A comparison of non-loc
Page 619 and 620: 21. Yessian M. The external review
Page 621 and 622: PART V. ANALYZING THE PRACTICES Cha
Page 623 and 624: Chapter 56. Methodology for Summari
Page 625 and 626: Details about Decision Rules and Ju
Page 627 and 628: determining the specific elements t
Page 629 and 630: Chapter 57. Practices Rated by Stre
Page 631 and 632: Table 57.2 Patient Safety Practices
Page 633 and 634: 17.1 Ventilator-associated pneumoni
Page 635 and 636: 57.5 Patient Safety Practices with
Page 637 and 638: Chapter 58. Practices Rated by Rese
Page 639 and 640: 9 Adverse events related to anticoa
Page 641 and 642: 42.4 Failures to communicate signif
Page 643 and 644: Chapter 59. Listing of All Practice
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Ch. # Patient Safety Target 16.4 Ce
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Ch. # Patient Safety Target Patient
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Ch. # Patient Safety Target Patient
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Comments Section 1 Medium strength
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29 High complexity for implementati
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55 Rated as low, but this practices
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84 Most evidence available outside
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Appendix: List of Contributors Edit
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Sharon K. Inouye, MD, MPH Associate
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Jean Ann Seago, PhD, RN Assistant P
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Index abdominal pain, acute analges
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described, 601 research needs, 604
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Natural Death Acts, 561 nursing iss
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decision rules and judgment conside
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