Abdominal aortic aneurysm pathway: outcome analysis.

The current and future health care environment demands that health care providers place increased emphasis on the achievement of acceptable patient outcomes within an effective timeline and with more efficient use of resources. Clinical pathways provide a tool that defines the processes and activities that must occur to meet these goals. The purpose of this study is to describe a process for analysis of clinical and fiscal outcomes of a clinical pathway initiated at an academic medical center for elective abdominal aortic aneurysm repair. Patients were monitored throughout their preoperative and postoperative course to identify and trend variances, assess opportunities for improved resource use, and determine patient/family satisfaction. Data were collected by use of multiple electronic databases available within the university information systems network and analyzed to determine impact on patient charges, treatment course, and length of stay. Outliers were profiled as a means to identify prognostic indicators or establish a high preoperative risk. Results of a sample of 42 patients revealed a reduction in gross charges by 33% per case in comparison to the baseline data obtained before pathway implementation. This study will describe the rationale and process for instituting changes in resource use, such as diagnostic testing and blood use. Clinical outcomes and related nursing implications will also be discussed, including preoperative management, a streamlined same-day admission process, and factors associated with prolonged stay in the intensive care unit. Finally, strategies designed to enlist the support and participation of nurses, physicians, and other health team members will be discussed.

Faculty practice: creating a new culture.

This article provides specifics on the development of a clinical track for faculty appointments at the University of Pittsburgh. The criteria to be used for appointment and promotion on the clinical track are discussed along with the practice requirements of 60 hours per term of participation in and responsibility for direct care of patients. The purposes of faculty practice are set forth along with the formation and functioning of a Faculty Practice Council which handles decisions related to faculty practice. Results of the first year after implementation of a clinical track showed that 64 per cent (18) of the faculty had met all of their faculty practice obligations; of the remaining 36 percent (10) who had not, a variety of circumstances were cited. The Income to the School of Nursing for faculty practice, although modest, has helped to highlight that practice is valued and an integral part of the faculty role.

The midlevel practitioner role: one medical center's experience.

Numerous trends in the current health-care environment have converged to produce an increased emphasis on the role of the midlevel practitioner. Financial constraints head the list, including a mandate for the best care at the lowest rates and a resulting shift from costly specialists to primary care providers. The desire to conserve human and technologic resources requires a practitioner with advanced knowledge and skills to serve as gatekeeper in terms of facilitating access to health care, establishing efficient referral patterns, and developing a holistic care plan. The midlevel practitioner also is prepared to facilitate the transition from the intensive care unit to the less costly general care areas. In addition, the inevitable reduction in funds for graduate medical education and the dwindling number of first-year medical students choosing internal medicine as a specialty threaten the ability of academic medical centers in particular to provide adequate housestaff coverage to full-time and voluntary faculty members. Physicians eager to provide efficient, seamless care to patients in the acute care setting, while maintaining an office practice and caseloads at several hospitals, find the support provided by a midlevel practitioner an enhancement to their clinical practice and a solution to the continuous management of acute and chronically ill patients. In this article, the authors describe one medical center's experience in implementing the midlevel practitioner role.

Cancer metastasis.

Understanding of the process by which tumor cells develop heterogeneity, invade local tissues, and spread to distant tissues is a major goal of cancer research, as it will determine whether clinicians will be able to design more effective therapies for different cancers. Although much has been learned, much remains to be learned. The following summarizes our current knowledge about metastasis: 1. Cancer is the result of transformation of single cells. 2. Transformed cells are less stable and have an increased rate of spontaneous mutation than non-metastatic cells of similar origin. 3. Cells within a tumor are heterogeneous in biological characteristics. 4. The metastatic process is selective for highly malignant cells from within the heterogeneous tumor. 5. The metastatic process is a complex sequence of events with an outcome dependent on both tumor cell and host properties. 6. By the time of diagnosis, many primary solid tumors are biologically heterogeneous and have disseminated to regional or distant sites. 7. By the time of initial diagnosis, metastases in some state of development are thought to exist in approximately 50% of patients. 8. Cancer metastasis is the major cause of treatment failure and mortality in individuals with malignant tumors. The complexity and diversity of human cancer, in conjunction with the complexity and diversity of human beings diagnosed with cancer presents a major challenge to oncology clinicians and researchers.