Clinical pathway for pneumonia: development, implementation, and initial experience.

BACKGROUND: As part of a large multidisciplinary project to reduce cost, decrease hospital length of stay, and improve efficiency of patient care at Saint Mary's Hospital, a clinical pathway for pneumonia was developed and implemented. METHODS: After using analysis of severity-adjusted data to determine which conditions would be best targets for improvement, a utilization management steering committee created a multidisciplinary group to develop a clinical pathway for pneumonia. This group was led by physician champions and consisted of representatives from nursing, respiratory therapy, pharmacy, and home healthcare. With information gained from chart abstraction, which identified "best practice" patterns, guidance from the medical literature, and local expertise, this group developed a clinical pathway that included an auxiliary protocol for respiratory care and a detailed educational brochure for patients. Before implementing the clinical pathway, extensive educational activities were undertaken involving the medical staff, house staff, nurses, and other staff. Data collected on consecutive patients discharged after implementation of the pathway were compared with data collected on patients discharged before the pathway in 1994. RESULTS: For DRG 89, the patients who were on the pathway in comparison to the control patients from 1994 had a lower average length of stay by 1.45 days (5.84 vs. 7.29 days) and a lower average total charge by $1,453 ($9,511 vs. $10,964). For DRG 90, the patients who were on the pathway in comparison to the control patients from 1994 had a lower average length of stay by 1.83 days (3.45 vs. 5.28 days) and a lower average total charge by $1319 ($5450 vs. $6769). CONCLUSIONS: The pneumonia clinical pathway that was implemented was associated with reductions in the length of stay and total charges. These reductions were seen in relationship to historical controls and to patients cared for concurrently who were not placed on the pathway. Although not fully used on all pneumonia patients, the presence of the pathway probably had some positive effects even on patients not formally on the pathway, through systems changes and educational influences. The pathway also positively influenced other conditions by the use of ancillary algorithms for conditions other than pneumonia, and the more rapid administration of antibiotics for other infectious diseases. Also, lessons learned in the creation of this first pathway have been helpful in streamlining the process of future pathway development.

Management considerations for the granuloma of pregnancy.

The epulis gravidarum, or granuloma of pregnancy, represents a vascular lesion observed during gravidism. While histologic features may mimic those of generic pyogenic granulomas, the management may differ. Remarkably, the plastic surgical literature is conspicuously void of information concerning this common entity, with approximately 40 new cases being diagnosed and treated annually at our institution. With a review of the literature, we offer four typical and representative case reports that serve to highlight the pertinent physiology and treatment options. Guidelines are proposed to assist in the management of this disease process.

The Cincinnati initiative.

Nationwide, purchaser coalitions are forming to use their buying clout to reform the delivery of health care. In Cincinnati, a collaborative effort between purchasers and providers is producing profound changes in the local health care market. After the first year in operation, data show a significant overall decrease in length of stay (LOS), a return to single-digit inflation, and intriguing changes in provider practice patterns. These results have been achieved through voluntary hospital and physician practice pattern changes without additional contractual allowances, price controls, or utilization management imposed by the initiative. This article explores the development of the Cincinnati initiative, results to date, lessons learned, and future implications.

Using measurement and feedback to reduce health care costs and modify physician practice patterns.

Rising health care costs coupled with an inability to determine what constitutes value in the delivery of health care services lead a group of Cincinnati health care purchasers to seek answers and solutions. The formation of a collaborative effort that includes both purchasers and providers is producing profound changes in the Cincinnati health care market. After one year in operation, data show a significant overall decrease in length of stay, a return to single-digit inflation, and intriguing changes in provider practice patterns.

Detection of optic nerve lesions in optic neuritis using frequency-selective fat-saturation sequences.

MRI was performed on seven patients with acute optic neuritis, using two sequences which suppress the signal from orbital fat: frequency-selective fat-saturation and inversion recovery with a short inversion time. Lesions were seen on both sequences in all the symptomatic optic nerves studied.

Persistent cardiovascular effects with repeated caffeine administration.

Although habitual caffeine users ingest the drug repeatedly throughout each day, the persistence of caffeine's known cardiovascular effects with such repeated use has not been investigated. Blood pressure and heart rate were measured under resting conditions in 10 healthy, male coffee or tea drinkers for 2 hours following a pretreatment dose of caffeine (125 mg) on two separate days after overnight abstinence. Either a second caffeine dose or placebo was administered and measurements continued for 1.5 hours. Compared to placebo, the second dose of caffeine produced significant increases in heart rate and diastolic and mean arterial, but not systolic, blood pressures. The results suggest that the cardiovascular effects of caffeine may persist throughout the day with repeated administration of moderate amounts of caffeine. Habitual caffeine use does not necessarily lead to complete tolerance, which suggests that caffeine's cardiovascular effects could contribute to an increased risk of cardiovascular disease.