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.

Simplified captopril renography in diagnosis and treatment of renal artery stenosis.

To improve the diagnosis and forecast the response to surgery or renal angioplasty in patients with hypertension and renal artery stenosis, we employed a simplified captopril renography protocol in conjunction with renal arteriography in 94 clinically selected patients. Fifty hypertensive patients (group 1) with a high clinical likelihood of renovascular hypertension were evaluated using a simplified captopril renography protocol and renal angiography on the arterial side. Criteria for normal captopril renal scintigrams were established based on this original cohort and validated in an additional 44 clinically comparable patients (group 2). Renal revascularization or nephrectomy was performed in 39 patients, and success of the procedure was determined in the 34 patients for whom 3-month follow-up was available. In the 94 patients, 44 (47%) had renal artery stenosis. Simplified captopril renography was 91% sensitive and 94% specific in identifying or excluding renal artery stenosis in the combined group, with no difference in the diagnostic utility between groups 1 and 2, or in those with renal insufficiency (n = 38) or those with bilateral disease (n = 17). Scintigraphic abnormalities induced by captopril were strongly associated with cure or improvement in blood pressure control following revascularization or nephrectomy (15 of 18), while the lack of captopril-induced changes was associated with failure of such intervention (13 of 16) (p = 0.0004). We conclude that simplified captopril renography is highly sensitive and specific in the diagnosis of renal artery stenosis in a clinically selected high-risk population and that the test accurately predicts the success or failure of therapeutic intervention.

Patients at high risk for renal artery stenosis: a simple method of renal scintigraphic analysis with Tc-99m DTPA and captopril.

Fifty patients with suspected renal artery stenosis (RAS) were studied with renal scintigraphy before and after administration of captopril. Twenty-three patients had RAS (greater than or equal to 75% RAS or greater than or equal to 50% RAS with poststenotic dilatation) and 27 had normal renal arteries at angiography. Angiotensin-converting enzyme inhibitors were discontinued 24 hours prior to renal scintigraphy; all other medications were continued. Each patient was evaluated with a simplified captopril renal scintigraphic protocol: renal imaging after administration of 12 mCi (444 MBq) of technetium-99m diethylenetriaminepentaacetic acid (DTPA), a 3-hour wait, oral administration of 50 mg of captopril, a 1-hour wait, and another scintigram obtained after administration of 12 mCi (444 MBq) of Tc-99m DTPA. Times of peak renal activity (Tmax) were determined from renal time-activity curves, and glomerular filtration rates (GFRs) were calculated with the Gates technique. A Tmax greater than or equal to 11 minutes after injection or a GFR ratio (larger GFR/smaller GFR) greater than 1.5 enabled detection of RAS with 91% sensitivity, 93% specificity, and 92% accuracy. Renal scintigraphy without captopril had only 43%-68% sensitivity in detecting RAS, depending on the criteria used.