BACKGROUND: Pediatric cardiac care is costly and requires extensive resources. We studied the effect of clinical pathways on practice patterns and patient care outcomes in infants and children hospitalized for cardiac surgery. METHODS: In consecutive patients admitted for selected cardiac surgical procedures before (n = 69) and after (n = 173) implementation of clinical pathways, outcomes including hospital length of stay, days in the ICU, time to extubation, ordering of blood studies, costs, and readmissions were compared. Data were analyzed for each of five cardiac surgical procedures: repair of an atrial septal defect, repair of a ventricular septal defect, division of a patent ductus arteriosus, repair of tetralogy of Fallot, and neonatal arterial switch operation to correct transposition of the great arteries. RESULTS: A significant reduction in length of hospital stay, including days in the ICU (decreased 1 to 2 days per admission), was achieved after the clinical pathway was implemented. Reductions in average duration of mechanical ventilation ranged from 28% for repair of a ventricular septal defect to 63% for repair of tetralogy of Fallot. The number of blood studies ordered decreased 20% to 30%. A significant reduction in hospital costs for each procedure, ranging from 16% to 29%, was also achieved with no adverse effects on patients' outcomes. CONCLUSIONS: Use of clinical pathways with children hospitalized for cardiac surgery can shorten length of stay in the hospital, reduce use of resources, and improve cost-effectiveness with beneficial outcomes for patients.
While the ultimate goal of discharge planning is discharge from the hospital, many steps come between admission and discharge of the head-injured patient. This article outlines those steps.
The results of such physiologic and pathologic anatomic studies enable us to learn more of functional alterations which give rise to important physical consequences. All this subject must be interpreted clinically by a study of the venous pulse. Most of the work must be done with instruments applied to the peripheral veins; some, perhaps, by sounds in the esophagus giving curves of the left auricle. But it is important to remember that at present we are not yet able to interpret all the waves seen. It is indispensable to have precise clinical investigations, such as Dr. Grosh has done so well, worked out carefully by so careful and experienced a physiologist as Cushny and confirmed by the master mind of Mackenzie. When we consider the immense impetus given to the study of Adams-Stokes disease by the investigations of Erlanger, we can be encouraged in the hope that even more intricate clinical problems, and much more common ones, will in time be solved.Dr. Arthur Hirsciifelder, Baltimore, said that the essayists' interpretation of the C waves differs considerably from the interpretation Mackenzie placed on them in his recent communication, basing them on the very curves mentioned.The latter writer ascribes the C waves entirely to the carotid. It is interesting that Grosh and Cushny corroborate the observations of Morrow and Bard of Geneva and of himself in contradiction of Mackenzie. The V waves are very often
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