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Historically, negative clinical and economic outcomes have been associated with patients who need long-term mechanical ventilation. Institutions and clinicians charged with the care of these patients are understandably interested in exploring clinical strategies that assure positive outcomes. This article describes the evidence base for clinical pathways, weaning teams, protocols, and care-managed approaches. In addition, the article describes how different elements of system initiatives designed for a university teaching hospital and a community hospital were implemented and evaluated. The systematic approaches encourage multidisciplinary input and decrease variation, thus improving both quality and cost.

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Improving the long-term outcome of the cardiac patient presenting to the emergency depart¬ ment with myocardial infarction was an undertaking that the Cardiovascular Services CPI Team of Dominican Hospital chose as a key initiative in 1995. Through selective planning, and the collaborative efforts of physicians and staff of the emergency department and car¬ diovascular services, we have successfully streamlined the transport time of the patient from the initial emergency department presentation to cardiac catheterization laboratory delivery to an average of approximately 58 minutes.Address reprint requests to: