重症急性胰腺炎临床路径探讨

临床路径作为一种规范化的医疗管理模式,应用于临床已30年,其意义在于维持或改进医疗品质的基础上缩短住院日数、减少医疗费用.就某种疾病而言,大多数病人可以施行临床路径,少部分则须用个案管理来处理.重症急性胰腺炙是普通外科常见的严重急腹症,该疾病病情凶险,复杂多变,治疗过程中个体化差异较大,故在临床工作中,应结合病人实际情...     

甲状腺疾病手术治疗临床路径探讨

临床路径是近年来发展起来一种规范医疗服务的单病种质量管理现代新模式。中国医科大学附属第一医院血管甲状腺外科目前已尝试应用医护版临床路径表和病人版临床路径告知单以及临床路径流程图等工具对拟行甲状腺疾病手术治疗的病人进行管理。临床路径的实施能较好地规范医疗行为,在一定程度上缩短了平均住院日,降低了医疗费用,提高了病人满意度,有利于促进医护间的相互协作,实现了医疗质量持续改进。临床路径的构建应与最佳诊疗方案相结合, 需通过不断改进使其逐渐优化。     

临床护理路径在子宫肌瘤手术病人中的应用研究

目的:探讨临床路径在子宫肌瘤病人中的应用.方法:将96例病人随机分为对熙组和实验组,对照组俺常规医疗护理方法处理,实验组按预先制定好的临床护理路径进行护理.结果:实验纽病人的医疗护理质量明显提高,术前病人心里状况良好,平均住院日和医疗费用明显降低,护理满意度也明显增加,与对照组比较均有统计学意义.结论:在子宫肌瘤手术病人中应用临床护理路径可缩短平均住院目、降低医疗成本、同时能提高护理服务质量,提升病人的满意度,是病人获得更佳的医疗护理服务.     

临床路径在胆囊摘除术围术期护理中的应用

临床路径是对某种疾病的大多数病人最有效和最有效率的照顾流程的护理规范，是一种高品质、高效率、低成本的医疗护理服务模式。我院自2006年3月至2007年10月应用临床路径为106例胆囊摘除术病人实施围术期护理，取得良好效果。现报告如下：     

临床路径在血液科的实施体会

探讨应用临床路径对血液疾病患者的实施效果.通过对患者的宣教、建立管理标准的临床路径规程,规范医疗秩序,降低医疗费用和住院天数,提升了医疗质量和患者满意率.因此,临床路径对促进医疗资源的合理利用、提高医院的竞争力具有十分重要的意义.     

乳腺癌围手术期中西医结合临床路径实施分析

目的评估乳腺癌围手术期临床路径实施对住院日、住院费用及医疗质量的影响。方法制订乳腺癌围手术期中西医结合临床路径表,选择2004-2005年可手术的乳腺癌病人167例随机分为2组,临床路径组83例按路径表实施诊疗过程,对照组84例按传统方法完成治疗;同时筛选2003年符合临床路径纳入标准的病人74例,作为前后对照组,比较3组间的治疗效果。结果实施临床路径可降低住院费用(P<0.05),缩短住院天数(P<0.01),且3组间各项医疗质量指标均无差异(P>0.05)。结论乳腺癌临床路径可降低住院费用,缩短住院天数,确保医疗质量,值得推广应用。     

甲状腺肿瘤手术病人实施临床路径管理探讨

目的探讨甲状腺肿瘤手术病人临床路径的应用效果。方法将120例甲状腺肿瘤手术病人分为两组,各60例。对照组采用传统的医疗护理方法,观察组实施临床路径的医疗护理。结果观察组等候手术时间、住院日较对照组短,平均住院费用较对照组低(均P<0.01);病人满意度及健康知识掌握率较对照组高(均P<0.05)。结论实施临床路径,可增加医院服务人次,减轻病人负担,提高医院的社会效益和经济效益。     

临床路径在社区早期糖尿病肾病患者的应用评价

目的：评价应用临床路径在社区早期糖尿病患者诊疗过程中的实用性、可操作性及效益,为规范基层早期糖尿病肾病患者的诊疗,合理控制医疗费用提供借鉴。方法：对住院的早期2型糖尿病肾病患者进行分组,经社区转入住院接受临床路径者作为实验组（n=30）,同期住院的同种疾病住院未接受临床路径者作为对照组（n=30）。实验组患者均接受相同的临床路径实施方法,并进行严格质量控制。对两组患者的临床疗效、住院天数、再住院率、住院医疗总费用、分项费用,病人满意率,进行比较。结果：实验组与对照组患者平均住院天数、再住院率、住院医疗总费用间均有统计学差异（P〈0.05）;实验组与对照组患者住院除治疗费间无统计学差异外,在化验费、检查费、西药费、床位费间均有统计学差异（P〈0.05）。结论：早期糖尿病肾病患者在住院天数、再住院率、住院医疗总费用方面及在分项费用上,实验组患者明显低于对照组,说明临床路径在社区糖尿病及高血压病诊疗中有一定积极意义。     

临床路径在心脏瓣膜置换术后ICU管理中的应用

目的评价临床路径在心脏瓣膜置换病人术后重症监护病房(intensivecareunit,ICU)实施的效果。方法回顾性分析了南京市心血管病研究所实施临床路径前(1999年,Ⅰ组)和实施临床路径后(2004年,Ⅱ组)择期心脏瓣膜置换术后在ICU监护治疗的病人各70例。比较两组病人在术后机械通气时间、血气分析次数、ICU停留时间、ICU期间费用及并发症等方面差异有无显著性。结果Ⅱ组在平均机械通气时间、血气分析检查次数、ICU停留时间、ICU期间费用等方面低于Ⅰ组(P<0.05),并发症发生率两组间差异无显著性(P>0.05)。结论心脏瓣膜置换病人术后ICU临床路径的实施降低了ICU停留时间和医疗费用,同时保证了医疗质量。     

临床护理路径在脊柱损伤救治护理中的应用研究

目的:探讨临床护理路径( CNP)在脊柱损伤救治护理中的应用价值.方法:建立脊柱损伤救治的临床护理路径并对60例患者实施.结果:应用临床护理路径实施救治护理的患者急诊医疗护理的质量明显提高,患者的生存率提高,并发症减少,患者及家属对相关疾病知识及急救技能掌握程度有所提高,对护理质量的满意度显著提高.结论:通过实施临床快捷护理路径,为患者赢得了宝贵的救治时间,提高了综合医院的急救能力,提高了抢救效率,使病人及家属的满意度明显提高.     

Clinical pathways. A useful steering instrument or a limitation for medical treatment?

Clinical pathways can be used to organize the optimal sequence for medical procedures. This process is patient centered and developed through the collaborative work of the participating medical specialties. The goals of clinical pathways are facilitation of outcomes, reduction of variance in patient care and cost containment. Clinical pathways can be used for patient information, internal and external transparency and in total quality management. The management of medical organisations can be supported by introducing the data from clinical pathways into prospective clinical and financial control.     

Klinische Pfade

Clinical pathways can be used to organize the optimal sequence for medical procedures. This process is patient centered and developed through the collaborative work of the participating medical specialties. The goals of clinical pathways are facilitation of outcomes, reduction of variance in patient care and cost containment. Clinical pathways can be used for patient information, internal and external transparency and in total quality management. The management of medical organisations can be supported by introducing the data from clinical pathways into prospective clinical and financial control.     

Safety improvement through implementation of clinical pathways

In Japan the clinical path (or critical path) is attracting attention as a tool for the improvement of healthcare in terms of optimization of informed consent, development of a team approach in healthcare, transformation of the healthcare system into a patient-centered pattern, economizing on medical resources, etc. As clinical pathways can contribute to the reduction of medical errors and the early detection of abnormalities, they are also very effective in promoting patient safety. Important aspects of risk management include gathering and analyzing past incident reports and establishing countermeasures; they imply that each individual health professional, including each physician and nurse, improve their medical knowledge with regard to risk management and that health professionals improve their communication skills and share as much information as possible. In addition, it is imperative for risk management to standardize medical care, streamline the components of healthcare, and avoid unnecessary tests and treatment measures. Clinical pathways are remarkably useful for all of these goals. Another important consideration is the fact that patients and their relatives can promptly identify irregularities arising from deviations from clinical path stipulations. Clinical pathways are highly useful with regard to risk management.     

Clinical pathways. Implementation in a urological department

BACKGROUND: Clinical pathways are directions for standardised treatment processes for different diseases or procedures in a hospital. These pathways are developed within a team of several professions and are used as order and procedure sheets. Experiences with this element of quality management are limited in Germany. METHODS: The development and the implementation process of 15 pathways in a urological department are described. A clinical pathway for female incontinence surgery (suburethral tape) is presented as an example. The effects of the pathways are evaluated on a routine basis. RESULTS: Seventy-two percent of the patients were treated according to a clinical pathway. The advantages of clinical pathways are a better structuring and transparency of medical processes, a reduction of documentation, improvements in medical education and savings in time, hospital stay of the patients and costs. Expenses for pharmaceuticals were significantly reduced in connection with development of the pathways. CONCLUSIONS: The implementation of clinical pathways is a complex but rewarding project. It can be expected that clinical pathways will be rapidly distributed in the near future and that they will contribute to improvements of health care quality.     

Management of the 'normal' appendix during surgery for right fossa syndrome: proposed clinical algorithm

The management of the normal appearing appendix during laparoscopy for right fossa syndrome remains a matter of debate when no other cause is found. Recent data suggest that the appendix modulates both the normal brain-gut axis and the pathophysiology of inflammatory bowel disease by neuro-immunological pathways. Recurrence of symptoms caused by acute appendicitis is uncommon when the appendix is left in place. The decision to remove a normal appendix should therefore not be taken lightly, but after consideration of the patient's age, medical history and expectations as well as the timing and specificity of the presenting symptoms. An overview of the relevant literature is provided with an algorithm to aid in clinical decision making.     

Klinische Behandlungspfade

Background

Clinical pathways are directions for standardised treatment processes for different diseases or procedures in a hospital. These pathways are developed within a team of several professions and are used as order and procedure sheets. Experiences with this element of quality management are limited in Germany.

Methods

The development and the implementation process of 15 pathways in a urological department are described. A clinical pathway for female incontinence surgery (suburethral tape) is presented as an example. The effects of the pathways are evaluated on a routine basis.

Results

Seventy-two percent of the patients were treated according to a clinical pathway. The advantages of clinical pathways are a better structuring and transparency of medical processes, a reduction of documentation, improvements in medical education and savings in time, hospital stay of the patients and costs. Expenses for pharmaceuticals were significantly reduced in connection with development of the pathways.

Conclusions

The implementation of clinical pathways is a complex but rewarding project. It can be expected that clinical pathways will be rapidly distributed in the near future and that they will contribute to improvements of health care quality.     

Emergency medicine tomorrow

Emergency medical services (EMS) systems represent and important part within our health care system. However rapidly changing basic conditions define the need to reconsider current structures and objectives of the German EMS system and to implement appropriate modifications. The steadily decreasing number of emergency physicians advises to delegate more and more "technical" duties to paramedic personnel. In contrast the mobile intensive care unit will be reserved to cases in which complex treatment strategies or decisions have to be undertaken (i.e. thrombolysis). Moreover, the emergency physician's role will deeply expand beyond individual medical assistance. The most urgent duties Medical Advisers for Emergency Services will have to comply with are: 1. to develop plans of action and guidelines for paramedic personnel and 2. to secure a consistently high level of emergency medical care. As a consequence of ongoing structural reforms in the German Health Care System (ie. the implementation of diagnosis related groups, DRGs) emergency medicine will break down with traditional EMS structures. In contrast emergency medical departments of large hospitals will be reorganized to deliver both prehospital and in-hospital emergency medical care ("Centers of excellence"). Devoted to comply with clinical pathways this concept will improve medical efficacy as well as economic efficiency. The breakdown of traditional social structures as well as the increasing number of psychosocial emergencies constitute a major challenge to out EMS system. As it is not suitable to strictly differentiate medical from social emergencies we urgently need to establish integrated psychosocial networks. For a long period of time the role of the emergency physician has been restricted to the stabilisation of disturbed vital functions. To assure the competitiveness of the German EMS system it will be indispensible to expand our scope of practice. As anesthetists we should not hesitate to take over our new position as "managers in acute care medicine".     

Rational management of transient obstructive hydrocephalus secondary to a cerebellar infarct.

INTRODUCTION: Cerebrovascular disease is a common occurrence in adults with immediate as well as long-term neurological effects. Sequelae are disabling for patients and lead to a greater demand for healthcare infrastructure and search for treatment options. The acute phase in a cerebellar infarction may become complicated with transient obstructive hydrocephalus, subsequent intracranial hypertension, and the need for surgical management. Although many patients respond well to medical treatment, clinical findings and neuroimaging methods must be considered to determine whether the hydrocephalus can be surgically treated in a timely fashion. A series of cases is presented and a proposal is made for adding endoscopic third ventriculostomy to the available treatment armamentarium. CLINICAL CASES: Fourteen patients with cerebellar strokes and their clinical course are reported. Six required surgery for hydrocephalus management. Three of the cases had an endoscopic third ventriculostomy without complications, the rest were managed conservatively. As an average, patency was re-established in the aqueduct three months post ictus. CONCLUSIONS: Management of obstructive hydrocephalus in the acute phase of a cerebellar stroke must be individualized. In cases with transient obstructive hydrocephalus, endoscopic third ventriculostomy is a good surgical treatment option that avoids the risks of a long-term ventricular shunt.     

Transurethral microwave thermotherapy: what role should it play versus medical management in the treatment of benign prostatic hyperplasia?

Both transurethral microwave thermotherapy (TUMT) and medical management by alpha-blockade or 5-alpha-reductase inhibition are increasingly being considered as alternatives to surgery for treatment of patients with benign prostatic hyperplasia (BPH). We review current evidence supporting the effectiveness and safety of TUMT and medical management. Factors for consideration in appropriately selecting patients for TUMT versus medical management are suggested. Available data indicate that TUMT confers greater long-term benefits than medical management as judged by symptom score and peak urinary flow rate improvements. TUMT-associated morbidity is comparatively low. Alpha-blockade affords more rapid relief than TUMT for patients with BPH; however, other strategies such as the use of temporary intraurethral endoprostheses during the acute post-TUMT recovery period may diminish or abolish the differences in time-course of symptom and flow rate improvement between TUMT and alpha-blockade. 5-Alpha-reductase inhibition with finasteride offers a favorable side-effect profile, although the magnitude of symptom and flow rate improvements is modest, and maximal effects of finasteride do not become manifest until after several months of treatment. As TUMT continues to evolve, increasing attention is being accorded the delivery of high thermal doses and precise targeting of the thermal energy delivered. The development of alpha-blockers with a more favorable side-effect profile continues to be a major focus of investigation. The potential clinical utility of combination therapy with TUMT and alpha-blockade is currently under investigation.