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Clinical pathways for the high-risk patient
Clinical Pathways for the High-Risk Patient John Butterworth, MD The goal of managed health care is to reduce health care costs while maintaining or improving the quality of care given to patients. Clinical pathways, which outline the services and therapies planned for a typical patient admitted with a specific diagnosis, may provide a way to control costs and improve patient outcome. These pathways are under development by medical centers and managed-care organizations nationwide, with the aim of planning, managing, documenting, and evaluating multidisciplinary care. A coordinated care plan can take a number of approaches. Time lines identify predictable clinical landmarks and time intervals for a specific medical episode or illness within a given diagnostic-related group or set of diagnostic-related groups. Case-management plans and case managers coordinate a
patient's care throughout an episode, eg, an operation, enabling patients to reach defined time points in the course of their care at the expected time. Critical pathways are the favored method of documenting the patient's progress according to the predicted time schedule. This report discusses ways to successfully implement a care plan, highlighting the commitment and effort needed from a multidisciplinary staff to achieve the goal of optimizing efficiency and quality of patient care.
R
centers and managed-care organizations nationwide, with the aim of planning, managing, documenting, and evaluating multidisciplinary care. The most common techniques outlined in the administrative and nursing literature in the last few years are (I) time lines, (2) case-management plans, and (3) critical paths.
E IMBURSEM ENT for medical care has come under intense downward pressure as the United States has moved from a fee-far-service reimbursement system to the various cost-containment schemes now lumped together under managed health care. The entrance of market forces into the health care arena and an oversupply of providers introduce the commercial concept of outsourcing into medicine. Physicians and nurses do not like thinking of themselves as workers on a factory line; nevertheless, much like assembly-line workers, physicians and nurses are now expected to increase their productivity.' Often, in the hospital, as on the assembly line, unnecessary variability must be eliminated to increase productivity. Amazingly, higher patient satisfaction and improved outcome can result, even as per-patient expenditures and lengths of hospital stay decline.? In a study of Medicare patients undergoing coronary artery bypass graft (CABO) surgery, so-called routine care (those items related merely to the patient's housing in the hospital) accounted for nearly 21% of charges," Substantial cost-savings can result from earlier hospital discharge (provided that earlier discharge does not produce commensurate increases in outpatient costs or lead to expensive complications). Many factors influence length of hospital stay, and hence, expenditure." Important considerations, not often investigated or reported in the medical literature, relate to relatively simple things such as patients' nutritional status, physical fitness, and mental health and attitude; in other words, their ability to get up and about and to eat a relatively normal diet. Pain and other stressors will negatively influence this, whereas support offamily and friends can encourage the patient to want to leave the hospital. Clinical pathways, which outline the services and therapies planned for a typical patient admitted with a specific diagnosis, may provide a way to control costs and improve patient outcome. These pathways are under development by medical
From the Department of Anesthesiology, Bowman Gray School of Medicine, Winston-Salem, N'C, Address reprint requests to John Butterworth, MD, Associate Professor of Anesthesia, Vice Chairman for Research. Bowman Gray School of Medicine, Wake Forest Medical Center Blvd, Winston-Salem, NC 27157. Copyright © 1997 by W:B. Saunders Company 1053-0770/97/1102-1004$3.00/0
16
Copyright© 1997 by WS. Saunders Company KEY WORDS: critical pathways, care plan, coronary artery bypass surgery
TIME LINES
Time lines identify predictable clinical landmarks and time intervals for a specific medical episode or illness. An important consideration in the development of time lines is to identify the key problems expected within a given diagnosis-related group (DRG) or set of DRGs. Expected outcomes must be identified, preferably using the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) categories: health, knowledge, activity/function, and absence of complications. The time-line approach is problematic from the viewpoint of staff involved in patient care, because it results in a document too complex and unwieldy to be attached to the patient's record or used for tracking variances. CASE MANAGEMENT
Acute-care case management coordinates a single patient's care throughout an episode, eg, an operation. Case managers monitor patient care to ensure that desired quality and cost outcomes of the patient's episode are met. They coordinate the services needed to enable patients to reach defined time points or landmarks in the course of their care at the expected time. An important role for the case manager is to intervene when significant variances are identified. For example, if anesthesiologists are not achieving the extubation target postoperatively or if total hip-replacement patients are consistently not mobilized by the desired time, these aggregate variances must be discussed and problems and solutions addressed with the entire care team. Opportunities to enhance patient outcome are thereby increased. Diplomacy is an essential quality for a successful case manager. CRITICAL PATHS
Critical paths are currently the favored way to deliver collaborative health care in hospitals and outpatient units. A critical path is "a standardized, prewritten one- or two-page document showing the interventions of all disciplines along a
Journal of Cardiothoracicand VascularAnesthesia, Vo111, No 2, Suppl1 (April), 1997: pp 16-18
CLINICAL PATHWAYS FOR THE HIGH-RISK PATIENT
time schedule. In effect, it is a grid, with time as one axis and staff actions as the other.'?' The document is intended for inclusion in the patient's medical records.
The Philosophy of Clinical Path The philosophies underlying clinical paths have their roots in industry, where quality control and the idea of measuring variances in results began and led to improved methods of diagnosing failures. The most famous student of this process was W.E. Deming, sent by the US government to Japan after World War II to help rebuild Japanese industry. Today, the most successful industrial manufacturers have developed process quality-control methods to produce reliable, quality products at minimal production costs. In addition, the successful manufacturer is committed to continually improving product quality and service. In principle, these ideas should be applicable to health care industries. Choosing the appropriate patient population is one of the first decisions in a clinical-path project. DRGs or ICD-9 codes that are high-cost and high-volume are obvious choices. However, in practical terms, it may be more effective to initially focus on DRGs with the greatest degree of homogeneity among patients. Successful outcome of the project is more likely if the patient population has similar pathophysiology, and the common problems and complications are identifiable and relatively uniform across the group. The DRG chosen should be recognized as having the opportunity for quality improvement. Success will not occur without effective leadership. To start, cohesive groups with good communication should be chosen, leaving the more difficult groups for when situations/personalities may have changed or after greater experience with the clinical-path program has been obtained.
Getting the Program Off the Ground Developing a care plan for a given set of patients requires a certain amount of trust on the part of all participants. There has to be a consensus that optimizing the efficiency and quality of care is the goal, not breathing new life into some outdated pet aspect of patient care. Participants on the steering committee should be respected members of their departments, because they will need to report to and from their own departments and elicit their colleagues' support for the program. They need not be the most senior (or junior) members, but they must have the authority to initiate changes. The committee must obtain assurance from the administration that supplies, data, printing, and other requirements will be available and appropriately funded. The project manager should be an individual who has the time to undertake the volume of work involved; generally, this will be a nurse whose time will be dedicated to the process. Committee meetings of reasonable length (less than I hour) should identify key problems and issues. The committee must have access to good, "unsanitized" data regarding patient costs, lengths of stay, and outcomes. In many cases, data previously off-limits to the clinical staff will have to be liberated from the accountants! Benchmark data from similar institutions that have achieved low costs and reduced lengths of stay are helpful in defining reasonable tnrgets.' Good data showing that adherence to the plan results in reduced costs and lengths of stay are
17
generally quite convincing, even to the most skeptical member of the team. Baseline data need to be collected quickly, with minimal advertisement. As soon as staff become aware that data are being collected, the baseline will shift. To track the plan's progress, the goals set for it need to be measurable. The main goals will be related to increased efficiency, improved quality, and improved patient satisfaction.
Implementing the Critical Path A draft pathway document will be produced and tried out on a few patients, with a limited number of staff involved. Choose those staff who are receptive to change; avoid those on the "lunatic fringe." This pilot phase will provide the experience necessary to revise the document, improving clarity, accuracy, and ease of use. All staff need to be educated as to the objectives of the project and the correct use of the path document. Documentation then can be applied to all patients, and variances can be tracked as part of the quality-improvement plan. The chart or care map can also form part of the nursing documentation.
Do Collaborative Approaches to Health Care Produce Promised Results? Evidence that a planned program of treatment for a specific group of patients could reduce length of hospital stay was collected in the 1980s and published before care paths were devised. Krohn et al6 reported an accelerated recovery program for cardiac surgery patients, a central feature of which was prevention or early treatment of noncardiac complications. Peri operative management included teaching the patients what to expect and what to do after the operation so they could participate in the recovery process. Patients were extubated as soon as possible and encouraged to get out of bed on the night of the operation. Food intake (whatever patients could or would swallow) was started as soon after extubation as possible; therapeutic diets were withheld until appetite improved. The median length of stay for 240 patients after operation was 4 days; 39 patients were discharged on the third day. Krohn et al's success in achieving earlier discharge of their patients probably also related to their direct participation in all postoperative treatment and discharge decisions. This sort of personal involvement in patient care by a referring cardiologist cannot often be practiced in teaching hospitals, where residents require varying degrees of autonomy as part of their education. However, their achievements were made by having a set of goals for this group of patients and then tracking the variances of the results, the exact methods now being adopted with the critical-path approach. Engelman et al? followed up the accelerated recovery program of Krohn et al with a "fast-track" protocol, which enabled approximately half of the patients to be discharged home safely 3 to 5 days after cardiac surgery, yielding significant costsavings. Similar data have been reported by member institutions of the University HealthSystem Consortium." A clinical practice guideline (CPG) to reduce length of stay and lower patient charges after atrial septal defect repair was introduced at Children's Hospital (Boston, MA) in 1992. R Introduction of the new guidelines lowered hospital charges by
JOHN F. 8UTIERWORTH
18
27% and reduced length of stay from 5.1 to 3.5 days. Tracheal extubation in the operating room was part of the CPG, and a retrospective review of the data found savings of $500 per patient from lower mechanical ventilation charges. Early extubation per se had no effect on length of hospital stay, again indicating the importance of the process over anyone particular clinical landmark event.
Clinical Pathway Variances Early identification of variances from expected outcomes in individual patients permits timely intervention. However, patterns of variances in the selected patient population (particularly when patient characteristics associated with variances can be identified) may prompt improvements in the clinical path. Variances charted and included in the medical record provide a structure for the change-of-shift reporting, identify those patients progressing as expected along the clinical path, and identify those who need assistance to reach the expected benchmarks; this will be useful in discharge planning. Periodic meetings with the multidisciplinary team will need to deal with negative variance patterns. Of particular concern will be high-impact variances such as postoperative wound infections that can adversely affect length of stay and increase costs significantly. Clinical pathways can become untracked for many reasons." Two of the main reasons are lack of involvement by the clinicians and poor or inefficient use of the data collected. Lengthy and too frequent meetings of the committee can be detrimental to the smooth running of a clinical path.
The Legal Perspective There is concern among some practitioners about legal issues associated with the use of clinical pathways. One advantage of the introduction of care plans is the increased tendency for communication between patients and providers. Patients know what to expect, when discharge is likely, and what problems, if any, to anticipate. They thus have more realistic expectations in relation to their hospital stays. Communication among staff is also improved, an expected outcome of regular attendance at meetings with colleagues. This improved patient education and the more detailed documentation of the care plan, plus analysis of variances as they arise, may in practice have benefits in relation to legal liability. Nevertheless, undocumented and apparently unnecessary deviations from the standard pathway that lead to complications may prove difficult to defend. CONCLUSION
Clinical pathways are here to stay because they make it easier to define optimal clinical practices. They document all clinical interactions with patients, an advance that may transform the patient medical record into a more useful document. And they hold practitioners accountable for patient outcomes, good or bad. The greatest hurdle impeding the success of clinical pathways may be the lack of full participation of the hospital administration. To use care paths to their fullest advantage, administrators must be prepared to share accounting and outcome data, data that are released only grudgingly in most hospitals.
REFERENCES 1. AndersG: Requiredsurgery: Healthplans forcesharp cutsin costs
even at top-ranked teaching hospitals. Wall St J 1994 Mar 8; sect A:1(col. I), Mar 8,1994 2. Trubo R: If this is cookbook medicine, you may like it. Med Bcon 22:69-82; 1993 3. The AdvisoryBoardCompany: Aggressivebypasssurgeryrecovery: Decreasing pcstoperative length of stay, in Cardiology Preeminence Roundtable, Reducing Bypass SurgeryCosts, vol 1. Washington, DC, AdvisoryBoard Company, 1993, p 199 4. Zander K: ManagingOutcomes ThroughCollaborative Care: The Application of Care Mapping and Case Management. Chicago, IL, American HospitalPublishing, 1995 5. University HealthSystem Consortium Services Corporation: The
1995CoronaryArteryBypass Graft (CABG):Clinical ProcessImprovement/Benchmarking Database Report. Oak Brook, IL, University HealthSystem ConsortiumServicesCorp (Report2, March 1), 1995 6. Krohn BO, Kay JH, Mendez MA, et al: Rapid sustained recovery after cardiac operations.J Thorac CardiovascSurg 100:194-197, 1990 7. EngelmanRM, Rousou JA, FlackIE, et al: Fast-track recovery of the coronarybypasspatient. Ann ThoracSurg 58:1742-1746, 1994 8. Laussen PC, Reid RW, Stene RA, et al: Tracheal extubation of childrenin the operatingroomafter atrialseptaldefect repair as part of a clinicalpractice guideline.AnesthAnalg82:988-993,1996 9. Musfeldt C: A clinical look at critical pathways. Healthcarc InformaticsFeb:44-48, 1995
patient's care throughout an episode, eg, an operation, enabling patients to reach defined time points in the course of their care at the expected time. Critical pathways are the favored method of documenting the patient's progress according to the predicted time schedule. This report discusses ways to successfully implement a care plan, highlighting the commitment and effort needed from a multidisciplinary staff to achieve the goal of optimizing efficiency and quality of patient care.
R
centers and managed-care organizations nationwide, with the aim of planning, managing, documenting, and evaluating multidisciplinary care. The most common techniques outlined in the administrative and nursing literature in the last few years are (I) time lines, (2) case-management plans, and (3) critical paths.
E IMBURSEM ENT for medical care has come under intense downward pressure as the United States has moved from a fee-far-service reimbursement system to the various cost-containment schemes now lumped together under managed health care. The entrance of market forces into the health care arena and an oversupply of providers introduce the commercial concept of outsourcing into medicine. Physicians and nurses do not like thinking of themselves as workers on a factory line; nevertheless, much like assembly-line workers, physicians and nurses are now expected to increase their productivity.' Often, in the hospital, as on the assembly line, unnecessary variability must be eliminated to increase productivity. Amazingly, higher patient satisfaction and improved outcome can result, even as per-patient expenditures and lengths of hospital stay decline.? In a study of Medicare patients undergoing coronary artery bypass graft (CABO) surgery, so-called routine care (those items related merely to the patient's housing in the hospital) accounted for nearly 21% of charges," Substantial cost-savings can result from earlier hospital discharge (provided that earlier discharge does not produce commensurate increases in outpatient costs or lead to expensive complications). Many factors influence length of hospital stay, and hence, expenditure." Important considerations, not often investigated or reported in the medical literature, relate to relatively simple things such as patients' nutritional status, physical fitness, and mental health and attitude; in other words, their ability to get up and about and to eat a relatively normal diet. Pain and other stressors will negatively influence this, whereas support offamily and friends can encourage the patient to want to leave the hospital. Clinical pathways, which outline the services and therapies planned for a typical patient admitted with a specific diagnosis, may provide a way to control costs and improve patient outcome. These pathways are under development by medical
From the Department of Anesthesiology, Bowman Gray School of Medicine, Winston-Salem, N'C, Address reprint requests to John Butterworth, MD, Associate Professor of Anesthesia, Vice Chairman for Research. Bowman Gray School of Medicine, Wake Forest Medical Center Blvd, Winston-Salem, NC 27157. Copyright © 1997 by W:B. Saunders Company 1053-0770/97/1102-1004$3.00/0
16
Copyright© 1997 by WS. Saunders Company KEY WORDS: critical pathways, care plan, coronary artery bypass surgery
TIME LINES
Time lines identify predictable clinical landmarks and time intervals for a specific medical episode or illness. An important consideration in the development of time lines is to identify the key problems expected within a given diagnosis-related group (DRG) or set of DRGs. Expected outcomes must be identified, preferably using the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) categories: health, knowledge, activity/function, and absence of complications. The time-line approach is problematic from the viewpoint of staff involved in patient care, because it results in a document too complex and unwieldy to be attached to the patient's record or used for tracking variances. CASE MANAGEMENT
Acute-care case management coordinates a single patient's care throughout an episode, eg, an operation. Case managers monitor patient care to ensure that desired quality and cost outcomes of the patient's episode are met. They coordinate the services needed to enable patients to reach defined time points or landmarks in the course of their care at the expected time. An important role for the case manager is to intervene when significant variances are identified. For example, if anesthesiologists are not achieving the extubation target postoperatively or if total hip-replacement patients are consistently not mobilized by the desired time, these aggregate variances must be discussed and problems and solutions addressed with the entire care team. Opportunities to enhance patient outcome are thereby increased. Diplomacy is an essential quality for a successful case manager. CRITICAL PATHS
Critical paths are currently the favored way to deliver collaborative health care in hospitals and outpatient units. A critical path is "a standardized, prewritten one- or two-page document showing the interventions of all disciplines along a
Journal of Cardiothoracicand VascularAnesthesia, Vo111, No 2, Suppl1 (April), 1997: pp 16-18
CLINICAL PATHWAYS FOR THE HIGH-RISK PATIENT
time schedule. In effect, it is a grid, with time as one axis and staff actions as the other.'?' The document is intended for inclusion in the patient's medical records.
The Philosophy of Clinical Path The philosophies underlying clinical paths have their roots in industry, where quality control and the idea of measuring variances in results began and led to improved methods of diagnosing failures. The most famous student of this process was W.E. Deming, sent by the US government to Japan after World War II to help rebuild Japanese industry. Today, the most successful industrial manufacturers have developed process quality-control methods to produce reliable, quality products at minimal production costs. In addition, the successful manufacturer is committed to continually improving product quality and service. In principle, these ideas should be applicable to health care industries. Choosing the appropriate patient population is one of the first decisions in a clinical-path project. DRGs or ICD-9 codes that are high-cost and high-volume are obvious choices. However, in practical terms, it may be more effective to initially focus on DRGs with the greatest degree of homogeneity among patients. Successful outcome of the project is more likely if the patient population has similar pathophysiology, and the common problems and complications are identifiable and relatively uniform across the group. The DRG chosen should be recognized as having the opportunity for quality improvement. Success will not occur without effective leadership. To start, cohesive groups with good communication should be chosen, leaving the more difficult groups for when situations/personalities may have changed or after greater experience with the clinical-path program has been obtained.
Getting the Program Off the Ground Developing a care plan for a given set of patients requires a certain amount of trust on the part of all participants. There has to be a consensus that optimizing the efficiency and quality of care is the goal, not breathing new life into some outdated pet aspect of patient care. Participants on the steering committee should be respected members of their departments, because they will need to report to and from their own departments and elicit their colleagues' support for the program. They need not be the most senior (or junior) members, but they must have the authority to initiate changes. The committee must obtain assurance from the administration that supplies, data, printing, and other requirements will be available and appropriately funded. The project manager should be an individual who has the time to undertake the volume of work involved; generally, this will be a nurse whose time will be dedicated to the process. Committee meetings of reasonable length (less than I hour) should identify key problems and issues. The committee must have access to good, "unsanitized" data regarding patient costs, lengths of stay, and outcomes. In many cases, data previously off-limits to the clinical staff will have to be liberated from the accountants! Benchmark data from similar institutions that have achieved low costs and reduced lengths of stay are helpful in defining reasonable tnrgets.' Good data showing that adherence to the plan results in reduced costs and lengths of stay are
17
generally quite convincing, even to the most skeptical member of the team. Baseline data need to be collected quickly, with minimal advertisement. As soon as staff become aware that data are being collected, the baseline will shift. To track the plan's progress, the goals set for it need to be measurable. The main goals will be related to increased efficiency, improved quality, and improved patient satisfaction.
Implementing the Critical Path A draft pathway document will be produced and tried out on a few patients, with a limited number of staff involved. Choose those staff who are receptive to change; avoid those on the "lunatic fringe." This pilot phase will provide the experience necessary to revise the document, improving clarity, accuracy, and ease of use. All staff need to be educated as to the objectives of the project and the correct use of the path document. Documentation then can be applied to all patients, and variances can be tracked as part of the quality-improvement plan. The chart or care map can also form part of the nursing documentation.
Do Collaborative Approaches to Health Care Produce Promised Results? Evidence that a planned program of treatment for a specific group of patients could reduce length of hospital stay was collected in the 1980s and published before care paths were devised. Krohn et al6 reported an accelerated recovery program for cardiac surgery patients, a central feature of which was prevention or early treatment of noncardiac complications. Peri operative management included teaching the patients what to expect and what to do after the operation so they could participate in the recovery process. Patients were extubated as soon as possible and encouraged to get out of bed on the night of the operation. Food intake (whatever patients could or would swallow) was started as soon after extubation as possible; therapeutic diets were withheld until appetite improved. The median length of stay for 240 patients after operation was 4 days; 39 patients were discharged on the third day. Krohn et al's success in achieving earlier discharge of their patients probably also related to their direct participation in all postoperative treatment and discharge decisions. This sort of personal involvement in patient care by a referring cardiologist cannot often be practiced in teaching hospitals, where residents require varying degrees of autonomy as part of their education. However, their achievements were made by having a set of goals for this group of patients and then tracking the variances of the results, the exact methods now being adopted with the critical-path approach. Engelman et al? followed up the accelerated recovery program of Krohn et al with a "fast-track" protocol, which enabled approximately half of the patients to be discharged home safely 3 to 5 days after cardiac surgery, yielding significant costsavings. Similar data have been reported by member institutions of the University HealthSystem Consortium." A clinical practice guideline (CPG) to reduce length of stay and lower patient charges after atrial septal defect repair was introduced at Children's Hospital (Boston, MA) in 1992. R Introduction of the new guidelines lowered hospital charges by
JOHN F. 8UTIERWORTH
18
27% and reduced length of stay from 5.1 to 3.5 days. Tracheal extubation in the operating room was part of the CPG, and a retrospective review of the data found savings of $500 per patient from lower mechanical ventilation charges. Early extubation per se had no effect on length of hospital stay, again indicating the importance of the process over anyone particular clinical landmark event.
Clinical Pathway Variances Early identification of variances from expected outcomes in individual patients permits timely intervention. However, patterns of variances in the selected patient population (particularly when patient characteristics associated with variances can be identified) may prompt improvements in the clinical path. Variances charted and included in the medical record provide a structure for the change-of-shift reporting, identify those patients progressing as expected along the clinical path, and identify those who need assistance to reach the expected benchmarks; this will be useful in discharge planning. Periodic meetings with the multidisciplinary team will need to deal with negative variance patterns. Of particular concern will be high-impact variances such as postoperative wound infections that can adversely affect length of stay and increase costs significantly. Clinical pathways can become untracked for many reasons." Two of the main reasons are lack of involvement by the clinicians and poor or inefficient use of the data collected. Lengthy and too frequent meetings of the committee can be detrimental to the smooth running of a clinical path.
The Legal Perspective There is concern among some practitioners about legal issues associated with the use of clinical pathways. One advantage of the introduction of care plans is the increased tendency for communication between patients and providers. Patients know what to expect, when discharge is likely, and what problems, if any, to anticipate. They thus have more realistic expectations in relation to their hospital stays. Communication among staff is also improved, an expected outcome of regular attendance at meetings with colleagues. This improved patient education and the more detailed documentation of the care plan, plus analysis of variances as they arise, may in practice have benefits in relation to legal liability. Nevertheless, undocumented and apparently unnecessary deviations from the standard pathway that lead to complications may prove difficult to defend. CONCLUSION
Clinical pathways are here to stay because they make it easier to define optimal clinical practices. They document all clinical interactions with patients, an advance that may transform the patient medical record into a more useful document. And they hold practitioners accountable for patient outcomes, good or bad. The greatest hurdle impeding the success of clinical pathways may be the lack of full participation of the hospital administration. To use care paths to their fullest advantage, administrators must be prepared to share accounting and outcome data, data that are released only grudgingly in most hospitals.
REFERENCES 1. AndersG: Requiredsurgery: Healthplans forcesharp cutsin costs
even at top-ranked teaching hospitals. Wall St J 1994 Mar 8; sect A:1(col. I), Mar 8,1994 2. Trubo R: If this is cookbook medicine, you may like it. Med Bcon 22:69-82; 1993 3. The AdvisoryBoardCompany: Aggressivebypasssurgeryrecovery: Decreasing pcstoperative length of stay, in Cardiology Preeminence Roundtable, Reducing Bypass SurgeryCosts, vol 1. Washington, DC, AdvisoryBoard Company, 1993, p 199 4. Zander K: ManagingOutcomes ThroughCollaborative Care: The Application of Care Mapping and Case Management. Chicago, IL, American HospitalPublishing, 1995 5. University HealthSystem Consortium Services Corporation: The
1995CoronaryArteryBypass Graft (CABG):Clinical ProcessImprovement/Benchmarking Database Report. Oak Brook, IL, University HealthSystem ConsortiumServicesCorp (Report2, March 1), 1995 6. Krohn BO, Kay JH, Mendez MA, et al: Rapid sustained recovery after cardiac operations.J Thorac CardiovascSurg 100:194-197, 1990 7. EngelmanRM, Rousou JA, FlackIE, et al: Fast-track recovery of the coronarybypasspatient. Ann ThoracSurg 58:1742-1746, 1994 8. Laussen PC, Reid RW, Stene RA, et al: Tracheal extubation of childrenin the operatingroomafter atrialseptaldefect repair as part of a clinicalpractice guideline.AnesthAnalg82:988-993,1996 9. Musfeldt C: A clinical look at critical pathways. Healthcarc InformaticsFeb:44-48, 1995