Schoenenberger R A, Pearson S D, Goldhaber S Z, Lee T H
Section for Clinical Epidemiology, Harvard Community Health Plan, Brigham and Women's Hospital, Boston, Massachusetts, USA.
Am J Med. 1996 Mar;100(3):278-82. doi: 10.1016/S0002-9343(97)89485-5.
To evaluate the potential impact of a practice guideline in the form of a critical pathway on variation and quality of care in patients with deep vein thrombosis (DVT).
Goals were identified for key steps and processes that were believed to be important for meeting a length-of-stay (LOS) goal of 5.5 days, and for improving quality of care for patients with DVT. Data collected via chart review were used to determine the percentage o patients with uncomplicated DVT admitted in the year after October 1, 1992, whose management would have met these goals.
Only 11 (12%) of 92 eligible patients with a primary discharge diagnosis of DVT met the LOS goal. In 30%, the activated partial thromboplastin time (aPTT) was >60 seconds within a target of 12 hours after admission. The goals for the initiation of warfarin (within 12 hours after aPTT >60 seconds) and the achievement of a therapeutic international normalized ratio (INR) level (within 120 hours) were met in 51% and 58% of patients, respectively. The target duration of intravenous heparin therapy was achieved in 78% of patients. Only 18% of patients, however, were discharged within 12 hours after 96 hours of heparin therapy had been given and a therapeutic INR had been achieved.
These data demonstrate considerable variation in management of uncomplicated DVT at a single hospital, suggesting that a critical pathway could have impact on both LOS and quality of care.
评估以关键路径形式呈现的实践指南对深静脉血栓形成（DVT）患者护理差异及质量的潜在影响。
确定了关键步骤和流程的目标，这些步骤和流程被认为对于实现5.5天的住院时长（LOS）目标以及改善DVT患者的护理质量至关重要。通过病历审查收集的数据用于确定1992年10月1日之后入院的无并发症DVT患者中，其治疗管理符合这些目标的患者百分比。
92例以DVT为主要出院诊断的合格患者中，只有11例（12%）达到了住院时长目标。30%的患者在入院后12小时内活化部分凝血活酶时间（aPTT）>60秒，这在目标范围内。分别有51%和58%的患者达到了华法林起始治疗（aPTT>60秒后12小时内）和达到治疗性国际标准化比值（INR）水平（120小时内）的目标。78%的患者达到了静脉注射肝素治疗的目标时长。然而，只有18%的患者在接受96小时肝素治疗且达到治疗性INR后12小时内出院。
这些数据表明，一家医院在无并发症DVT的治疗管理方面存在相当大的差异，这表明关键路径可能对住院时长和护理质量都有影响。
