The integrated care pathway reduced the number of hospital days by half: a prospective comparative study of patients with acute hip fracture

BACKGROUND: The incidence of hip fracture is expected to increase during the coming years, demanding greater resources and improved effectiveness on this group of patients. The aim of the present study was to evaluate the effectiveness of an integrated care pathway (ICP) in patients with an acute fracture of the hip. METHODS: A nonrandomized prospective study comparing a consecutive series of patients treated by the conventional pathway to a newer intervention. 112 independently living patients aged 65 years or older admitted to the hospital with a hip fracture were consecutively selected. Exclusion criteria were pathological fracture and severe cognitive impairment. An ICP was developed with the intention of creating a care path with rapid pre-operative attention, increased continuity and an accelerated training programme based on the individual patient's prerequisites and was used as a guidance for each patient's tailored care in the intervention group (N = 56) The main outcome measure was the length of hospital stay. Secondary outcomes were the amount of time from the emergency room to the ward, to surgery and to first ambulation, as well as in-hospital complications and 30-day readmission rate. RESULTS: The intervention group had a significantly shorter length of hospital stay (12.2 vs. 26.3 days; p < 0.000), a shorter time to first ambulation (41 vs. 49 h; p = 0.01), fewer pressure wounds (8 vs. 19; p = 0.02) and medical complications (5 vs. 14; p = 0.003) than the comparison group. No readmissions occurred within 30 days post-intervention in either group. CONCLUSION: Implementing an ICP for patients with a hip fracture was found to significantly reduce the length of hospital stay and improve the quality of care

Effects of continuous versus bolus infusion of enteral nutrition in critical patients Efeitos da administração contínua versus intermitente da nutrição enteral em pacientes críticos

PURPOSE: Enteral alimentation is the preferred modality of support in critical patients who have acceptable digestive function and are unable to eat orally, but the advantages of continuous versus intermittent administration are surrounded by controversy. With the purpose of identifying the benefits and complications of each technique, a prospective controlled study with matched subjects was conducted. PATIENTS AND METHODS: Twenty-eight consecutive candidates for enteral feeding were divided into 2 groups (n = 14 each) that were matched for diagnosis and APACHE II score. A commercial immune-stimulating polymeric diet was administered via nasogastric tube by electronic pump in the proportion of 25 kcal/kg/day, either as a 1-hour bolus every 3 hours (Group I), or continuously for 24 hours (Group II), over a 3-day period. Anthropometrics, biochemical measurements, recording of administered drugs and other therapies, thorax X-ray, measurement of abdominal circumference, monitoring of gastric residue, and clinical and nutritional assessments were performed at least once daily. The principal measured outcomes of this protocol were frequency of abdominal distention and pulmonary aspiration, and efficacy in supplying the desired amount of nutrients. RESULTS: Nearly half of the total population (46.4%) exhibited high gastric residues on at least 1 occasion, but only 1 confirmed episode of pulmonary aspiration occurred (3.6%). Both groups displayed a moderate number of complications, without differences. Food input during the first day was greater in Group II (approximately 20% difference), but by the third day, both groups displayed similarly small deficits in total furnished volume of about 10%, when compared with the prescribed diet. CONCLUSIONS: Both administration modalities permitted practical and effective administration of the diet with frequent registered abnormalities but few clinically significant problems. The two groups were similar in this regard, without statistical differences, probably because of meticulous technique, careful monitoring, strict patient matching, and conservative amounts of diet employed in both situations. Further studies with additional populations, diagnostic groups, and dietetic prescriptions should be performed in order to elucidate the differences between these commonly used feeding modalities.<br>ANTECEDENTES: A alimentação enteral é a modalidade preferida de suporte em pacientes graves com função digestiva aceitável porém incapazes de se alimentar por via oral, entretanto as vantagens da oferta contínua em contraste com a intermitente são rodeadas de controvérsias. Tendo como objetivo identificar os benefícios e as complicações destas técnicas, realizou-se um estudo prospectivo e controlado com casos pareados. PACIENTES E MÉTODOS: Vinte e oito pacientes consecutivos candidatos a alimentação enteral foram divididos em dois Grupos (n= 14), pareados segundo diagnóstico e índice APACHE II.Uma dieta polimérica comercial imuno-estimulante foi administrada por sonda nasogástrica e bomba de infusão na proporção de 25 kcal/kg/dia, em forma de bolo por uma hora a cada três horas (Grupo I), ou continuamente nas 24 horas (Grupo II), durante três dias. Os métodos incluiram antropometria, dosagens bioquímicas, registro de uso de drogas e outras terapêuticas, RX de tórax, circunferência abdominal, resíduo gástrico, e avaliação clínica e nutricional, efetuada no mínimo uma vez por dia. Os principais desfechos colimados neste estudo foram frequência de distensão abdominal e aspiração pulmonar, e capacidade de atingir a meta calórica pretendida. RESULTADOS: Quase metade da população total (46,4%) apresentou resíduos gástricos elevados em pelo menos uma ocasião, porém somente foi registrado um episódio confirmado de aspiração pulmonar (3,6%). Ambos os grupos padeceram de um número moderado de complicações, sem diferenças. O ganho de dieta no Grupo II foi maior no primeiro dia, porém no terceiro dia ambos os grupos exibiam déficits pequenos e semelhantes no ganho dietético, quando comparados com o volume prescrito. CONCLUSÕES: Ambas as modalidades de oferta permitiram a administração prática e eficiente da dieta, com freqüentes anormalidades registradas porém escassas complicações clinicamente significativas. Os dois grupos se comportaram analogamente, com poucas diferenças nos resultados, provavelmente devido à técnica meticulosa, monitorização cuidadosa, rígido pareamento dos pacientes, e volumes modestos da dieta empregados nas duas circunstâncias. Investigações subseqüentes deveriam ser elaboradas com populações, grupos diagnósticos e prescrições dietéticas adicionais, a fim de elucidar as diferenças entre estas modalidades de alimentação comumente usadas