How to Use Lean Thinking for the Optimization of Clinical Pathways: A Systematic Review and a Proposed Framework to Analyze Pathways on a System Level.

Lean Thinking and clinical pathways are commonly used concepts to improve healthcare. However, little is known on how to use Lean Thinking for the optimization of pathways or the quantification of both concepts. This study aims to create a framework to analyze pathways with Lean Thinking on a system level, by quantifying the seven wastes, flow and pull. A systematic literature review was performed. Inclusion criteria were the focus of the article on a well-defined group of patients and studied a pathway optimization with Lean Thinking. Data were extracted on measured outcomes, type of intervention and type of researched pathway. Thirty-six articles were included. No articles described the implementation of the Lean Thinking philosophy or studied the development of their people and partners ("4 P" model). Most articles used process optimization tools or problem-solving tools. The majority of the studies focused on process measures. The measures found in the review were used as input for our suggested framework to identify and quantify wastes, flow, and pull in a clinical pathway. The proposed framework can be used to create an overview of the improvement potential of a pathway or to analyze the level of improvement after an enhancement is introduced to a pathway. Further research is needed to study the use of the suggested quantifications.

Appointing 'trained donation practitioners' results in a higher family consent rate in the Netherlands: a multicenter study.

The consent process for organ and tissue donation is complex, both for families and professionals. To help professionals in broaching this subject we performed a multicenter study. We compared family consent to donation in three hospitals between December 2007 and December 2009. In the intervention hospital, trained donation practitioners (TDP) guided 66 families throughout the time in the ICU until a decision regarding donation had been reached. In the first control hospital, without any family guidance or training, 107 families were approached. In the second control hospital 'hostesses', who were not trained in donation questions, supported 99 families during admittance. A total of 272 families were requested to donate. We primarily compared consent rates, but also asked families about their experiences through a questionnaire. Family consent rate was significantly higher in the intervention hospital: 57.6% (38/66), than in the control hospitals: 34.6% (37/107) and 39.4% (39/99). The 69% response rate to the questionnaire -~5 months after death - showed no confounding variables that could have influenced the consent rate. Appointing TDPs in the intervention hospital to guide families during admittance and the donation decision-making process, results in higher family consent rates.

Malnutrition in hospitalised neurological patients approximately doubles in 10 days of hospitalisation.

AIMS AND OBJECTIVES: To measure the nutritional status of neurological patients during admission and after 10 days, with a special focus on those with malnutrition and those at risk of malnutrition, and to measure the association of clinical variables and nutritional status, which may be important for the early detection of patients at risk of malnutrition. BACKGROUND: Studies have shown high prevalence of malnutrition in hospitalised patients and recommend structured screening and nutritional intervention for these patients. There is a lack of information concerning the nutritional status of neurological patients. DESIGN: A prospective descriptive study. METHOD: Neurological patients (n = 196) were included from departments of neurology and neurosurgery in Dutch university hospital. Nutritional status was measured with the Mini Nutritional Assessment and functional status with the Barthel Index and the Rankin Scale at admission to the hospital and after 10 days. RESULT: Of the patients, 34% were at risk of malnutrition, 7% were malnourished, whereas 59% of the patients were well nourished according to the MNA. After 10 days, 57% were at risk of malnutrition, 22% were malnourished and 21% were well nourished. The total group of patients malnourished and at risk of malnutrition was 41% at admission, which had grown to 79% in 10 days. Significant association was found between various clinical variables and nutritional status. CONCLUSIONS: A large group of neurological patients is malnourished and at risk of malnutrition during hospital admission, and the nutritional status of most patients worsens in 10 days. Various clinical variables may be of importance in detecting malnourished patients. RELEVANCE TO CLINICAL PRACTICE: Nurses need to observe the symptoms of malnutrition and provide evidence-based nutritional interventions to these patients. Improved education of nurses and good collaboration between the professionals and the facilitation of hospital management is essential to improve nutritional care of neurological patients.

Malnutrition and risk of malnutrition in patients with stroke: prevalence during hospital stay.

BACKGROUND: Although various studies have shown high prevalence of malnutrition in hospitalized patients with stroke, recent studies on how the nutritional status of patients with acute stroke develops during the first weeks of hospital stay are scarce. Information is lacking concerning the identification of patients with stroke who are at risk of malnutrition during an acute hospital stay, because these patients may have a significant chance to improve their nutritional status. PURPOSE: This study aimed to investigate the prevalence of malnutrition and risk of malnutrition of patients with acute stroke during the first 10 days of hospitalization. METHODS: A prospective, descriptive study was conducted in a neurological department of a university hospital in The Netherlands. Seventy-three patients with acute stroke were included, of which 23 patients could be followed up after 10 days. The nutritional status was determined with the Mini Nutritional Assessment at admission and after 10 days. RESULTS: At admission, 5% of the patients (n = 73) were malnourished, 14% were at risk of malnutrition, and 81% were well nourished. Of the patients who could be followed up (n = 23), at admission, no patients were malnourished, 9% were at risk of malnutrition, and 91% were well nourished; whereas 10 days later, 26% of these patients were malnourished, 39% were at risk of malnutrition, and 35% were well nourished. This means that, within the followed-up group, the proportion of patients with malnutrition or risk of malnutrition increased significantly during hospital stay from 9% to 65%. CONCLUSIONS: Our study shows that the prevalence of malnutrition and risk of malnutrition in patients with acute stroke increases strongly during the first 10 days of admission. Therefore, screening of the nutritional status of these patients throughout this period is highly recommended to enable timely nutritional intervention and nutritional management of these patients.