Clinical Pathways
Outlines:
Introduction
Definition
Importance of clinical pathway
Components of clinical pathway
Criteria of clinical pathway
Limitation of clinical pathway
Potential problems and barriers to the
introduction of ICPs
Example of implementation of clinical pathway.
Introduction
The clinical pathway concept appeared for the first time at the
New England Medical Center (Boston, United States) in 1985,
inspired by Karen Zander and Kathleen Bower [non-primary
source needed] Clinical pathways appeared as a result of the
adaptation of the documents used in industrial quality
management, the standard operating procedures (SOPs),
whose goals are:
Improve efficiency in the use of resources.
Finish work in a set time.
Definition
Evidence-based multidisciplinary management plan, which
identifies the appropriate sequence of clinical interventions,
timeframes, milestones and expected outcomes for a
homogenous patient group. (Quality Improvement and
Enhancement Program, Clinical Pathways Board: 2002).
Importance of clinical pathway
support the implementation of evidence-based practice
improve clinical processes by reducing risk
reduce duplication through the use of a standardized tool
reduce variation in health service process delivery
Components of Clinical Pathway.
Clinical Pathways have four main components (Hill, 1994, Hill
1998): a timeline, the categories of care or activities and their
interventions, intermediate and long term outcome criteria, and
the variance record (to allow deviations to be documented and
analyzed).
1. Timeline: pre admission, admission, procedure, post-op ,
discharge.
2. Categories of care: medical intervention, assessment,
tests, activities, medications& treatment, nutrition &
fluids, teaching, discharge plan, tubes& monitoring,
outcomes ( Physician , nurse).
3. Intermediate and long term outcome criteria:
assessment, diagnostics, laboratory, patient / family
education.
4. Variance record: look for common variance, improve
pathway, improve compliance.
Criteria of clinical pathway
The following five criteria were derived from the three
sentinel articles mentioned above:
(1) The intervention was a structured multidisciplinary plan of
care.
(2) The intervention was used to channel the translation of
guidelines or evidence into local structures.
(3) The intervention detailed the steps in a course of treatment
or care in a plan, pathway, algorithm, guideline, protocol or
other 'inventory of actions.
(4) The intervention had timeframes or criteria-based
progression (that is, steps were taken if designated criteria were
met)
(5) the intervention aimed to standardize care for a specific
clinical problem, procedure or episode of healthcare in a specific
population.
Selection criteria
The following signals may indicate that it may be useful to
commit resources to establish and implement a clinical
pathway for a particular condition:
Prevalent pathology within the care setting
Pathology with a significant risk for patients
Pathology with a high cost for the hospital
Predictable clinical course
Pathology well defined and that permits homogeneous care
Existence of recommendations of good practices or experts
opinions
Unexplained variability of care
Possibility of obtaining professional agreement
Multidisciplinary implementation
Motivation by professionals to work on a specific condition
Limitation of clinical pathway.
1) Implementation of the care pathways has not been tested in
scientific or controlled fashion.
2) Not controlled study has shown critical pathway to
reduced length of study, decrease resource use , or
improve patient satisfaction
3) Most importantly, no controlled study has shown
improvement in patient outcome.
4) The recommend is often lacking misleading or
misinterpreted may be misleading because of design flaws
which contribute to bias or poor generalizability.
5) The recommendation may be wrong or at least wrong for
individual patient apart from human consideration such as
in advertent by busy or weary.
Potential problems and barriers to the introduction of
ICPs
May appear to discourage personalized care
Risk increasing litigation
Don't respond well to unexpected changes in a patient's
condition
Suit standard conditions better than unusual or
unpredictable ones
Require commitment from staff and establishment of an
adequate organizational structure
Problems of introduction of new technology
May take time to be accepted in the workplace
Need to ensure variance and outcomes are properly
recorded, audited and acted upon.
Example of implementation of clinical pathway
Day 2 Day 3 Day 4,5,6 Day 7
Assess for Assess for Assess Assess
ogist complication complicati patient complication
patient Inform on complicati before
f not yet patient, Refer to on Discharge
relatives of general Prepare reinforce
possible ward patient for patient
MB 2ND discharge to ECG home D7 education
H hour home by day 2nd Echo Educate and insure
7 if no major for day 6/ on life through
complication if not yet Style knowledge
olytics ECG fating changes Of
ipids next lipid profil ordered
Off Off continuing
Hourly vital telemetry telemetry care and life
ain if in VT signs if yet style
ne in pain continuous if fit
Off 6 adjustment
ECG hourly 2nd Echo
vital signs monitorig
uous ECG blood appointment
ring pressure as out
monitorin patient if not
g already done
Discharge if
fit outpatient
follow up in
5-6 weaks
Day 4,5,6 Day 7
Assess patient Assess complication
complication before
Prepare patient for Discharge reinforce
home D7 patient education
Educate on life and insure through
Style changes knowledge
Off telemetry if yet Of continuing care
and life style
adjustment
2nd Echo
appointment as out
patient if not already
done
Discharge if fit
outpatient follow up
in 5-6 weaks
Nursing role in clinical pathway:
1_nurse should participate in setting clinical pathway related to
certain procedure or disease
2_ nurse must be aware about printed guidelines related to
certain pathway
3_nurse must follow all interventions and instructions related to
certain pathway
4_nurse should report doctor about abnormal action that can
occur during care
5_Explain nursing procedures to the patient
6_Educate patient about nutrition, medication , warning
symptoms that must be reported to nurse or doctor if occurred
References:
Vanhaecht ., Bollmann M., Bower K., Gallagher C., Gardini
A.& Parella M. (2005) Result of the European pathway
association international survey.
Antioch K., Chapman R., Elliott B., Santa maria N.,
Crawford R. & Fiddes K. (2001) Cost effective clinical
pathway at the Alferd hospital.
arawn@gbhs.on.ca
