Clinical pathway

Not to be confused with clinical guideline.

Clinical pathways, also known as care pathways, critical pathways, integrated care pathways, or care maps, are one of the main tools used to manage the quality in healthcare concerning the standardization of care processes. It has been proven that their implementation reduces the variability in clinical practice and improves outcomes. Clinical pathways promote organized and efficient patient care based on the evidence based practice. Clinical pathways optimize outcomes in the acute care and homecare settings.

Generally clinical pathways refer to medical guidelines. However a single pathway may refer to guidelines on several topics in a well specified context.

Definition of Clinical Pathway

Multidisciplinary management tool based on evidence-based practice for a specific group of patients with a predictable clinical course, in which the different tasks (interventions) by the professionals involved in the patient care are defined, optimized and sequenced either by hour (ED), day (acute care) or visit (homecare). Outcomes are tied to specific interventions.

History

The clinical pathway concept appeared for the first time at the New England Medical Center (Boston, USA) in 1985 inspired by Karen Zander and Kathleen Bower. 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.

In April, 1991, VNA FIRST, in consultation with the Center for Case Management, Inc., South Natick, MA, developed the Home Health Care Map Tools (now called VNA FIRST Home Care Steps Protocols.)

In 2005, the telehealth clinical pathway was introduced to standardize telehealth visits and telephone calls in homecare.

Characteristics

Clinical pathways (integrated care pathways) can be seen as an application of process management thinking to the improvement of patient healthcare. An aim is to re-centre the focus on the patient's overall journey, rather than the contribution of each specialty or caring function independently. Instead, all are emphasised to be working together, in the same way as a cross-functional team.

More than just a guideline or a protocol, a care pathway is typically crystallised in the development and use of a single all-encompassing bedside document, that will stand as an indicator of the care a patient is likely to be provided in the course of the pathway going forward; and ultimately as a single unified legal record of the care the patient has received, and the progress of their condition, as the pathway has been undertaken.

The pathway design tries to capture the foreseeable actions which will most commonly represent best practice for most patients most of the time, and include prompts for them at the appropriate time in the pathway document to ascertain whether they have been carried out, and whether results have been as expected. In this way results are recorded, and important questions and actions are not overlooked. However, pathways are typically not prescriptive; the patient's journey is an individual one, and an important part of the purpose of the pathway documents is to capture information on "variances", where due to circumstances or clinical judgment different actions have been taken, or different results unfolded. The combined variances for a sufficiently large population of patients are then analysed to identify important or systematic features, which can be used to improve the next iteration of the pathway.

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 a 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

Examples

• Liverpool Care Pathway for the dying patient
• Depression in adults care map Map of Medicine, updated 30 July 2010

See also

• European Pathway Association (EPA)
• Evidence-based medicine
• Nursing care plan
• Case management
• Health economics

References

• History of Clinical Pathways
• Karen Zander and Kathleen Bower, Nursing Case Management, Blueprint for Transformation, 1987
• Ricard Rosique, "Care Pathways: The basics", Asian Hospital & Healthcare Management, 2008, Issue 17
• Virginia Maturen and Lisa Van Dyck, Home Health Care Management & Practice, Using Outcome-Based Critical Pathways to Improve Documentation, 1996
• Anthony Jerant and Rahman Azari, Home Health Care Services Quarterly, A Randomized Trial of Telenursing to Reduce Hospitalization for Heart Failure: Patient-Centered Outcomes and Nursing Indicators, 2003
• The Value of Clinical Pathways in Homecare Caring. 1997 Jun;16(6):42-4, 46.
• Meister, S.et al. Journal of Nursing Administration, Home Care Steps Protocols: Homecare's Answer to Changes in Reimbursement. 1995 Jun;25(6):33-42
• [1] (Indonesian)

External links

• European Pathway Association
• Belgian Dutch Clinical Pathway Network
• NHS Evidence Health Information Resources (UK)
• Map of Medicine
• About Integrated Care Pathways, NHS Protocols & Care Pathways Specialist Library (now discontinued). Version of 19 October 2007, via archive.org.
• [2] (Indonesian)