Defining pathways

Towards a New System for the Assessment of the Quality in Care Pathways: An Overview of Systematic Reviews

Clinical or care pathways are developed by a multidisciplinary team of healthcare practitioners, based on clinical evidence, and standardized processes. The evaluation of their framework/content quality is unclear. The aim of this study was to describe which tools and domains are able to critically evaluate the quality of clinical/care pathways. An overview of systematic reviews was conducted, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses, using Medline, Embase, Science Citation Index, PsychInfo, CINAHL, and Cochrane Library, from 2015 to 2020, and with snowballing methods. The quality of the reviews was assessed with Assessment the Methodology of Systematic Review (AMSTAR-2) and categorized with The Leuven Clinical Pathway Compass for the definition of the five domains: processes, service, clinical, team, and financial. We found nine reviews. Three achieved a high level of quality with AMSTAR-2. The areas classified according to The Leuven Clinical Pathway Compass were: 9.7% team multidisciplinary involvement, 13.2% clinical (morbidity/mortality), 44.3% process (continuity-clinical integration, transitional), 5.6% financial (length of stay), and 27.0% service (patient-/family-centered care). Overall, none of the 300 instruments retrieved could be considered a gold standard mainly because they did not cover all the critical pathway domains outlined by Leuven and Health Technology Assessment. This overview shows important insights for the definition of a multiprinciple framework of core domains for assessing the quality of pathways. The core domains should consider general critical aspects common to all pathways, but it is necessary to define specific domains for specific diseases, fast pathways, and adapting the tool to the cultural and organizational characteristics of the health system of each country.

Perinatal Resilience for the First 1,000 Days of Life. Concept Analysis and Delphi Survey

Background

The ability to cope with challenges and stress in life is generally understood as resilience. Pregnancy and parenthood are challenging times. The concept of resilience is receiving increasing interest from researchers, clinicians, and policy staff because of its potential impact on health, well-being, and quality of life. Nevertheless, the concept is less studied during the perinatal period.

Objectives

The aim of this study is to understand the concept of perinatal resilience, including the underlying processes and more specifically for the first 1,000 days of life.

Methods

A concept analysis according to the Walker and Avant (2011) framework was used, to investigate the basic elements of the concept. Concurrently, a two-round Delphi survey involving researchers, clinicians, epidemiologists, mothers, and fathers (N = 21), was conducted to prioritize the terms associated with perinatal resilience. Data collection took place between January and April 2019.

Results

Through concept analysis and Delphi survey, five defining attributes for perinatal resilience were identified: social support, self-efficacy, self-esteem, sense of mastery and personality. The additional terms, rated important by the Delphi survey, were linked to the consequences of being resilient during the perinatal period for the individual and his/her family. Specifically, highlighted were the experiences of families in personal growth and achieving family balance, adaptation, or acceptance.

Conclusion

Based on the results of the concept analysis and Delphi survey, we describe perinatal resilience for the first 1,000 days as a circular process towards a greater well-being in the form of personal growth, family balance, adaptation or acceptance, when faced with stressors, challenges or adversity during the perinatal period. The presence of resiliency attributes such as social support, sense of mastery, self-efficacy, and self-esteem enhance the capacity to be resilient and probably prevent mental health problems.

Effects of oncological care pathways in primary and secondary care on patient, professional and health systems outcomes: a systematic review and meta-analysis

BACKGROUND

Pathways are frequently used to improve care for cancer patients. However, there is little evidence about the effects of pathways used in oncological care. Therefore, we performed a systematic review and meta-analysis aiming to identify and synthesize existing literature on the effects of pathways in oncological care.

METHODS

All patients diagnosed with cancer in primary and secondary/tertiary care whose treatment can be characterized as the strategy "care pathways" are included in this review. A systematic search in seven databases was conducted to gather evidence. Studies were screened by two independent reviewers. Study outcomes regarding patients, professionals, and system level were extracted from each study.

RESULTS

Out of 13,847 search results, we selected 158 articles eligible for full text assessment. One hundred fifty studies were excluded and the remaining eight studies represented 4786 patients. Most studies were conducted in secondary/tertiary care. Length of stay (LOS) was the most common used indicator, and was reported in five studies. Meta-analysis based on subgroups showed an overall shorter LOS regarding gastric cancer (weighted mean difference (WMD)): - 2.75, CI: - 4.67 to - 0.83) and gynecological cancer (WMD: - 1.58, CI: - 2.10 to - 1.05). Costs were reported in six studies and most studies reported lower costs for pathway groups.

CONCLUSIONS

Despite the differences between the included studies, we were able to present an evidence base for cancer care pathways performed in secondary/tertiary care regarding the positive effects of LOS in favor of cancer care pathways.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017057592.

Optimal Care Pathways for People with Lung Cancer- a Scoping Review of the Literature

INTRODUCTION

Much of the existing work around implementation of cancer optimal care pathways (OCP) has either focused exclusively on the clinical elements of care or has targeted individual stages in the cancer trajectory, rather than using a patient-centred or service delivery lens to inform the integration of care across the continuum. This review aimed to identify and summarise the available literature on lung cancer OCP.

METHODS

A scoping review was conducted, with literature across multiple databases and grey literature searched. Articles were included if the OCP was being used to manage adult patients with lung cancer and reported on either the development process and outcomes and/or barriers and facilitators associated with optimal care pathway development and/or uptake.

RESULTS

Of the 381 references screened, 32 articles were included. The lung cancer pathways reviewed varied significantly. A number of themes were identified including the development and implementation of the OCP; the use of quality indicators to audit the OCP; and studies on outcomes of the OCP incorporating timeliness of care delivery, patient experiences and health care utilisation and costs.

CONCLUSIONS

The limited number of relevant articles found in this review may suggest that an OCP for lung cancer is still in its preliminary stages across the broader health systems.

Data-Driven Personalization of a Physiotherapy Care Pathway: Case Study of Posture Scanning

Background

Advanced sensor, measurement, and analytics technologies are enabling entirely new ways to deliver health care. The increased availability of digital data can be used for data-driven personalization of care. Data-driven personalization can complement expert-driven personalization by providing support for decision making or even by automating some parts of decision making in relation to the care process.

Objective

The aim of this study was to analyze how digital data acquired from posture scanning can enhance physiotherapy services and enable more personalized delivery of physiotherapy.

Methods

A case study was conducted with a company that designed a posture scan recording system (PSRS), which is an information system that can digitally record, measure, and report human movement for use in physiotherapy. Data were collected through interviews with different stakeholders, such as health care professionals, health care users, and the information system provider, and were analyzed thematically.

Results

Based on the results of our thematic analysis, we propose three different types of support that posture scanning data can provide to enhance and enable more personalized delivery of physiotherapy: 1) modeling the condition, in which the posture scanning data are used to detect and understand the health care user’s condition and the root cause of the possible pain; 2) visualization for shared understanding, in which the posture scanning data are used to provide information to the health care user and involve them in more collaborative decision-making regarding their care; and 3) evaluating the impact of the intervention, in which the posture scanning data are used to evaluate the care progress and impact of the intervention.

Conclusions

The adoption of digital tools in physiotherapy has remained low. Physiotherapy has also lacked digital tools and means to inform and involve the health care user in their care in a person-centered manner. In this study, we gathered insights from different stakeholders to provide understanding of how the availability of digital posture scanning data can enhance and enable personalized physiotherapy services.

Implementation of an easy in-hospital educational stoma pathway results in decrease of home nursing care services after discharge

AIM

New stoma patients often rely heavily on the assistance of the ward nursing staff during the hospital stay and on the availability of home nursing care services (HNCS) after discharge. An easily executable 4-day in-hospital educational stoma pathway was developed and implemented. The aim was to increase their level of independence (LOI) in order to reduce the need for HNCS after discharge.

METHOD

All new stoma patients on the gastrointestinal surgery ward, physically and psychologically capable of performing independent stoma care (SC), were enrolled in this pathway. They were compared to a retrospective control group of new stoma patients before the onset of the stoma pathway. The primary outcome is the need and frequency of HNCS for SC at the moment of discharge. Secondary outcome is the LOI in SC at discharge.

RESULTS

A total of 145 patients [m:f = 102:43, median age 67 (range 27-90) years] were included in the present study. Patients requiring daily HNCS for SC decreased from 80% to 50%, P < 0.001; patients discharged without HNCS for SC increased from 5% to 27%. Patients' independence in SC at discharge increased from 8% to 68%, P < 0.001.

CONCLUSION

This study shows that a clinical 4-day in-hospital educational stoma pathway is feasible and effective in increasing the LOI in SC of new stoma patients and significantly reducing their need for HNCS. Cost-benefit analysis and applicability of this pathway in multicentre settings are currently being investigated.

Exploring integrated supply chain performance in healthcare: a service provider perspective

Purpose

The paper identifies the antecedents and consequences of integrated supply chain performance (ISCP) in healthcare systems.

Design/methodology/approach

Based on a review of the literature constructs of supply chain flexibility (SCF), employee relationships (ERs), organizational orientation (OO) and knowledge exchange (KE) were identified as antecedents of ISCP, and patient centricity (PC) emerged as its consequence. This structural relationship was tested using partial least square structural equation modeling (PLS-SEM).

Findings

ERs, SCF, OO and KE positively impacted the performance of an integrated healthcare supply chain. Furthermore, enhanced ISCP in operational processes of the hospital positively influenced patient centeredness and care quality.

Research limitations/implications

Paper contributes by identifying antecedents and consequences of ISCP. Future researchers may explore the inter-relationships among the antecedents of ISCP.

Practical implications

Insights from this study will help practitioners in enhancing hospital operations by integrating processes along the healthcare service supply chain and developing a patient-centric approach.

Social implications

This paper highlights how PC may be achieved by focusing on a facilitative internal environment. This understanding may help in designing processes that deliver health as a social good in an effective manner.

Originality/value

The empirical evidence from this study can help hospitals integrate their functions, thus, enabling them to deliver quality care.

The effect of acute coronary syndrome care pathways on in-hospital patients: A systematic review

BACKGROUND

Health care institutions need to construct management strategies for patients diagnosed with acute coronary syndrome (ACS) that focus on evidence-based treatments, adherence to treatment guidelines, and organized care. These help to reduce variations as well as the mortality and morbidity rates, which indicates the critical need for standardized care and adherence to evidence-based practices for patients hospitalized with ACS. The care pathways translate research and guidelines into clinical practice to close the gap between the guidelines and the clinical practices.

OBJECTIVES

This review focuses on identifying the indicators used to evaluate ACS care pathways and their effect on the care process and clinical outcomes.

METHODS

This review follows the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. The systematic research was conducted using five research databases. Two groups were created by dividing the studies according to their year of publication. The first group included those studies published from 1997 to 2007 ("Group 1"), while the second included those published from 2008 to 2018 ("Group 2"). Selected studies were screened using the Effective Public Health Practice Project (EPHPP) quality assessment tool.

RESULTS

Seventeen studies were included in this review. One study was a randomized controlled trial, 14 were predesigns and postdesigns, and two were longitudinal observational designs. The Group 1 studies demonstrated that ACS care pathways had a positive effect on reducing the length of the hospital stay and the door-to-balloon times. Similar effects were observed for the Group 2 studies.

CONCLUSION

Implementing ACS care pathway helps to organize care processes and decrease treatment delays as well as improve the patient outcomes without adverse consequences for patients or additional resources and costs. While the current level of evidence is inadequate to warrant a formal recommendation, there is a need for more studies with an emphasis on well-designed randomization to measure patient outcomes.

Elderly patients with complex health problems in the care trajectory: a qualitative case study

BACKGROUND

Elderly patients with multiple health problems often experience disease complications and functional failure, resulting in a need for health care across different health care systems during care trajectory. The patients' perspective of the care trajectory has been insufficiently described, and thus there is a need for new insights and understanding. The study aims to explore how elderly patients with complex health problems engage in and interact with their care trajectory across different health care systems where several health care personnel are involved.

METHODS

The study had an explorative design with a qualitative multi-case approach. Eleven patients (n = 11) aged 65-91 years participated. Patients were recruited from two hospitals in Norway. Observations and repeated interviews were conducted during patients' hospital stays, discharge and after they returned to their homes. A thematic analysis method was undertaken.

RESULTS

Patients engaged and positioned themselves in the care trajectory according to three identified themes: 1) the patients constantly considered opportunities and alternatives for handling the different challenges and situations they faced; 2) patients searched for appropriate alliance partners to support them and 3) patients sometimes circumvented the health care initiation of planned steps and took different directions in their care trajectory.

CONCLUSIONS

The patients' considerations of their health care needs and adjustments to living arrangements are constant throughout care trajectories. These considerations are often long term, and the patient engagement in and management of their care trajectory is not associated with particular times or situations. Achieving consistency between the health care system and the patient's pace in the decision-making process may lead to a more appropriate level of health care in line with the patient's preferences and goals.

Sustainability of clinical pathway guided care in cardiac surgery ICU patients; 9-years experience in over 7500 patients

OBJECTIVE

To determine trends over time regarding inclusion of post-operative cardiac surgery intensive care unit (ICU) patients in a clinical pathway (CP), and the association with clinical outcome.

DESIGN

Retrospective cohort study.

SETTING

ICU of an academic hospital.

PARTICIPANTS

All cardiac surgery patients operated between 2007 and 2015.

MEASURES AND RESULTS

A total of 7553 patients were operated. Three patient groups were identified: patients treated according to CP (n = 6567), patients excluded from the CP within the first 48 h (n = 633) and patients never included in CP (n = 353). Patients treated according to CP increased significantly over time from 74% to 95% and the median Log EuroSCORE (predicted mortality score) in this group increased significantly over time (P = 0.016). In-hospital length of stay (LOS) decreased in all groups, but significantly in CP group (P < 0.001). Overall, the in-hospital, and 1-year mortality decreased from 1.5 to 1.1% and 3.7 to 2.9%, respectively (both P < 0.05). Patients with a Log EuroSCORE >10 were more likely excluded from CP (P < 0.001), but, if included in CP, these patients had a significantly shorter Intensive Care stay and in-hospital stay compared to excluded patients with a Log EuroSCORE >10 (both P < 0.001).

CONCLUSIONS

The use of a CP for all post-operative cardiac surgery patients in the ICU is sustainable. While more complex patients were treated according to the CP, clinical outcome improved in the CP group.

Towards standardisation of evidence-based clinical care process specifications

There is a strong push towards standardisation of treatment approaches, care processes and documentation of clinical practice. However, confusion persists regarding terminology and description of many clinical care process specifications which this research seeks to resolve by developing a taxonomic characterisation of clinical care process specifications. Literature on clinical care process specifications was analysed, creating the starting point for identifying common characteristics and how each is constructed and used in the clinical setting. A taxonomy for clinical care process specifications is presented. The De Bleser approach to limited clinical care process specifications characterisation was extended and each clinical care process specification is successfully characterised in terms of purpose, core elements and relationship to the other clinical care process specification types. A case study on the diagnosis and treatment of Type 2 Diabetes in the United Kingdom was used to evaluate the taxonomy and demonstrate how the characterisation framework applies. Standardising clinical care process specifications ensures that the format and content are consistent with expectations, can be read more quickly and high-quality information can be recorded about the patient. Standardisation also enables computer interpretability, which is important in integrating Learning Health Systems into the modern clinical environment. The approach presented allows terminologies for clinical care process specifications that were widely used interchangeably to be easily distinguished, thus, eliminating the existing confusion.

Quantification and visualisation methods of data-driven chronic care delivery pathways: protocol for a systematic review and content analysis

INTRODUCTION

Chronic conditions require long periods of care and often involve repeated interactions with multiple healthcare providers. Faced with increasing illness burden and costs, healthcare systems are currently working towards integrated care to streamline these interactions and improve efficiency. To support this, one promising resource is the information on routine care delivery stored in various electronic healthcare databases (EHD). In chronic conditions, care delivery pathways (CDPs) can be constructed by linking multiple data sources and extracting time-stamped healthcare utilisation events and other medical data related to individual or groups of patients over specific time periods; CDPs may provide insights into current practice and ways of improving it. Several methods have been proposed in recent years to quantify and visualise CDPs. We present the protocol for a systematic review aiming to describe the content and development of CDP methods, to derive common recommendations for CDP construction.

METHODS AND ANALYSIS

This protocol followed the Preferred Reporting Items for Systematic review and Meta-Analysis Protocols. A literature search will be performed in PubMed (MEDLINE), Scopus, IEEE, CINAHL and EMBASE, without date restrictions, to review published papers reporting data-driven chronic CDPs quantification and visualisation methods. We will describe them using several characteristics relevant for EHD use in long-term care, grouped into three domains: (1) clinical (what clinical information does the method use and how was it considered relevant?), (2) data science (what are the method's development and implementation characteristics?) and (3) behavioural (which behaviours and interactions does the method aim to promote among users and how?). Data extraction will be performed via deductive content analysis using previously defined characteristics and accompanied by an inductive analysis to identify and code additional relevant features. Results will be presented in descriptive format and used to compare current CDPs and generate recommendations for future CDP development initiatives.

ETHICS AND DISSEMINATION

Database searches will be initiated in May 2019. The review is expected to be completed by February 2020. Ethical approval is not required for this review. Results will be disseminated in peer-reviewed journals and conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42019140494.

The Care Process Organization Triangle: A Framework to Better Understand how Clinical Pathways Work

Clinical pathways, also known as care pathways or integrated care pathways, are used worldwide to make care processes transparent and organize care around patient needs. Although this is in international use, it is still unclear why pathways sometimes work and sometimes do not. To better understand how pathways work, there is a growing need for paradigms or organizing concepts. Different quality and health-care management gurus have developed frameworks to better understand how certain processes or methods work. This paper will provide an overview of several frameworks and integrate them into Donabedian's Structure–Process–Outcome configuration. In view of this configuration, the care process organization triangle was developed. In this paper, we will describe the three cornerstones of this triangle by integrating the literature on clinical pathways. The care process organization triangle is only one model, but as Deming described it: ‘Some models can be quite useful’.

Ischemic stroke: clinical pathway impact

PURPOSE

A clinical pathway for patients with acute ischemic stroke was implemented in 2014 by one Italian teaching hospital multidisciplinary team. The purpose of this paper is to determine whether this clinical pathway had a positive effect on patient management by comparing performance data.

DESIGN/METHODOLOGY/APPROACH

Volume, process and outcome indicators were analyzed in a pre-post retrospective observational study. Patients' (admitted in 2013 and 2015) medical records with International Classification of Diseases, ICD-9 code 433.x (precerebral artery occlusion and stenosis), 434.x (cerebral artery occlusion) and 435.x (transient cerebral ischemia) and registered correctly according to hospital guidelines were included.

FINDINGS

An increase context-sensitive in-patient numbers with more severe cerebrovascular events and an increase in patient transfers from the Stroke to Neurology Unit within three days (70 percent, p=0.25) were noted. Clinical pathway implementation led to an increase in patient flow from the Emergency Department to dedicated specialized wards such as the Stroke and Neurology Unit (23.7 percent, p<0.001). Results revealed no statistically significant decrease in readmission rates within 30 days (5.7 percent, p=0.85) and no statistically significant differences in 30-day mortality.

RESEARCH LIMITATIONS/IMPLICATIONS

The pre-post retrospective observational study design was considered suitable to evaluate likely changes in patient flow after clinical pathway implementation, even though this design comes with limitations, describing only associations between exposure and outcome.

ORIGINALITY/VALUE

Clinical pathway implementation showed an overall positive effect on patient management and service efficiency owing to the standardized application in time-dependent protocols and multidisciplinary/integrated care implementation, which improved all phases in acute ischemic stroke care.

Connolly Hospital Trauma Assessment Clinic (TAC): a virtual solution to patient flow

BACKGROUND

Trauma Assessment Clinics (TAC) were pioneered by the Glasgow Royal Infirmary Group. Patients deemed for non-operative management are referred to the TAC for review by an orthopaedic consultant with multidisciplinary team (MDT) support. Connolly Hospital launched a TAC on 11 September 2018.

AIMS

The goal of this study was to evaluate the effect the introduction of this initiative had on patient flow in our institution.

METHODS

We performed a retrospective review of the Connolly Hospital TAC for the 6-month period since its introduction. We evaluated patient demographics, injuries and outcomes. Furthermore, we retrospectively reviewed the fracture and elective clinic attendances pre- and post-TAC introduction.

RESULTS

Over the first 6 months of this initiative, there were 36 trauma assessment clinics. Two hundred forty-seven patients were reviewed with an average age of 42.3 years. 42.9% (N = 106) was reviewed directly by the physiotherapy department. 31.6% (N = 78) was scheduled directly for fracture clinic follow-up from the TAC. 8.2% (N = 45) was discharged directly to their GP from TAC. A review of fracture clinic attendances for the corresponding time period the previous year (from September 2017), highlighted a 22% decrease in new fracture clinic appointments.

CONCLUSIONS

Following the introduction of the TAC, we noted a marked reduction in fracture clinic attendances. Our outcomes were consistent with results from other units. We established two injection clinics as a direct result of the time saved from the TAC. It has proven to be of benefit to both the trauma and elective patients in our institution.

Municipal Acute Units as Part of the Clinical Pathway for Older Patients

Introduction

Since 2016, Norwegian municipalities have been obliged to provide municipal acute 24-hour services representing a service before or instead of hospital treatment. This study explores two municipal acute units (MAUs) as part of the clinical pathway for older patients.

Methods

Patients and healthcare providers from MAUs, purchaser offices, home-based nursing, and physicians were interviewed. Interview transcripts were analysed using systematic text condensation.

Results

The collaboration between the MAU staff and the GPs, the purchaser offices and the home-based services is described as challenging, mostly due to disagreement regarding patients' admission and discharge. The providers' different understanding seems to derive especially from where they are working in a way that suits their own work functions.An exigent collaboration between providers in the MAUs and their collaborative partners hampers the clinical pathway for older patients in the municipal healthcare service.

Conclusion and discussion

When a new healthcare service such as an MAU becomes a part of the clinical pathway in a municipality, it is important to invest a considerable effort in measures designed to strengthen relational and structural collaboration to make the clinical pathway smooth.

The Dutch chaos case: A scoping review of knowledge and decision support tools available to clinicians in the Netherlands

BACKGROUND

To keep clinicians up-to-date with the latest evidence, clinical practice and patient preferences, more and more knowledge tools - aiming to synthesise knowledge and support (shared) decision-making - are being developed. Unfortunately, it seems that in the Netherlands, and possibly elsewhere, the amount of different knowledge tool types makes it difficult to see the forest through the trees.

METHODS

A scoping review, exploring types of knowledge tools available to Dutch clinicians (and patients) and how these tools are described. The search terms were collected from thesauri and textbooks, and used to search the websites and documents of selected national tool developing organisations.

RESULTS

The review yielded 126 tool types. We included 67 different tool types, such as guidelines, protocols, standards and clinical pathways. Half of those tool types were aimed at clinicians, 14 at patients and 18 at both. In general, descriptions of the tool types were hard to find or incomplete.

CONCLUSIONS

There exists a myriad of knowledge tool types and their descriptions are mostly unclear. The information overload experienced by clinicians is not addressed effectively by developing numerous unclearly defined knowledge tools. We recommend limiting the number of tool types and making a greater effort in clearly defining them. This abundance of poorly defined tools does not seem to be restricted to the Netherlands.

A conceptual framework for patient-directed knowledge tools to support patient-centred care: Results from an evidence-informed consensus meeting

OBJECTIVE

Patient-directed knowledge tools are designed to engage patients in dialogue or deliberation, to support patient decision-making or self-care of chronic conditions. However, an abundance of these exists. The tools themselves and their purposes are not always clearly defined; creating challenges for developers and users (professionals, patients). The study's aim was to develop a conceptual framework of patient-directed knowledge tool types.

METHODS

A face-to-face evidence-informed consensus meeting with 15 international experts. After the meeting, the framework went through two rounds of feedback before informal consensus was reached.

RESULTS

A conceptual framework containing five patient-directed knowledge tool types was developed. The first part of the framework describes the tools' purposes and the second focuses on the tools' core elements.

CONCLUSION

The framework provides clarity on which types of patient-directed tools exist, the purposes they serve, and which core elements they prototypically include. It is a working framework and will require further refinement as the area develops, alongside validation with a broader group of stakeholders.

PRACTICE IMPLICATIONS

The framework assists developers and users to know which type a tool belongs, its purpose and core elements, helping them to develop and use the right tool for the right job.

Clinical pathway modelling: a literature review

Hospital information systems are increasingly used as part of decision support tools for planning at strategic, tactical and operational decision levels. Clinical pathways are an effective and efficient approach in standardising the progression of treatment, to support patient care and facilitate clinical decision making. This literature review proposes a taxonomy of problems related to clinical pathways and explores the intersection between Information Systems (IS), Operational Research (OR) and industrial engineering. A structured search identified 175 papers included in the taxonomy and analysed in this review. The findings suggest that future work should consider industrial engineering integrated with OR techniques, with an aim to improving the handling of multiple scopes within one model, while encouraging interaction between the disjoint care levels and with a more direct focus on patient outcomes. Achieving this would continue to bridge the gap between OR, IS and industrial engineering, for clinical pathways to aid decision support.

Vessel Health and Preservation: a model and clinical pathway for using vascular access devices

Use of intravenous devices for the delivery of medical treatment spans all healthcare facilities ranging from hospitals to clinics and home care. Clinical pathways are processes used by healthcare providers to integrate and illustrate the best evidence and approach to care for a specific area of practice. The Vessel Health and Preservation (VHP) model is a framework and pathway process, consisting of four quadrants, to guide initiation and management of treatment requiring intravenous access. The pathway is designed to promote preservation of the vasculature of patients from admission through discharge with a focus on acute care. This article describes the model and pathway process. Moving through the quadrants of assessment/selection, insertion, management and evaluation of outcomes the clinician receives vascular access education to establish an understanding of the key principles and is then better able to provide care to the patient. Research on the VHP model has found that patients, clinicians and healthcare facilities benefit from the evidence integrated within the VHP model for improved outcomes, greater success with insertion, time saved through improved efficiency, risk reduced through appropriate device discontinuation, and greater patient satisfaction.

Evaluation of a Collaborative Protocolized Approach by Community Pharmacists and General Medical Practitioners for an Australian Minor Ailments Scheme: Protocol for a Cluster Randomized Controlled Trial

Background

Internationally, governments have been investing in supporting pharmacists to take on an expanded role to support self-care for health system efficiency. There is consistent evidence that minor ailment schemes (MASs) promote efficiencies within the health care system. The cost savings and health outcomes demonstrated in the United Kingdom and Canada open up new opportunities for pharmacists to effect sustainable changes through MAS delivery in Australia.

Objective

This trial aims to evaluate the clinical, economic, and humanistic impact of an Australian Minor Ailments Service (AMAS) compared with usual pharmacy care in a cluster randomized controlled trial (cRCT) in Western Sydney, Australia.

Methods

The cRCT design has an intervention group and a control group, comparing individuals receiving a structured intervention (AMAS) with those receiving usual care for specific health ailments. Participants will be community pharmacies, general practices, and patients located in Western Sydney Primary Health Network (WSPHN) region. A total of 30 community pharmacies will be randomly assigned to either intervention or control group. Each will recruit 24 patients, aged 18 years or older, presenting to the pharmacy in person with a symptom-based or product-based request for one of the following ailments: reflux, cough, common cold, headache (tension or migraine), primary dysmenorrhea, or low back pain. Intervention pharmacists will deliver protocolized care to patients using clinical treatment pathways with agreed referral points and collaborative systems boosting clinician-pharmacist communication. Patients recruited in control pharmacies will receive usual care. The coprimary outcomes are rates of appropriate recommendation of nonprescription medicines and rates of appropriate medical referral. Secondary outcomes include self-reported symptom resolution, health services resource utilization, and EuroQoL Visual Analogue Scale. Differences in primary outcomes between groups will be analyzed at the individual patient level accounting for correlation within clusters with generalized estimating equations. The economic impact of the model will be evaluated by cost-utility and cost-effectiveness analysis compared with usual care.

Results

The study began in July 2018. Thirty community pharmacies were recruited. Pharmacists from the 15 intervention pharmacies were trained. A total of 27 general practices consented. Pharmacy patient recruitment began in August 2018 and was completed on March 31, 2019.

Conclusions

This study may demonstrate the efficacy of a protocolized intervention to manage minor ailments in the community and will assess the clinical, economic, and humanistic impact of this intervention in Australian pharmacy practice. Pharmacists supporting patient self-care and appropriate self-medication may contribute to greater efficiency of health care resources and integration of self-care in the health system. The proposed model and developed educational content may form the basis of a national MAS service in Australia, using a robust framework for management and referral for common ailments.

Trial Registration

Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12618000286246; http://www.anzctr.org.au/ACTRN12618000286246.aspx

International Registered Report Identifier (IRRID)

DERR1-10.2196/13973

A Process-Centered Approach to the Description of Clinical Pathways-Forms and Determinants

The aim of the study is to indicate the need for variability in the presentation of clinical pathways, in various phases of their implementation, and to define the forms of presentation of clinical pathways required by physicians in both the Hospital Information Systems (HIS) and Electronic Medical Records (EMR) Systems, as well as the determinants of the selection of the forms of description, in relation to the performed medical actions. The results of the study are a significant lead-in towards further research on the required form of the user interface in systems supporting dynamic business process management (dynamic BPM). The research is a pilot of a survey study, conducted to ascertain the usefulness and feasibility of the adopted methodology, for a wider project on the determinants of the form of description of clinical pathways. An exploratory pilot survey, in a large multi-specialization hospital in Poland, was conducted. The survey sample consisted of 28 purposely selected heads of all hospital departments, and the medical team of the pediatric ward. Descriptive analysis was carried out on the data collected. The results of the study have unambiguously supported the claim that physicians require the form of presentation of clinical pathways to change, depending on the particular phase of the diagnostic–therapeutic process, as well as establishing the main determinants thereof. This pilot study is one of the first attempts to establish the factors determining the choice of clinical pathway presentation in HIS/EMR systems. While not conclusively decisive in terms of the forms of presentation or the determinants of their choice, it indicates the directions of further research, both from the point of view of ergonomics and the usability of HIS/EMR systems, as well as the management of medical knowledge, as part of the dynamic management of clinical pathways.

Development of a program theory for clinical pathways in hospitals: protocol for a realist review

BACKGROUND

Despite the increased utilization of clinical pathways (CPWs) as a strategy to improve patient and system outcomes in hospitals, there remain ongoing challenges with their conceptualization, implementation, and evaluation. Theories that explain how CPWs work in hospitals are lacking, making it difficult to identify important factors for sustaining changes arising from CPWs implemented in hospitals. The objective of this realist review is to develop a program theory for CPWs in hospitals.

METHODS

This is a protocol for a realist review. The review will use a six-step iterative process to develop a program theory for CPWs in hospitals: (1) development of a preliminary program theory; (2) search strategy and literature search; (3) study selection and appraisal; (4) data extraction; (5) data analysis and synthesis; and (6) stakeholder engagement. In addition to searching the gray literature and contacting authors, we will search electronic databases such as MEDLINE, NHSEED, CINAHL EBSCO, HMIC, and PsycINFO. Studies will be included based on their ability to provide data that test some aspect of the program theory. Two independent reviewers will select, screen, and extract data related to the program theory from all relevant sources. A realist logic of analysis will be used to identify all context-mechanism-outcome heuristics that explains how CPWs implemented in hospitals translates to better health system outcomes.

DISCUSSION

Overall, the review aims to develop a program theory for CPWs in hospitals and to explore how, why, to what extent, and in what contexts does the implementation of CPWs in hospitals contribute to better health system outcomes. As a result, the review will provide a theoretical framework of how CPWs work in hospitals.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018103220.

Trauma assessment clinic: Virtually a safe and smarter way of managing trauma care in Ireland

INTRODUCTION

The Trauma Assessment Clinic [TAC], also referred to as Virtual Fracture Clinic, offers a novel care pathway for patients and is being increasingly utilised across the Irish and UK health care systems. The provision of safe, patient centred, efficient and cost-effective treatment via a multidisciplinary team [MDT] approach is the primary focus of TAC. The Trauma and Orthopaedic unit at Tullamore Hospital was the first centre to introduce a TAC in Ireland and this overview outlines the experiences of this pilot.

METHODS AND PATIENTS

Patients arriving to the Emergency Department with injuries that were TAC appropriate were treated as per a recognised protocol. They were given information regarding their injury and a removable splint or cast and told to expect a follow up phone call from the orthopaedic team. Within 24 h the patient's clinical notes and x-rays were assessed by the TAC MDT and patients were called immediately to be advised as to their planned treatment.

RESULTS

To date the TAC pilot in Tullamore Hospital has reviewed 2704 patients. 35% of patients were discharged at the TAC review stage, 27% were referred to an appropriate clinic (e.g. Shoulder injuries referred to an upper limb specialist) or a general trauma follow-up clinic, and 38% were referred onto physiotherapy services local and community based for follow-up. A survey of patients reviewed in the TAC revealed that 97% of respondents agreed or strongly agreed that they were satisfied with their recovery. The cost of each TAC consultation was €28 versus €129 for a traditional fracture clinic appointment.

CONCLUSION

Our experience of the TAC is that it provides a very safe, patient focused and cost-effective means of delivering trauma care. It provides a more streamlined and improved patient journey in select patients with certain fracture patterns, allowing for patient empowerment without compromising clinical care and marries current available technology with up to date best clinical practice.

Effects of a Standardized Care Protocol for Patients with Degenerative Spine Disease

Background:

Many patients facing spinal surgery experience fear and anxiety about surgery, anesthesia, risk of postoperative pain or complications, or even death. Spinal surgery patients often experience mobility disorders due to lasting postoperative pain and require aids such as spinal braces, which can induce depression. Alleviating patients’ anxiety and depression during the perioperative period by utilizing consistent and standardized information is required for high-quality care.

Objective:

We developed and assessed a standardized care protocol for degenerative spinal surgery patients.

Methods:

The protocol was developed through focus group interviews with spinal surgery patients and the recommendations of an expert panel. Then, a quasi-experimental design was employed to comparatively study patients undergoing spinal surgery. Ninety-eight Patients were assigned to either a treatment group (n= 49) or a control group (n= 49). The treatment group received an intervention based on the newly developed standardized care protocol, while the control group received traditional care. After treatment, participants’ anxiety, depression, uncertainty, and care satisfaction were compared between groups.

Results:

Patients who had received the care protocol-based intervention showed lower anxiety, depression, and uncertainty, and higher satisfaction than did those who received traditional care.

Conclusion:

The developed care protocol may be useful for reducing anxiety and depression and for improving the healthcare provided to spinal surgery patients, as it involves the proactive dissemination of accurate information throughout the hospitalization process. The protocol also positively affected patients’ uncertainty and satisfaction with their medical care.

An integrative approach to improving patient care pathways

PURPOSE

Globally, healthcare managers continue to struggle with increasing demands for their services being delivered with limited or shrinking resources. It is, therefore, clear that systems, processes and practices need to change to meet these challenges. The purpose of this paper is to assess how integrating two improvement technologies, Lean and integrated care pathways (ICP) might help.

DESIGN/METHODOLOGY/APPROACH

Lean and ICP in healthcare provide a platform to develop conceptual frameworks for integrating two approaches.

FINDINGS

A conceptual integrated framework is provided to assist care pathway designers and implementers to consider the synergistic benefits of combining approaches to improvement.

RESEARCH LIMITATIONS/IMPLICATIONS

The authors provide a conceptual framework that requires empirically testing.

PRACTICAL IMPLICATIONS

This research provides a conceptual framework to aid practitioners to improve healthcare design and delivery.

ORIGINALITY/VALUE

For the first time, the authors bring together two approaches to improving patient care pathway design and consider how these are linked in relation to improving healthcare delivery.

Identifying and classifying indicators affected by performing clinical pathways in hospitals: a scoping review

AIM

To analyse the evidence regarding indicators affected by clinical pathways (CPW) in hospitals and offer suggestions for conducting comprehensive systematic reviews.

METHODS

We conducted a systematic scoping review and searched the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, Scopus, OVID, Science Direct, ProQuest, EMBASE and PubMed. We also reviewed the reference lists of included studies. The criteria for inclusion of studies included experimental and quasi-experimental studies, implementing CPW in secondary and tertiary hospitals and investigating at least one indicator. Quality of included studies was assessed by two authors independently using the Critical Appraisal Skills Program for clinical trials and cohort studies and the Joanna Briggs Institute Critical Appraisal Tool for Quasi-Experimental Studies.

RESULTS

Forty-seven out of 2191 studies met the eligibility and inclusion criteria. The majority of included studies had pretest-posttest quasi-experimental design and had been done in developed countries, especially the United States. The investigation of evidence resulted in identifying 62 indicators which were classified into three categories: input indicators, process and output indicators and outcome indicators. Outcome indicators were more frequent than other indicators. Complication rate, hospital costs and length of hospital stay were dominant in their own category. Indicators such as quality of life and adherence to guidelines have been considered in studies that were done in recent years.

CONCLUSION

Implementing CPW can affect different types of indicators such as input, process, output and outcome indicators, although outcome indicators capture more attention than other indicators. Patient-related indicators were dominant outcome indicators, whereas professional indicators and organizational factors were considered less extensively. WHAT IS KNOWN ABOUT THE TOPIC?: WHAT DOES THIS ARTICLE ADD?

Acquired Velopharyngeal Dysfunction: Survey, Literature Review, and Clinical Recommendations

PURPOSE

The aim of this study was to describe the clinical assessment recommendations for acquired velopharyngeal dysfunction (AVPD) and, through a literature review and online survey, summarize current practice patterns for evaluation and treatment pathway determination for this target population.

METHOD

An online survey to query current assessment procedures and treatment pathway recommendations for AVPD was developed. Following survey results, a literature review was completed to determine evidence-based recommendations for assessment procedures and intervention recommendations based on assessment findings. Literature search terms included the following: acquired velopharyngeal dysfunction, hypernasality, non-cleft velopharyngeal dysfunction, velopharyngeal dysfunction, velopharyngeal dysfunction AND iatrogenic, velopharyngeal dysfunction AND neurogenic, velopharyngeal dysfunction AND assessment OR evaluation, velopharyngeal dysfunction AND treatment OR intervention, velopharyngeal dysfunction AND practice patterns OR clinical guidelines, velopharyngeal insufficiency. Inclusion criteria were limited to practice patterns/recommendations for assessment and/or treatment recommendations for AVPD, English language articles published between 2000 and 2017, and peer-reviewed journals. Studies regarding solely congenital or cleft palate velopharyngeal dysfunction and intervention outcome studies were excluded. Forty articles met inclusionary criteria.

RESULTS

The online survey results indicated lack of consensus for AVPD assessment and treatment recommendation protocols, with 93% of respondents indicating the need for a clinical guide for developing treatment recommendations. The majority of recommendations were filtered into an algorithm for clinical decision making.

CONCLUSIONS

Clinical uncertainty among speech-language pathologists surveyed and the paucity of published clinical guidelines for assessing individuals with AVPD indicate the need for additional clinical research for this disorder, one that is heterogeneous and distinct from those with congenital velopharyngeal dysfunction. The proposed evidence-based clinical worksheet may assist in determining management for patients with AVPD and may serve as a starting place for validation of a clinical guideline.

Defining barriers and enablers for clinical pathway implementation in complex clinical settings

BACKGROUND

While clinical pathways have the potential to improve patient outcomes and reduce healthcare costs, their true impact has been limited by variable implementation strategies and suboptimal research designs. This paper explores a comprehensive set of factors perceived by emergency department staff and administrative leads to influence clinical pathway implementation within the complex and dynamic environments of community emergency department settings.

METHODS

This descriptive, qualitative study involved emergency health professionals and administrators of 15 community hospitals across Ontario, Canada. As part of our larger cluster randomized controlled trial, each site was in the preparation phase to implement one of two clinical pathways: pediatric asthma or pediatric vomiting and diarrhea. Data were collected from three sources: (i) a mediated group discussion with site champions during the project launch meeting; (ii) a semi-structured site visit of each emergency department; and (iii) key informant interviews with an administrative lead from each hospital. The Theoretical Domains Framework (TDF) was used to guide the interviews and thematically analyze the data. Domains within each major theme were then mapped onto the COM-B model-capability, opportunity, and motivation-of the Behaviour Change Wheel.

RESULTS

Seven discrete themes and 58 subthemes were identified that comprised a set of barriers and enablers relevant to the planned clinical pathway implementation. Within two themes, three distinct levels of impact emerged, namely (i) the individual health professional, (ii) the emergency department team, and (iii) the broader hospital context. The TDF domains occurring most frequently were Memory, Attention and Decision Processes, Environmental Context and Resources, Behavioural Regulation, and Reinforcement. Mapping these barriers and enablers onto the COM-B model provided an organized perspective on how these issues may be interacting. Several factors were viewed as both negative and positive across different perspectives. Two of the seven themes were limited to one component, while four involved all three components of the COM-B model.

CONCLUSIONS

Using a theory-based approach ensured systematic and comprehensive identification of relevant barriers and enablers to clinical pathway implementation in ED settings. The COM-B system of the Behaviour Change Wheel provided a useful perspective on how these factors might interact to effect change.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT01815710 .

Multidisciplinary first-day consultation accelerates diagnostic procedures and throughput times of patients in a head-and-neck cancer care pathway, a mixed method study

BACKGROUND

Head and neck cancers are fast growing tumours that are complex to diagnose and treat. Multidisciplinary input into organization and logistics is critical to start treatment without delay. A multidisciplinary first-day consultation (MFDC) was introduced to reduce throughput times for patients suffering from head and neck cancer in the care pathway. In this mixed method study we evaluated the effects of introducing the MFDC on throughput times, number of patient hospital visits and compliance to the Dutch standard to start treatment within 30 calendar-days.

METHODS

Data regarding 'days needed for referral', 'days needed for diagnostic procedures', 'days to start first treatment', and 'number of hospital visits' (process indicators) were retrieved from the medical records and analysed before and after implementation of the MFDC (before implementation: 2007 (n = 21), and after 2008 (n = 20), 2010 (n = 24) and 2013 (n = 24)). We used semi-structured interviews with medical specialists to explore a sample of outliers.

RESULTS

Comparing 2007 and 2008 data (before and after MFDC implementation), days needed for diagnostic procedures and to start first treatment reduced with 8 days, the number of hospital visits reduced with 1.5 visit on average. The percentage of new patients treated within the Dutch standard of 30 calendar-days after intake increased from 52 to 83%. The reduction in days needed for diagnostic procedures was sustainable. Days needed to start treatment increased in 2013. Semi-structured interviews revealed that this delay could be attributed to new treatment modalities, patients needed more time to carefully consider their treatment options or professionals needed extra preparation time for organisation of more complex treatment due to early communication on diagnostic procedures to be performed.

CONCLUSIONS

A MFDC is efficient and benefits patients. We showed that the MFDC implementation in the care pathway had a positive effect on efficiency in the care pathway. As a consequence, the extra efforts of four specialist disciplines, a nurse practitioner, and a coordinating nurse seeing the patient together during intake, were justified. Start treatment times increased as a result of new treatment modalities that needed more time for preparation.

Short- and long-term effects of clinical pathway on the quality of surgical non-small cell lung cancer care in China: an interrupted time series study

Objective

To examine the short- and long-term effect of clinical pathway for non-small cell lung cancer surgery on the length of stay, the compliance of quality indicators and risk-adjusted post-operative complication rate.

Design

A retrospective quasi-experimental study from June 2011 to October 2015.

Setting

A tertiary cancer hospital in China.

Participants

Patients diagnosed as non-small cell lung cancer who underwent curative resection.

Intervention(s)

Clinical pathway was implemented at January 2013. Hence, the study period was divided into three periods: pre-pathway, from June 2011 to December 2012; short-term period, from January 2013 to December 2013; long-term period, from January 2014 to October 2015.

Main Outcome Measure(s)

Three length of hospital stay indicators, four process performance indicators and one outcome indicator.

Results

ITS showed there was a significant decline of 2 days (P = 0.0421) for total length of stay and 2.23 days (P = 0.0199) for post-operative length of stay right after the implementation of clinical pathway. Short-term level changes were found in the compliance rate of required number of lymph node sampling (-8.08%, P = 0.0392), and risk-adjusted complication rate (9.02%, P = 0.0001). There were no statistically significant changes in other quality of care indicators.

Conclusions

The clinical pathway had a positive impact on the length of stay but showed a transient negative effect on complication rate and the quality of lymph node sampling.

An umbrella review of clinical practice guidelines for the management of patients with hip fractures and a synthesis of recommendations for the pre-operative period

AIM

The aim of this review was to locate, retrieve and critically appraise practice guidelines for the management of hip fractures. Given increasing evidence that the early recognition and management of these fractures is integral to achieving optimal outcomes, recommendations for the pre-operative period were synthesized and compared.

BACKGROUND

Hip fractures are associated with high rates of adverse outcomes and high healthcare costs which has resulted in the development of multiple practice guidelines to inform clinical decision-making.

DESIGN

An umbrella review of practice guidelines was conducted which included a critical appraisal using the Appraisal of Guidelines, Research and Evaluation-II instrument and a synthesis of pre-operative management recommendations.

DATA SOURCES

Multi-phased search for practice guidelines published in English using three bibliographic databases; three guideline network websites and three healthcare safety and quality organization websites with no date limit applied. Search was supplemented by contacting front-line knowledge users and content experts.

REVIEW METHODS

Steps for evidence-informed practice were followed: form question then search for, appraise and synthesize the evidence.

RESULTS

Five practice guidelines were appraised revealing significant variability in quality. The largest variability was in "rigour of development". Recommendations for pre-operative management were grouped into six categories: timing of surgery, expedited patient management, identification and treatment of correctable co-morbidities, pain management, preventative measures and multidisciplinary management.

CONCLUSION

Results of this review illustrate that not all practice guidelines are of equal quality. Given the costs associated with the development and maintenance of high-quality practice guidelines, such work may be more efficiently completed through international collaborations and then adapted for national and regional healthcare contexts.

Simulation of patient flow in multiple healthcare units using process and data mining techniques for model identification

INTRODUCTION

An approach to building a hybrid simulation of patient flow is introduced with a combination of data-driven methods for automation of model identification. The approach is described with a conceptual framework and basic methods for combination of different techniques. The implementation of the proposed approach for simulation of the acute coronary syndrome (ACS) was developed and used in an experimental study.

METHODS

A combination of data, text, process mining techniques, and machine learning approaches for the analysis of electronic health records (EHRs) with discrete-event simulation (DES) and queueing theory for the simulation of patient flow was proposed. The performed analysis of EHRs for ACS patients enabled identification of several classes of clinical pathways (CPs) which were used to implement a more realistic simulation of the patient flow. The developed solution was implemented using Python libraries (SimPy, SciPy, and others).

RESULTS

The proposed approach enables more a realistic and detailed simulation of the patient flow within a group of related departments. An experimental study shows an improved simulation of patient length of stay for ACS patient flow obtained from EHRs in Almazov National Medical Research Centre in Saint Petersburg, Russia.

CONCLUSION

The proposed approach, methods, and solutions provide a conceptual, methodological, and programming framework for the implementation of a simulation of complex and diverse scenarios within a flow of patients for different purposes: decision making, training, management optimization, and others.

Risk factors for recurrence in deep vein thrombosis patients following a tailored anticoagulant treatment incorporating residual vein obstruction

BACKGROUND

Finding the optimal duration of anticoagulant treatment following an acute event of deep vein thrombosis (DVT) is challenging. Residual venous obstruction (RVO) has been identified as a risk factor for recurrence, but data on management strategies incorporating the presence of RVO and associated recurrence rates in defined clinical care pathways (CCP) are lacking.

OBJECTIVES

We aimed to investigate the long-term clinical outcomes and predictors of venous thromboembolism (VTE) recurrence in a contemporary cohort of patients with proximal DVT and managed in a CCP incorporating the presence of RVO.

PATIENTS

All patients treated at the Maastricht University Medical Center within an established clinical care pathway from June 2003 through June 2013 were prospectively followed for up to 11 years in a prospective management study.

RESULTS

Of 479 patients diagnosed with proximal DVT, 474 completed the two-year CCP (99%), and 457 (94.7%) the extended follow-up (2231.2 patient-years; median follow-up 4.6 years). Overall VTE recurrence was 2.9 per 100 patient-years, 1.3 if provoked by surgery, 2.1 if a non-surgical transient risk factor was present and 4.0 if unprovoked. Predictors of recurrent events were unprovoked VTE (adjusted hazard ratio [HR] 4.6; 95% CI 1.7, 11.9), elevated D-dimer one month after treatment was stopped (HR 3.3; 1.8, 6.1), male sex (HR 2.8; 1.5, 5.1), high factor VIII (HR 2.2; 1.2, 4.0) and use of contraceptives (HR 0.1; 0.0, 0.9).

CONCLUSIONS

Patients with DVT managed within an established clinical care pathway incorporating the presence of RVO had relatively low incidences of VTE recurrence.

Improved management of stillbirth using a care pathway

Purpose

Each year approximately 3,200 women have a stillbirth in the UK. Although national evidence-based guidance has existed since 2010, case reviews continue to identify suboptimal clinical care and communication with parents. Inconsistencies in management include induction and management of labour and the frequency of investigation after stillbirth. The paper aims to discuss these issues.

Design/methodology/approach

An audit of stillbirths was performed in 2014 in 13 maternity units in the North West of England, this confirmed variation in practice described nationally. An integrated care pathway (ICP) was developed from national guidelines to enable optimal care for the management of stillbirth, reduce variation, standardise investigations and coordinate patient-focussed care. This was launched in 2015 and updated in 2016 to resolve the issues that were apparent after implementation.

Findings

Each participating unit had commenced using the ICP by May 2015. Following implementation there were changes in care, most notably from diverse methods for the induction of labour to guideline-directed induction of labour. There were trends towards better care in terms of information given, choices offered, more appropriate analgesia in labour and improved post-delivery investigation for cause. Staff feedback about the ICP was positive.

Practical implications

The use of this ICP improved care for women who had a stillbirth and their families. Issues with implementing a changed care pathway meant that further iterations were required, ongoing improvement is expected following the refinement of the ICP.

Originality/value

ICPs have been used for various clinical conditions. However, this is the first example of their use in women who had a stillbirth.

An economic evaluation of an integrated care pathway in geriatric rehabilitation for older patients with complex health problems

Background

Integrated care pathways which cover multiple care settings are increasingly used as a tool to structure care, enhance coordination and improve transitions between care settings. However, little is known about their economic impact. The objective of this study is to determine the cost-effectiveness and cost-utility of an integrated care pathway designed for patients with complex health problems transferring from the hospital, a geriatric rehabilitation facility and primary care.

Methods

This economic evaluation was performed from a societal perspective alongside a prospective cohort study with two cohorts of patients. The care as usual cohort was included before implementation of the pathway and the care pathway cohort after implementation of the pathway. Both cohorts were measured over nine months, during which intervention costs, healthcare costs, patient and family costs were identified. The outcome measures were dependence in activities of daily living (measured with the KATZ-15) and quality adjusted life years (EQ-5D-3L). Costs and effects were bootstrapped and various sensitivity analyses were performed to assess robustness of the results.

Results

After nine months, the average societal costs were significantly lower for patients in the care pathway cohort (€50,791) versus patients in the care as usual cohort (€62,170; CI = -22,090, -988). Patients in the care pathway cohort had better scores on the KATZ-15 (1.04), indicating cost-effectiveness. No significant differences were found between the two groups on QALY scores (0.01).

Conclusions

The results of this study indicate that the integrated care pathway is a cost-effective intervention. Therefore, dissemination of the integrated care pathway on a wider scale could be considered. This would provide us the opportunity to confirm the findings of our study in larger economic evaluations. When looking at QALYs, no effects were found. Therefore, it is also recommended to explore if therapy in geriatric rehabilitation could also pay attention to other quality of life-related domains, such as mood and social participation.

What is known about pathways to mental health care for Australian Aboriginal young people?: a narrative review

OBJECTIVES

To (1) gain an understanding of current trajectories of Aboriginal young people through the mental health care system in Australia; (2) summarize what mental health care pathways have been developed or evaluated to guide mental health care delivery for Aboriginal young people; and (3) identify barriers and facilitators to the adoption of effective mental health care pathways for Aboriginal young people.

METHODS

Databases, including, AMED, Embase, Global Health, Health and Psychosocial Instruments, Healthstar, MEDLINE, PsychINFO via Ovid, CINAHL via EBSCO, The Cochrane Library, Indigenous Collections, Informit and Health Systems Evidence, were searched to identify evidence concerning mental health service delivery for Aboriginal young people in a primary care setting.

RESULTS

We did not identify any reports or publications explicitly describing the current trajectories of Aboriginal young people through the mental health care system in Australia. Furthermore, we were unable to locate any mental health-related treatment pathways which had been explicitly developed or modified to meet the needs of Aboriginal young people. The use of appropriate assessment tools, engagement of family and community, flexibility, and central coordination have been identified in the literature as potential facilitators of culturally appropriate mental health service delivery for Aboriginal children and adolescents.

CONCLUSIONS

Aboriginal children and adolescents may face additional difficulties navigating the mental health care system in Australia due to complex socio-cultural factors and the dearth of culturally appropriate and effective mental-health related treatment pathways. Additional research regarding (1) practice trends in Aboriginal settings and (2) how Aboriginal child and adolescent mental health can be improved is urgently needed to inform clinical practice and improve mental health service access and outcomes for Aboriginal young people in Australia.

Effects of nurse-led clinical pathway in coronary artery bypass graft surgery: A quasi-experimental study

AIMS AND OBJECTIVES

To develop and evaluate the effects of a nurse-led clinical pathway for patients undergoing coronary artery bypass graft surgery.

BACKGROUND

A clinical pathway is a multidisciplinary care plan, based on evidence and guidelines to provide consistent, quality care to patients and improve outcomes.

DESIGN

Prospective, quasi-experimental design.

METHODS

Patients hospitalised for coronary artery bypass graft between April 2014-November 2015 in a hospital in Turkey were studied. First 42 usual care patients were enrolled to determine outcomes and plan for the development of the clinical pathway followed by 40 patients in the newly developed clinical pathway. The primary outcome was length of stay and secondary outcomes related to recovery from surgery (e.g., time to extubation, first feeding).

RESULTS

The mean age for the clinical pathway group was 60 and for usual care was 63 years. Most were male (CP = 78%, UC = 69%). There were significant differences between groups for the primary outcome. Length of stay in the intensive care unit was 38.9 hr for CP and 50.7 hr for usual care patients p < .01. Total hospital time was 144.4 hr for clinical pathway and 162.2 hr for usual care, p < .05. For secondary measures, the following times were less for the clinical pathway group than for the usual care: time to extubation and nasogastric tube removal (5.7 vs. 8.6 hr, p < .01), first oral feeding (4.7 vs. 10.9 hr, p < .001), first mobilisation (8.4 vs. 22.9 hr, p < .001) and first bowel movement (69.8 vs. 85.9 hr, p < .01). There were no statistically significant differences in the 3-month readmission rates and complication rates between the groups, except the renal complication rates were higher in the usual care (n = 16, 38%) than in the clinical pathway (n = 7, 17.5%) (p < .05).

CONCLUSION

The nurse-led clinical pathway was effective in improving length of stay in both the ICU and hospital as well as the secondary outcomes.

RELEVANCE TO CLINICAL PRACTICE

This study contributes to previous studies supporting clinical pathway use can improve the length of stay and quality of care in patients undergoing coronary artery bypass graft surgery.

Discovering health-care processes using DeciClareMiner

Flexible, human-centric and knowledge-intensive processes occur in many service industries and are prominent in the health-care sector. Knowledge workers (e.g., doctors or other health-care personnel) are given the flexibility to address each process instance (i.e., episode of care) in the way that they deem most suitable. As a result, the knowledge of these processes is generally of a tacit nature, with many stakeholders lacking a clear view of a process. In this paper, we propose an algorithm called DeciClareMiner that combines process and decision mining to extract a process model and the corresponding knowledge from past executions of these processes. The algorithm was evaluated by applying it to a realistic health-care case and comparing the results to a complete search benchmark. In a relatively short time (10 min), DeciClareMiner was able to produce a DeciClare model that represents 93% of episodes of care with atomic constraints. Compared to the 50 h required to calculate the 100%-episode model via an exhaustive search approach, our result is considered a major improvement.

Development and implementation of a clinical pathway for cardiac surgery in the intensive care unit: Effects on protocol adherence

RATIONALE, AIMS AND OBJECTIVES

Cardiac surgery (CS) is facilitated by multiple perioperative guidelines and protocols. Use of a clinical pathway (CP) may facilitate the care of these patients.

METHODS

This is a pre-post design study in the ICU of a tertiary referral centre. A CP for CS patients in the ICU was developed by ICU-nurses and enabled them to execute proactively predefined actions in accordance with and within the preset boundaries which were part of a variance report. A tailored implementation strategy was used. Primary outcome measure was protocol adherence above 80% on the domains of blood pressure control, action on chest tube blood loss and electrolyte control within the CP.

RESULTS

In a 4-month period, 84 consecutive CP patients were included and compared with 162 matched control patients admitted in the year before implementation; 3 patients were excluded. Propensity score was used as matching parameter. CP patients were more likely to receive early adequate treatment for derangements in electrolytes (96% vs 47%, P < .001), blood pressure (90% vs 49%, P < .001) and adequate treatment for chest tube blood loss (90% vs 10%, P < .001). We found no differences in hospital and ICU LOS, ICU readmission or mortality.

CONCLUSION

Use of the CP improved postoperative ICU treatment for cardiac surgical patients. Implementation of a CP and the use of a special variance report could be a blueprint for the implementation and use of a CP in low-volume high complex surgery.

Integrated Care Planning for Cancer Patients: A Scoping Review

Introduction

There has been a growing emphasis on the use of integrated care plans to deliver cancer care. However little is known about how integrated care plans for cancer patients are developed including featured core activities, facilitators for uptake and indicators for assessing impact.

Methods

Given limited consensus around what constitutes an integrated care plan for cancer patients, a scoping review was conducted to explore the components of integrated care plans and contextual factors that influence design and uptake.

Results

Five types of integrated care plans based on the stage of cancer care: surgical, systemic, survivorship, palliative and comprehensive (involving a transition between stages) are described in current literature. Breast, esophageal and colorectal cancers were common disease sites. Multi-disciplinary teams, patient needs assessment and transitional planning emerged as key features. Provider buy-in and training alongside informational technology support served as important facilitators for plan uptake. Provider-level measurement was considerably less robust compared to patient and system-level indicators.

Conclusions

Similarities in design features, components and facilitators across the various types of integrated care plans indicates opportunities to leverage shared features and enable a management lens that spans the trajectory of a patient's journey rather than a phase-specific silo approach to care.

Are emergency department clinical pathway interventions adequately described, and are they delivered as intended? A systematic review

Introduction

The accurate reproduction of clinical interventions and the evaluation of provider adherence in research publications improve the evaluation and implementation of research findings into clinical practice. We sought to examine the proportion of clinical pathway publications in an emergency department setting that adequately reported the following: (1) the exact reproduction of the clinical pathway that was implemented in the study, (2) the adherence to and correct execution of the clinical pathway intervention, and (3) the presence of a pre-implementation education phase.

Methods

We performed a descriptive systematic review of the literature from 2006 to 2015 using MEDLINE, EMBASE, CENTRAL, and CINAHL. All types of prospective trial designs were eligible. Validated clinical pathway criteria were used to identify relevant publications. Two reviewers independently collected data using a piloted data abstraction tool. Risk of bias was assessed using the Cochrane Effective Practice and Organization of Care Group Risk of Bias Tool and the Newcastle-Ottawa Scale.

Results

We identified 5947 publications, 44 of which met our inclusion criteria. The formal clinical pathway was fully reproduced in 27 (61%) publications, partially reproduced in 9 (21%), and not reproduced in 8 (18%). Only 14 (32%) studies reported whether at least one decision step was executed correctly. The presence of a pre-implementation education phase was reported in 33 (75%) studies.

Conclusion

The underreporting of intervention elements may present a barrier to both the evaluation and accurate replication of clinical pathway interventions. These finding may be useful for the elaboration of complex intervention reporting guidelines, improved reporting in future clinical pathway publications, and improved knowledge translation and exchange of clinical pathway interventions.

Cost comparison of orthopaedic fracture pathways using discrete event simulation in a Glasgow hospital

OBJECTIVE

Healthcare faces the continual challenge of improving outcome while aiming to reduce cost. The aim of this study was to determine the micro cost differences of the Glasgow non-operative trauma virtual pathway in comparison to a traditional pathway.

DESIGN

Discrete event simulation was used to model and analyse cost and resource utilisation with an activity-based costing approach. Data for a full comparison before the process change was unavailable so we used a modelling approach, comparing a virtual fracture clinic (VFC) with a simulated traditional fracture clinic (TFC).

SETTING

The orthopaedic unit VFC pathway pioneered at Glasgow Royal Infirmary has attracted significant attention and interest and is the focus of this cost study.

OUTCOME MEASURES

Our study focused exclusively on patients with non-operative trauma attending emergency department or the minor injuries unit and the subsequent step in the patient pathway. Retrospective studies of patient outcomes as a result of the protocol introductions for specific injuries are presented in association with activity costs from the models.

RESULTS

Patients are satisfied with the new pathway, the information provided and the outcome of their injuries (Evidence Level IV). There was a 65% reduction in the number of first outpatient face-to-face (f2f) attendances in orthopaedics. In the VFC pathway, the resources required per day were significantly lower for all staff groups (p≤0.001). The overall cost per patient of the VFC pathway was £22.84 (95% CI 21.74 to 23.92) per patient compared with £36.81 (95% CI 35.65 to 37.97) for the TFC pathway.

CONCLUSIONS

Our results give a clearer picture of the cost comparison of the virtual pathway over a wholly traditional f2f clinic system. The use of simulation-based stochastic costings in healthcare economic analysis has been limited to date, but this study provides evidence for adoption of this method as a basis for its application in other healthcare settings.

Implementation and Evaluation of a Clinical Pathway for Pancreaticoduodenectomy Procedures: a Prospective Cohort Study

INTRODUCTION

Medical and nursing protocols in perioperative care for pancreaticoduodenectomy are mainly mono-disciplinary, limiting their integration and transparency in a continuous health care system. The aims of this study were to evaluate adherence to a multidisciplinary clinical pathway for all pancreaticoduodenectomy patients during their entire hospital stay and to determine if the use of this clinical pathway is associated with beneficial effects on clinical end points.

MATERIALS AND METHODS

A prospective cohort study was conducted in 95 pancreaticoduodenectomy patients treated according to a clinical pathway, including a variance report, compared to a historical control group (n = 52) with a traditional treatment regime.

RESULTS

Process evaluation of the clinical pathway group revealed that protocol adherence throughout all units was above 80%. Major complications according to Clavien-Dindo classification grade ≥3 decreased from 27 to 13%; p = 0.02. Hospital length of stay was significantly shorter in the clinical pathway group, median 10 days [IQR 8-15], compared with the control group, median 13 days [IQR 10-18]; p = 0.02.

CONCLUSION

The use of a clinical pathway in pancreaticoduodenectomy patients was associated with high protocol adherence, improved outcome and shorter hospital length of stay. Variance report analysis and protocol adherence with a Prepare-Act-Reflect Cycle are essential in surveillance of outcome.

Clinical pathway for patients with Chronic Myeloid Leukaemia: The Euriclea Project

BACKGROUND AND AIMS

The use of Tirosine Kinase Ihnibitors (TKIs) for the treatment of Chronic Myeloid Leukemia (CML) has definitely represented a turning point in the treatment of the onco-hematological diseases. Over the years, the interest of physicians, nurses, patients and caregivers has increasingly focused on the aspects of the humanization of care, the management of side effects and on the full and constant therapeutic adherence. The aim of the project was to define patient-oriented care processes, based on a proactive approach that can fully respond to the new health needs of CML patients.

METHODS

A nursing expert Working Group (WG) was established. WG reviewed literature about CML patients assistance and then it was conducted a survey on organizational models for the treatment of CML patients, adopted by Italian haematologic and transplant centers.  Finally, the main issues regarding CML patients care were identified and discussed on a multiprofessional basis.

RESULTS

Euriclea Project for care of CML patients with the description of a new and expanded nurse role was defined. The Nurse Case Manager or Nursing Clinical Experts were identified as key people for the management of the side effects of treatment, the promotion of the therapeutic adherence and the evaluation of efficacy and effectiveness of the process through the identification of specific indicators for structure, process and outcome.

DISCUSSION

The focal areas of the care process were identified so as to define a different approach to the CML patient, through a holistic view of care and the multidisciplinary interventions.