Reconceptualising clinical pathway system design

Development of integrated care pathways: toward a care management system to meet the needs of frail and disabled community-dwelling older people

INTRODUCTION

The home care and services provided to older adults with the same needs are often inadequate and highly varied. Integrated care pathways (ICPs) can resolve these issues. The aim of this study was to develop the content of ICPs to follow-up frail and disabled community-dwelling older people.

THEORY AND METHOD

A RIGOROUS PROCESS WAS APPLIED ACCORDING TO A SERIES OF STEPS: identification of desirable characteristics and a theoretical framework; review of evidence-based practices and current practices; and determination of ICPs by an interdisciplinary task team.

RESULTS

ICPs are intended to prevent specific problems, maximize independence, and promote successful aging. They are organized according to a dynamic process: (1) needs assessment and assessment of risk/protection factors; (2) data-collection summary and goals identification; (3) planning of interventions from a client-centered view; (4) coordination, delivery, and follow-up; and (5) identification of variances, as well as review and adjustment of plans.

CONCLUSION

Once computerized, these ICPs will facilitate the exchange of information as well as the clinical decision-making process with a perspective to adequately matching the needs of an individual person with resources that delay or slow the progression of frailty and disability. Once aggregated, the data will also support managers in organizing teamwork and follow-up for clients.

Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs

BACKGROUND

Clinical pathways are structured multidisciplinary care plans used by health services to detail essential steps in the care of patients with a specific clinical problem. They aim to link evidence to practice and optimise clinical outcomes whilst maximising clinical efficiency.

OBJECTIVES

To assess the effect of clinical pathways on professional practice, patient outcomes, length of stay and hospital costs.

SEARCH STRATEGY

We searched the Database of Abstracts of Reviews of Effectiveness (DARE), the Effective Practice and Organisation of Care (EPOC) Register, the Cochrane Central Register of Controlled Trials (CENTRAL) and bibliographic databases including MEDLINE, EMBASE, CINAHL, NHS EED and Global Health. We also searched the reference lists of relevant articles and contacted relevant professional organisations.

SELECTION CRITERIA

Randomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time series studies comparing stand alone clinical pathways with usual care as well as clinical pathways as part of a multifaceted intervention with usual care.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all titles to assess eligibility and methodological quality. Studies were grouped into those comparing clinical pathways with usual care and those comparing clinical pathways as part of a multifaceted intervention with usual care.

MAIN RESULTS

Twenty-seven studies involving 11,398 participants met the eligibility and study quality criteria for inclusion. Twenty studies compared stand alone clinical pathways with usual care. These studies indicated a reduction in in-hospital complications (odds ratio (OR) 0.58; 95% confidence interval (CI) 0.36 to 0.94) and improved documentation (OR 13.65: 95%CI 5.38 to 34.64). There was no evidence of differences in readmission to hospital or in-hospital mortality. Length of stay was the most commonly employed outcome measure with most studies reporting significant reductions. A decrease in hospital costs/ charges was also observed, ranging from WMD +261 US$ favouring usual care to WMD -4919 US$ favouring clinical pathways (in US$ dollar standardized to the year 2000). Considerable heterogeneity prevented meta-analysis of length of stay and hospital cost results. An assessment of whether lower hospital costs contributed to cost shifting to another health sector was not undertaken.Seven studies compared clinical pathways as part of a multifaceted intervention with usual care. No evidence of differences were found between intervention and control groups.

AUTHORS' CONCLUSIONS

Clinical pathways are associated with reduced in-hospital complications and improved documentation without negatively impacting on length of stay and hospital costs.

[Changes in treatment of squamous cell carcinoma over time. A process analysis]

BACKGROUND

The incidence of squamous cell carcinoma is rapidly increasing and requires process-optimized treatment dependent on the course of the patient's individual disease. Patient-based data on squamous cell carcinoma were used to analyze the treatment modalities before DRGs were introduced, after their introduction and after discussion about process-optimization in context of clinical pathways.

PATIENTS AND METHODS

From the recorded data in the department of dermatology, all squamous cell carcinoma cases were identified and evaluated. In addition to patient characteristics, parameters describing the process, for example, length of stay in hospital, pre- and post-interventional days, were collected.

RESULTS

Between 1998-2002, 2004-2006 and January to June 2007, 658 patients were treated for squamous cell carcinoma. In contrast to the times before DRGs, the treatment process has been significantly optimized, reducing the pre- and post-operative days and thus the duration of stay. Analysis of clinical pathways as part of the continuous improvement process was hardly able to detect further improvement. However, the weekly distribution of the admitted patients has been improved.

CONCLUSIONS

Patients with squamous cell carcinoma requiring surgical excision benefit from an optimized process, just as do impatient facilities. However, optimized treatment modalities carry hardly any potential of improvement by the invention of clinical pathways.

Is the organisation and structure of hospital postnatal care a barrier to quality care? Findings from a state-wide review in Victoria, Australia

OBJECTIVE

to describe the structure and organisation of hospital postnatal care in Victoria, Australia.

DESIGN

postal survey sent to all public hospitals in Victoria (n=71) and key-informant interviews with midwives and medical practitioners (n=38).

SETTING

Victoria, Australia.

PARTICIPANTS

providers of postnatal care in Victorian public hospitals.

FINDINGS

there is significant diversity across Victoria in the way postnatal units are structured and organised and in the way care is provided. There are differences in numerous practices, including maternal and neonatal observations and the length of time women spend in hospital after giving birth. Although the benefits of continuity of care are recognised by health care providers, continuity is difficult to provide in the postnatal period. Postnatal care is provided in busy, sometimes chaotic environments, with many barriers to providing effective care and few opportunities for women to rest and recover after childbirth. The findings in this study can, in part, be explained by the lack of evidence that has been available to guide early postnatal care.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

current structures such as standard postnatal documentation (clinical pathways) and fixed length of stay, may inhibit rather than support individualised care for women after childbirth. There is a need to move towards greater flexibility in providing of early postnatal care, including alternative models of service delivery; choice and flexibility in the length of stay after birth; a focus on the individual with far less emphasis on care being structured around organisational requirements; and building an evidence base to guide care.

Use and development of clinical pathways by registered nurses in an acute paediatric setting

Clinical pathways are widely regarded as providing valuable knowledge about specific types of patients and their care, as well as providing direct guidance in clinical practice. In Australia, the use of care pathways has occurred with seemingly minimal professional nursing debate as to their benefits in practice. Comments supporting the introduction of pathways into clinical practice have focused on assistance to decision making, facilitation of clinical judgements about care, assistance in improving practice and utility as educational tools, particularly for new staff, new graduates and casual employees. A survey of 259 nurses working in an acute paediatric setting sought to gain their views about pathways of care with regard to satisfaction with use, content of pathway, ability to use in practice, effect on practice and commitment to use. While the most positive findings to emerge from the research indicated that nurses liked clinical pathways because they saved time and reduced documentation requirements, issues were also raised about the need for a broader, more inclusive development process for pathways, and an improved education program for staff use. The implications to arise from these findings are important for senior staff and educators who are responsible for staff orientation programs and ongoing staff development as well as for those responsible for the development and implementation of clinical pathways into practice.