CNS facilitation of a cardiac surgery clinical pathway program

Implementation of peer specialist services in VA primary care: a cluster randomized trial on the impact of external facilitation

Background

Over 1100 veterans work in the Veterans Health Administration (VHA) as peer specialists (PSs)—those with formal training who support other veterans with similar diagnoses. A White House Executive Action mandated the pilot reassignment of VHA PSs from their usual placement in mental health to 25 primary care Patient Aligned Care Teams (PACTs) in order to broaden the provision of wellness services that can address many chronic illnesses. An evaluation of this initiative was undertaken to assess the impact of outside assistance on the deployment of PSs in PACTs, as implementation support is often needed to prevent challenges commonly experienced when first deploying PSs in new settings.

Methods

This study was a cluster-randomized hybrid II effectiveness-implementation trial to test the impact of minimal implementation support vs. facilitated implementation on the deployment of VHA PSs in PACT over 2 years. Twenty-five Veterans Affairs Medical Centers (VAMCs) were recruited to reassign mental health PSs to provide wellness-oriented care in PACT. Sites in three successive cohorts (n = 7, 10, 8) over 6-month blocks were matched and randomized to each study condition. In facilitated implementation, an outside expert worked with site stakeholders through a site visit and regular calls, and provided performance data to guide the planning and address challenges. Minimal implementation sites received a webinar and access to the VHA Office of Mental Health Services work group. The two conditions were compared on PS workload data and veteran measures of activation, satisfaction, and functioning. Qualitative interviews collected information on perceived usefulness of the PS services.

Results

In the first year, sites that received facilitation had higher numbers of unique veterans served and a higher number of PS visits, although the groups did not differ after the second year. Also, sites receiving external facilitation started delivering PS services more quickly than minimal support sites. All sites in the external facilitation condition continued in the pilot into the second year, whereas two of the sites in the minimal assistance condition dropped out after the first year. There were no differences between groups on veterans’ outcomes—activation, satisfaction, and functioning. Most veterans were very positive about the help they received as evidenced in the qualitative interviews.

Discussion

These findings demonstrate that external facilitation can be effective in supporting the implementation of PSs in primary care settings. The lack of significant differences across conditions after the second year highlights the positive outcomes associated with active facilitation, while also raising the important question of whether longer-term success may require some level of ongoing facilitation and implementation support.

Trial registration

This project is registered at ClinicalTrials.gov with number NCT02732600 (URL: https://clinicaltrials.gov/ct2/show/NCT02732600).

Physiotherapy mobility and walking management of uncomplicated coronary artery bypass graft (CABG) surgery patients: a survey of clinicians' perspectives in Australia and New Zealand

Background: This study aimed to determine current mobility and walking management by physiotherapists of patients undergoing coronary artery bypass graft (CABG) surgery, the clinical milestones expected and physiotherapists' perception of the severity of pain experienced by patients after surgery. Design: Cross sectional study using a questionnaire. Methods: All hospitals in Australia and New Zealand that perform cardiac surgery (n = 54) were invited to complete a questionnaire. Findings: Forty-one questionnaires were returned and analysed (response rate 76%). Walking distance was a clinical milestone after CABG surgery. Walking and transferring patients from bed to chair required the most time of physiotherapists during one treatment session. Physiotherapists perceived that patients experienced most pain on day one after surgery [mean (SD)] visual analogue scale (VAS) 41 (16) mm and this reduced by day four to VAS 15 (10) mm. Patients' pain was perceived to be significantly higher after physiotherapy sessions compared with before (p < 0.01). Thirty-seven respondents (90%) believed that patients' pain was well managed for physiotherapy treatments. A majority of the respondents (68%) believed that pain was not a limiting factor in the distance patients walked in a physiotherapy session and most (90%) believed that general fatigue limited walk distance. Conclusion: This research provides current mobility and walking management by physiotherapists of patients undergoing CABG surgery in Australia and New Zealand.

Standardized Clinical Pathways for Hospitalized Children and Outcomes

BACKGROUND AND OBJECTIVE

Clinical pathways standardize care for common health conditions. We sought to assess whether institution-wide implementation of multiple standardized pathways was associated with changes in utilization and physical functioning after discharge among pediatric inpatients.

METHODS

Interrupted time series analysis of admissions to a tertiary care children's hospital from December 1, 2009 through March 30, 2014. On the basis of diagnosis codes, included admissions were eligible for 1 of 15 clinical pathways implemented during the study period; admissions from both before and after implementation were included. Postdischarge physical functioning improvement was assessed with the Pediatric Quality of Life Inventory 4.0 Generic Core or Infant Scales. Average hospitalization costs, length of stay, readmissions, and physical functioning improvement scores were calculated by month relative to pathway implementation. Segmented linear regression was used to evaluate differences in intercept and trend over time before and after pathway implementation.

RESULTS

There were 3808 and 2902 admissions in the pre- and postpathway groups, respectively. Compared with prepathway care, postpathway care was associated with a significant halt in rising costs (prepathway vs postpathway slope difference -$155 per month [95% confidence interval -$246 to -$64]; P = .001) and significantly decreased length of stay (prepathway vs post-pathway slope difference -0.03 days per month [95% confidence interval -0.05 to -0.02]; P = .02), without negatively affecting patient physical functioning improvement or readmissions.

CONCLUSIONS

Implementation of multiple evidence-based, standardized clinical pathways was associated with decreased resource utilization without negatively affecting patient physical functioning improvement. This approach could be widely implemented to improve the value of care provided.

Improving care for pediatric diabetic ketoacidosis

OBJECTIVE

We sought to create and implement recommendations from an evidence-based pathway for hospital management of pediatric diabetic ketoacidosis (DKA) and to sustain improvement. We hypothesized that development and utilization of standard work for inpatient care of DKA would lead to reduction in hypokalemia and improvement in outcome measures.

METHODS

Development involved systematic review of published literature by a multidisciplinary team. Implementation included multidisciplinary feedback, hospital-wide education, daily team huddles, and development of computer decision support and electronic order sets.

RESULTS

Pathway-based order sets forced clinical pathway adherence; yet, variations in care persisted, requiring ongoing iterative review and pathway tool adjustment. Quality improvement measures have identified barriers and informed subsequent adjustments to interventions. We compared 281 patients treated postimplementation with 172 treated preimplementation. Our most notable findings included the following: (1) monitoring of serum potassium concentrations identified unanticipated hypokalemia episodes, not recognized before standard work implementation, and earlier addition of potassium to fluids resulted in a notable reduction in hypokalemia; (2) improvements in insulin infusion management were associated with reduced duration of ICU stay; and (3) with overall improved DKA management and education, cerebral edema occurrence and bicarbonate use were reduced. We continue to convene quarterly meetings, review cases, and process ongoing issues with system-based elements of implementing the recommendations.

CONCLUSIONS

Our multidisciplinary development and implementation of an evidence-based pathway for DKA have led to overall improvements in care. We continue to monitor quality improvement metric measures to sustain clinical gains while continuing to identify iterative improvement opportunities.

Do clinical pathways enhance access to evidence-based acute myocardial infarction treatment in rural emergency departments?

OBJECTIVE

 The objective of this study is to measure the impact of a five-step implementation process for an acute myocardial infarction (AMI) clinical pathway (CPW) on thrombolytic administration in rural emergency departments.

DESIGN

 Cluster randomised controlled trial.

SETTING

  Six rural Victorian emergency departments participated.

INTERVENTION

  The five-step CPW implementation process comprised (i) engaging clinicians; (ii) CPW development; (iii) reminders; (iv) education; and (v) audit and feedback.

MAIN OUTCOME MEASURES

The impact of the intervention was assessed by measuring the proportion of eligible AMI patients receiving a thrombolytic and time to thrombolysis and electrocardiogram.

RESULTS

Nine hundred and fifteen medical records were audited, producing a final sample of 108 patients eligible for thrombolysis. There was no significant difference between intervention and control groups for median door-to-needle time (29 mins versus 29 mins; P = 0.632), proportion of those eligible receiving a thrombolytic (78% versus 84%; P = 0.739), median time to electrocardiogram (7 mins versus 6 mins; P = 0.669) and other outcome measures. Results showed superior outcome measures than other published studies.

CONCLUSIONS

The lack of impact of the implementation process for a chest pain CPW on thrombolytic delivery or time to electrocardiogram in these rural hospitals can be explained by a ceiling effect in outcome measures but was also compromised by the small sample. Results suggest that quality of AMI treatment in rural emergency departments (EDs) is high and does not contribute to the worse mortality rate reported for AMIs in rural areas.

Effects of a clinical pathway 3 years after implementation in breast surgery

PURPOSE

The aim of the present study is to evaluate the effects of the implementation of clinical pathways into routine practice of breast surgery.

MATERIALS AND METHODS

We implemented a clinical pathway for breast surgery in 2006 and analysed for the following 3 years its path in respect to hospital stay, total costs per case, readmission rate, and patients' satisfaction.

RESULTS

The mean hospital stay decreased significantly from 4.5 days in 2006 to 3.7 days in 2007 and revealed 3.4 days in 2008. This is a decrease by 24.4% for the duration of hospital stay. The total cost per case between 2006 and 2007 showed a significant decrease of 23.4%. The total costs increased by 13.4% in 2008. Readmission rate was under 5% and remained constant. Patients' satisfaction remained constant, whereby more than 90% of the expected good results were attained.

CONCLUSIONS

There is substantial evidence that clinical pathways lead to various improvements in clinical care in surgery. We show a constantly significant effect on duration of hospital stay without any increase in the number of readmissions. In our view, it is not only an economic benefit which prevails here, but also especially a transparency of treatment which leads to higher compliance, better outcome and a shorter length of stay.

The impact of clinical nurse specialists on clinical pathways in the application of evidence-based practice

The purpose of this article was to address the call for evidence-based practice through the development of clinical pathways and to assert the role of the clinical nurse specialist (CNS) as a champion in clinical pathway implementation. In the current health care system, providing quality of care while maintaining cost-effectiveness is an ever-growing battle that institutions face. The CNS's role is central to meeting these demands. An extensive literature review has been conducted to validate the use of clinical pathways as a means of improving patient outcomes. This literature also suggests that clinical pathways must be developed, implemented, and evaluated utilizing validated methods including the use of best practice standards. Execution of clinical pathways should include a clinical expert, who has the ability to look at the system as a whole and can facilitate learning and change by employing a multitude of competencies while maintaining a sphere of influence over patient and families, nurses, and the system. The CNS plays a pivotal role in influencing effective clinical pathway development, implementation, utilization, and ongoing evaluation to ensure improved patient outcomes and reduced costs. This article expands upon the call for evidence-based practice through the utilization of clinical pathways to improve patient outcomes and reduce costs and stresses the importance of the CNS as a primary figure for ensuring proper pathway development, implementation, and ongoing evaluation.

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.

Coronary artery bypass graft (CABG) surgery patients in a clinical pathway gained less in health-related quality of life as compared with patients who undergo CABG in a conventional-care plan

AIMS AND OBJECTIVES

The aim of this study is to determine the difference between clinical pathway (CP) and conventional care in terms of health-related quality of life (HRQoL) domains, depression and anxiety, as well as to determine the relative contribution of CP towards an improved HRQoL after coronary artery bypass graft (CABG).

METHOD

A longitudinal quasi-experimental pre-test/post-test design was used to study and compare clinical outcome, HRQoL depression and anxiety for CP versus conventional-care patients after CABG. HRQoL was measured by using Sf-36, while depression and anxiety were measured by using hospital anxiety and depression scale. Length of stay and patient complications were derived from the hospital database.

RESULTS

We found that implementing a CP decreased hospital delay from 2.50 (+/-7.19) to 1.80 (+/-1.60), which was statistically significant P = 0.002. We also found that patients in the conventional-care plan improved more than patients in the CP in HRQoL. Outcomes in favour of patients in the conventional-care trajectory were based on the difference between small effect sizes (ES) (> or =0.20 <0.50) for pathway patients and moderate ES (> or =0.50 <0.80) for conventional-care patients, except for the domain of physical functioning and physical component summary, where the ES for conventional care was large (>0.80).

CONCLUSION

The aim of designing and implementing pathways is to decrease length of stay and costs, while maintaining quality of care and improving patient outcomes. Our findings suggest that these aims were not fulfilled in this CABG pathway. We recommend that when designing a CP, all patient-related characteristics, risk indicators, along with physiological status, be taken into consideration.

An interdisciplinary, evidence-based process of clinical pathway implementation increases pathway usage

Clinical pathways have been implemented in many healthcare settings as a link between evidence and practice. Most published research concludes that when clinical pathways are implemented and used by health professionals, there is a positive impact on health outcomes. However, some research also suggests that utilization of clinical pathways by health professionals is low and that implementation strategies for linking evidence with clinical practice often prove to be weak or ineffective. This paper describes a before and after study to determine whether an interdisciplinary, genuinely collaborative, and evidence-based process of clinical pathway implementation resulted in increased documented use of an acute myocardial infarction (AMI) clinical pathway by health professionals in a regional Australian hospital. Underpinning the design and implementation process was the belief that true team involvement would lead to ownership, acceptance, and, ultimately, to increased usage of the pathway. Documented clinical pathway usage was measured in two ways: (1) the presence of the AMI clinical pathway in the medical records of patients diagnosed with an AMI and (2) the proportion of the AMI clinical pathway completed when it was present in the medical record. A total of 195 medical records of those diagnosed with an AMI were audited before (n = 124) and after (n = 71) the implementation process. The interdisciplinary, truly collaborative, and evidence-based implementation process resulted in a statistically significant increase in documented usage of the AMI pathway (22.6% vs. 57.7%; p <.000). Results indicate that involvement of key users in the design and implementation of a clinical pathway significantly increases staff utilization of the document.