The effects of clinical pathways for renal transplant on patient outcomes and length of stay

Behavioral signs of an unintended error in nursing information sharing with electronic clinical pathways: a mixed research approach

Electronic clinical pathways (ECPs) strongly encourage the standardization of medical treatment and the sharing of information among medical staff. The goal of this study was to determine the influence of ECPs on information sharing among nurses in a university hospital. Four experienced nurses, selected based on ECP composing and operation experience, were recruited from the department with the most frequent users in the first-round interview, 132 nurses' questionnaire answers were analyzed, and eight nurses participated in the second-round interview. This study conducted a mixed-method (interview-questionnaire-interview) investigation to extract the behavioral signs of unintended errors in information sharing after the ethical approval was obtained. On the basis of ANOVA and t-test for the questionnaire and constant comparison for interview, this study found that the greater extent of user dependency on convenient ECPs in the frequent-use group led to mistakes under hectic conditions. This study also found evidence of poor management of ECPs when problems occurred. The immature design of ECPs provoked inappropriate behaviors among nurses even though they brought about some benefits such as mitigation of the burden of daily recording tasks. The findings empirically showed the ECP user's behavioral changes regarding the technology-induced error.

Development and implementation of an enhanced recovery after surgery protocol for renal transplantation

BACKGROUND

Successful implementation of enhanced recovery after surgery (ERAS) in kidney transplantation requires multidisciplinary consultation, education and attention to protocol. This study discusses the process implementation pathway of the ERAS protocol and its outcome.

METHODS

A standardized ERAS protocol was designed for the renal transplant recipient and implemented in July 2017. Data collected prospectively of recipients transplanted from July 2017 to December 2018 were compared to prospectively collected data of recipients who were transplanted prior to ERAS implementation from January 2016 to July 2017 from our renal database. The parameters of interest included length of stay, incidence of delayed graft function and readmission rate.

RESULTS

There was no difference in the demographics and the incidence of delayed graft function across both groups, although subgroup analysis suggested a significantly lower incidence of delayed graft function with kidneys donated after circulatory death in the cohort that were managed by the ERAS protocol. The median length of stay for patients on the ERAS protocol was 5 days (range 3-16 days). This was 2 days shorter than the median length of stay for patients not on the ERAS protocol (7 days; range 5-14, P < 0.001). This statistically significant difference in length of stay was consistent across all donor subgroups (living donor, donor after cardiac death and donation after brainstem death). Seventy-nine percent of the patients on the ERAS protocol were discharged on post-operative day 4.

CONCLUSION

An ERAS protocol for renal transplant patients is feasible. Our data show that successful implementation of ERAS in kidney transplantation is possible and results in significant cost savings due to shorter length of stay.

An Integrated Care Pathway Appraisal Tool: A ‘Badge of Quality’

Integrated care pathways (ICPs) are being introduced as a tool to improve the quality of health care. Their local development usually involves some consensus-based approach which engages clinical staff in discussions about how to improve services. Whilst this has definite advantages, it also means that ICPs which are developed for ostensibly the same group of patients with a specific disease or condition will vary in content and quality. Many articles have been written expounding the benefits of using ICPs, but recently there have been a number of evaluations of ICPs which report little or no significant improvement in the quality of health care as a result of their introduction. Why is there this divergence of views about the value of ICPs? Could it be connected with the variability in quality of the ICPs being introduced? What is missing from many of the evaluations of ICPs undertaken so far is a consideration of how good those ICPs really are.

This article describes an appraisal instrument for ICPs — the integrated care pathway appraisal tool (ICPAT) — which has been developed within the West Midlands region of the UK and which can provide a framework for assessing the quality of ICPs.

Teaching Patients about Kidney Transplantation: Documentation

Increasing demands are being placed on transplant nurse coordinators for more precise documentation of their teaching of kidney transplant patients, but the amount of time nurses have for this added documentation remains unchanged or has diminished. After a thorough review of the literature, our transplant team found no patient teaching documentation format that assisted us in overcoming the problem of increased demands. Consequently, following the Joint Commission on Accreditation of Healthcare Organization standards, we developed a Renal Transplant Patient Teaching Record that has assisted our team in documenting the pre- and post-transplant patient teaching that we complete.

A qualitative survey of staff responses to an integrated care pathway pilot study in a mental healthcare setting

This qualitative study set out to discover a multidisciplinary team's impressions of an integrated care pathway pilot. Specific aims were: to explore participants' beliefs about the effectiveness and limitations of the pilot and its impact on practice, and to use the findings to develop recommendations for the future of integrated care pathways within the clinical area. The research setting was an in-patient dementia assessment service, forming part of the mental health directorate of an NHS trust in the east of England. Data were generated through semi-structured interviews with a purposive sample of the multidisciplinary team, based on the premise that a qualitative approach develops an insider view of the team's experiences, beliefs and perceptions. Theoretical analysis was conducted, based on the analytical framework described, and facilitated through the use of QSR.NUD.IST IV content analysis software. Four categories emerged, which focused on: the clinical impact of the pathway; team performance; pathway effectiveness; and practice development.

The team's impressions corroborated experiences of integrated care pathways outlined in the literature. Benefits identified by the team were the pathway's influence on managing care, increased efficiency, better team working and perceived positive impact on the experience of patient and carer. Particular new insights focused on the pathway's impact on professional roles and responsibilities. The study indicated that the pathway concept was adaptable to this mental health setting and that benefits had been derived. The study's limitations are the inherent complexities associated with validity and reliability. Recommendations relate to local evaluation of the integrated care pathway pilot and wider research considerations.

Reducing the burden of surgical harm: a systematic review of the interventions used to reduce adverse events in surgery

OBJECTIVE

To perform a systematic review of interventions used to reduce adverse events in surgery.

BACKGROUND

Many interventions, which aim to improve patient safety in surgery, have been introduced to hospitals. Little is known about which methods provide a measurable decrease in morbidity and mortality.

METHODS

MEDLINE, EMBASE, and Cochrane databases were searched from inception to Week 19, 2012, for systematic reviews, randomized controlled trials (RCTs), and cross-sectional and cohort studies, which reported an intervention aimed toward reducing the incidence of adverse events in surgical patients. The quality of observational studies was measured using the Newcastle-Ottawa Scale. RCTs were assessed using the Cochrane Collaboration's tool for assessing risk of bias.

RESULTS

Ninety-one studies met inclusion criteria, 26 relating to structural interventions, 66 described modifying process factors. Only 17 (of 42 medium to high quality studies) reported an intervention that produced a significant decrease in morbidity and mortality. Structural interventions were: improving nurse to patient ratios (P = 0.008) and Intensive Care Unit (ITU) physician involvement in postoperative care (P < 0.05). Subspecialization in surgery reduced technical complications (P < 0.01). Effective process interventions were submission of outcome data to national audit (P < 0.05), use of safety checklists (P < 0.05), and adherence to a care pathway (P < 0.05). Certain safety technology significantly reduced harm (P = 0.02), and team training had a positive effect on patient outcome (P = 0.001).

CONCLUSIONS

Only a small cohort of medium- to high-quality interventions effectively reduce surgical harm and are feasible to implement. It is important that future research remains focused on demonstrating a measurable reduction in adverse events from patient safety initiatives.

Shortened length of stay improves financial outcomes in living donor kidney transplantation

Kidney transplantation is the preferred clinical and most cost-effective option for end-stage renal disease. Significant advances have taken place in the care of the transplant patients with improvements in clinical outcomes. The optimization of the costs of transplantation has been a constant goal as well. We present herein the impact in financial outcomes of a shortened length of stay after kidney transplant.

Reducing Liver Transplant Length of Stay: A Lean Six Sigma Approach

Context

Organ transplant centers are under increasing scrutiny to maintain outcomes while controlling cost in a challenging population of patients. Throughout health care and transplant specifically, length of stay is used as a benchmark for both quality and resource utilization.

Objective

To decrease our length of stay for liver transplant by using Lean Six Sigma methods.

Design

The Six Sigma DMAIC (Define, Measure, Analyze, Improve, Control) method was used to systematically analyze our process from transplant listing to hospital discharge after transplant, identifying many factors affecting length of stay.

Patients or Other Participants

Adult, single-organ, primary liver transplant recipients between July 2008 and June 2012 were included in the study. Recipients with living donors or fulminant liver failure were excluded.

Intervention(s)

Multiple interventions, including a clinical pathway and enhanced communication, were implemented.

Main Outcome Measure(s)

Length of stay after liver transplant and readmission after liver transplant.

Results

Median length of stay decreased significantly from 11 days before the intervention to 8 days after the intervention. Readmission rate did not change throughout the study. The improved length of stay was maintained for 24 months after the study.

Conclusion

Using a Lean Six Sigma approach, we were able to significantly decrease the length of stay of liver transplant patients. These results brought our center's outcomes in accordance with our goal and industry benchmark of 8 days. Clear expectations, improved teamwork, and a multidisciplinary clinical pathway were key elements in achieving and maintaining these gains.

Forty-eight hour kidney transplant admissions

Forty-eight hour kidney transplantation admissions are a feasible option in selected recipients of live-donor allografts through the use of standardized post-operative protocols, multidisciplinary team patient care, and intensive follow-up at outpatient centers. Age, gender, and pre-transplant dialysis status did not impact the ability to achieve 48-hour admissions. We did not identify any other pre-operative risk factors that contributed to increased length of stay. Although ABO and highly sensitized recipients had longer lengths of stay, the subgroup was too small to achieve statistical significance. We did not encounter any readmissions within the first seven post-operative days. Further improvements in clinical management will enhance the potential to shorten the length of hospital stay for all kidney transplant recipients.

How has the impact of 'care pathway technologies' on service integration in stroke care been measured and what is the strength of the evidence to support their effectiveness in this respect?

EXECUTIVE SUMMARY:

BACKGROUND

Across the developed world, we are witnessing an increasing emphasis on the need for more closely coordinated forms of health and social care provision. Integrated care pathways (ICPs) have emerged as a response to this aspiration and are believed by many to address the factors which contribute to service integration. ICPs map out a patient's journey, providing coordination of services for users. They aim to have: 'the right people, doing the right things, in the right order, at the right time, in the right place, with the right outcome'. The value for ICPs in supporting the delivery of care across organisational boundaries, providing greater consistency in practice, improving service continuity and increasing collaboration has been advocated by many. However, there is little evidence to support their use, and the need for systematic evaluations in order to measure their effectiveness has been widely identified. A recent Cochrane review assessed the effects of ICPs on functional outcome, process of care, quality of life and hospitalisation costs of inpatients with acute stroke, but did not specifically focus on service integration or its derivatives. To the best of our knowledge, no such systematic review of the literature exists.

OBJECTIVES

• To systematically review all high-quality studies which have evaluated the impact of care pathway technologies on 'service integration' and its derivatives in stroke care • To examine how elements of service integration are defined in such studies • To examine the type of evidence utilised to measure service integration • To analyse the weight of evidence used to support claims about the effectiveness of ICPs on improving service integration • To produce recommendations for ICP developers, users and evaluators.

INCLUSION CRITERIA

Types of participants The review focused on the care of adult patients who had suffered a stroke. It included the full spectrum of services - acute care, rehabilitation and long-term support - in hospital and community settings. Types of intervention(s)/phenomena of interest Integrated care pathways were the intervention of interest, defined for the purpose of this review as 'a multidisciplinary tool to improve the quality and efficiency of evidence based care and is used as a communication tool between professionals to manage and standardise the outcome orientated care' Here 'multidisciplinary' is taken to refer to the involvement of two or more disciplines. Types of outcomes 'Service integration' was the outcome of interest however, this was defined and measured in the selected studies. Types of studies This review was concerned with how 'service integration' was defined in evaluations of ICPs; the type of evidence utilised in measuring the impact of the intervention and the weight of evidence to support the effectiveness of care pathway technologies on 'service integration'. Studies that made an explicit link between ICPs and service integration were included in the review. Evidence generated from randomised controlled trials, quasi-experimental, qualitative and health economics research was sought. The search was limited to publications after 1980, coinciding with the emergence of ICPs in the healthcare context. Assessment for inclusion of foreign papers was based on the English-language abstract, where available. These were included only if an English translation was available.

EXCLUSION CRITERIA

This review excluded studies that: • focused only on a single aspect of stroke care (e.g. dysphasia) • evaluated ICPs as part of a wider program of service development • did not make an explicit link between ICPs and service integration • did not meet the definition of ICP utilised for the purposes of the review • focused exclusively on the outcomes of variance analysis

SEARCH STRATEGY

In order to avoid replication, the Joanna Briggs Institute for Evidence Based Nursing and Midwifery Database and the Cochrane Library were searched to establish that no systematic reviews existed and none were in progress. A three-stage search strategy was then used to identify both published and unpublished studies (see Appendix III).

DATA COLLECTION

Our search strategy located 2123 papers, of which 39 were retrieved for further evaluation. We critically appraised seven papers, representing five studies. These were all evaluation studies and, as is typical in this field, comprised a range of study designs and data collection methods. Owing to the diversity of the study types included in the review, we developed a single-appraisal checklist and data-extraction tool which could be applied to all research designs.(32) The tool drew on the Joanna Briggs Institute (JBI) appraisal checklists for experimental studies and interpretive and critical research, and also incorporated specific information and issues which were relevant for our purposes (see Appendix VI). This extends the thinking outlined in Lyne et al.(31) in which, drawing on Campbell and Stanley's classic paper, the case is made for developing an appraisal tool which is applicable to all types of evaluation, irrespective of study design. In assessing the quality of the papers, we were sympathetic to the methodological challenges of evaluating complex interventions such as ICPs. We were also cognisant of the very real constraints in which service evaluations are frequently undertaken in healthcare contexts. In accordance with the aims of this particular review, we have included studies, which are methodologically weaker than is typical of many systematic reviews because, in our view, in the absence of stronger evidence, they yield useful information.

DATA SYNTHESIS

Given the heterogeneity of the included studies, meta-analysis and/or qualitative synthesis was not possible. A narrative summary of the study findings is presented.

RESULTS

1 ICPs can be effective in ensuring that patients receive relevant clinical interventions and/or assessments in a timely manner, although these improvements may reflect better documentation rather than actual changes in practice. 2 ICPs can be effective in improving the documentation of rehabilitation goals, documentation of communication with patients, carers (diagnosis, prognosis and follow-up arrangements) and documentation of notification of primary care physicians of discharge. However, this can create additional burdens of work for staff. 3 Early studies of ICP-managed care in the acute stroke context have demonstrated reduced length of stay without any associated adverse effects on discharge destination, morbidity or mortality. These effects do not reach statistical significance, however, and may reflect wider changes in service provision and a general trend towards reduced length of hospital stay. While later studies in the acute and rehabilitation contexts do not reveal any significant reduction in length of stay, they do report greater documented use of certain clinical interventions and assessments, suggesting that ICPs can be effective in mobilising hospital resources around the patient. 4 ICPs implemented in the context of acute stroke care can be effective in reducing the occurrence of urinary tract infections, although we do not know whether this can be attributed to improved service integration. 5 ICP management in stroke rehabilitation may not be flexible enough to meet diverse patient needs and can result in insufficient attention to higher-level functioning and carer needs influencing perceptions of quality of life. 6 ICP management may assist in clarifying role boundaries and a shared understanding of the work, but this can result in some members of the disciplinary team perceiving that their contribution is not appropriately reflected in the documentation. 7 There is some evidence that ICPs may be effective in changing professional behaviours in the desired direction where there is scope for improvement, but in situations in which multidisciplinary working is effective, their positive effects may be limited. Furthermore, it is far from clear what the active ingredients of ICPs actually are. Kwan et al. suggest that it was the process of ICP development that had most impact on behaviours rather than the use of the artefact per se.(20) 8 None of the studies assessed the balance of costs and benefits of ICP use. Therefore, we do not know whether the costs of ICP development and implementation are justified by any of the reported benefits.

CONCLUSIONS

Implications for practice There is some evidence that ICPs may support certain elements of service integration in the context of stroke care. This seems to be as a result of their ability to support the timely implementation of clinical interventions and the mobilisation of resources around the patient without incurring additional increases in length of stay. ICPs appear to be most successful in improving service coordination in the acute stroke context where patient care trajectories are predictable. Their value in the context of rehabilitation settings in which recovery pathways are more variable is less clear. There is some evidence that ICPs may be effective in bringing about behavioural changes in contexts where deficiencies in service provision have been identified. Their value in contexts where inter-professional working is well established is less clear. While earlier before and after studies show a reduction in length of stay in ICP-managed care, this may reflect wider healthcare trends, and the failure of later studies to demonstrate further reductions suggests that there may be limits as to how far this can continue to be reduced. There is some evidence to suggest that ICPs bring about improvements in documentation, but we do not know how far documented practice reflects actual practice. It is unclear how ICPs have their effects and the relative importance of the process of development and the artefact in use. (ABSTRACT TRUNCATED)

A systematic approach to postoperative management of deceased donor kidney transplant patients with a clinical pathway

CONTEXT

Clinical pathways have been used in many acute hospital settings.

OBJECTIVES

To develop a systematic approach to postoperative care of adult recipients of deceased donor kidney transplants at the University of Mississippi Medical Center.

DESIGN AND SETTING

A pilot quality improvement project that uses implementation of a clinical pathway 24 hours after surgery for adult recipients of a deceased donor kidney transplant for 7 months. Charts from the same 7 months of the preceding year were retrospectively reviewed for comparison. The project occurred on the transplant floor in an acute care hospital and did not include any patients admitted to the intensive care unit.

MAIN OUTCOME MEASURES

To demonstrate that clinical pathways can (1) promote a method for standardizing postoperative care, (2) decrease postoperative length of stay, and (3) contain costs by minimizing hospital charges related to laboratory and room fees and promote efficient medication use in adult recipients of a deceased donor kidney transplant.

RESULTS

All 24 patients in the clinical pathway group met daily goals of the implemented clinical pathway. The clinical pathway group had statistically significant decreases in postoperative length of stay, use of laboratory tests, and use of intravenous medications compared with the comparison group. The 2 groups were similar in race, sex, age, and body mass index. Surgical readmissions did not differ significantly between the 2 groups.

A Systematic Approach to Postoperative Management of Deceased Donor Kidney Transplant Patients with a Clinical Pathway

Context

Clinical pathways have been used in many acute hospital settings.

Objectives

To develop a systematic approach to postoperative care of adult recipients of deceased donor kidney transplants at the University of Mississippi Medical Center.

Design and Setting

A pilot quality improvement project that uses implementation of a clinical pathway 24 hours after surgery for adult recipients of a deceased donor kidney transplant for 7 months. Charts from the same 7 months of the preceding year were retrospectively reviewed for comparison. The project occurred on the transplant floor in an acute care hospital and did not include any patients admitted to the intensive care unit.

Main Outcome Measures

To demonstrate that clinical pathways can (1) promote a method for standardizing postoperative care, (2) decrease postoperative length of stay, and (3) contain costs by minimizing hospital charges related to laboratory and room fees and promote efficient medication use in adult recipients of a deceased donor kidney transplant.

Results

All 24 patients in the clinical pathway group met daily goals of the implemented clinical pathway. The clinical pathway group had statistically significant decreases in postoperative length of stay, use of laboratory tests, and use of intravenous medications compared with the comparison group. The 2 groups were similar in race, sex, age, and body mass index. Surgical readmissions did not differ significantly between the 2 groups.

Effects of a clinical pathway on quality of care in kidney transplantation: a non-randomized clinical trial

PURPOSE

Standardization of care is essential for improving outcome of kidney transplantation (KT). Clinical pathways (CPs) are known to standardize and improve perioperative care for a number of interventions. In transplantation medicine, however, pertinent evidence is very limited. This study evaluates effects of a CP on quality of care in KT.

MATERIALS AND METHODS

Consecutive patients (n=32) undergoing KT between July 2006 and August 2007 who were treated with a CP were compared to patients (n=44) treated without CP between January 2005 and June 2006. Several quality indicators regarding process and outcome were compared between groups.

RESULTS

Quality of care was significantly higher in the CP group for the following indicators: timely removal of central venous catheters, wound drains, and Foley catheters and control of cyclosporine levels, respiratory exercising, and pain control. Median stay decreased non-significantly from 21.4 to 18.3 days. There was significantly less delayed graft function in the CP group. All other outcome indicators showed no significant differences.

CONCLUSIONS

Implementation of a CP for KT improves the quality of perioperative treatment by standardizing care. Regarding effects on outcome, no clear conclusion can be drawn. We recommend that large randomized studies are conducted to evaluate the latter issue.

How has the impact of 'care pathway technologies' on service integration in stroke care been measured and what is the strength of the evidence to support their effectiveness in this respect?

BACKGROUND

Across the developed world, we are witnessing an increasing emphasis on the need for more closely coordinated forms of health and social care provision. Integrated care pathways (ICPs) have emerged as a response to this aspiration and are believed by many to address the factors which contribute to service integration. ICPs map out a patient's journey, providing coordination of services for users. They aim to have: 'the right people, doing the right things, in the right order, at the right time, in the right place, with the right outcome'. The value for ICPs in supporting the delivery of care across organisational boundaries, providing greater consistency in practice, improving service continuity and increasing collaboration has been advocated by many. However, there is little evidence to support their use, and the need for systematic evaluations in order to measure their effectiveness has been widely identified. A recent Cochrane review assessed the effects of ICPs on functional outcome, process of care, quality of life and hospitalisation costs of inpatients with acute stroke, but did not specifically focus on service integration or its derivatives. To the best of our knowledge, no such systematic review of the literature exists.

OBJECTIVES

INCLUSION CRITERIA: Types of participants The review focused on the care of adult patients who had suffered a stroke. It included the full spectrum of services - acute care, rehabilitation and long-term support - in hospital and community settings.Types of intervention(s)/phenomena of interest Integrated care pathways were the intervention of interest, defined for the purpose of this review as 'a multidisciplinary tool to improve the quality and efficiency of evidence based care and is used as a communication tool between professionals to manage and standardise the outcome orientated care'. Here 'multidisciplinary' is taken to refer to the involvement of two or more disciplines.Types of outcomes Service integration' was the outcome of interest however, this was defined and measured in the selected studies.Types of studies This review was concerned with how 'service integration' was defined in evaluations of ICPs; the type of evidence utilised in measuring the impact of the intervention and the weight of evidence to support the effectiveness of care pathway technologies on 'service integration'. Studies that made an explicit link between ICPs and service integration were included in the review. Evidence generated from randomised controlled trials, quasi-experimental, qualitative and health economics research was sought. The search was limited to publications after 1980, coinciding with the emergence of ICPs in the healthcare context. Assessment for inclusion of foreign papers was based on the English-language abstract, where available. These were included only if an English translation was available.

EXCLUSION CRITERIA

This review excluded studies that: SEARCH STRATEGY: In order to avoid replication, the Joanna Briggs Institute for Evidence Based Nursing and Midwifery Database and the Cochrane Library were searched to establish that no systematic reviews existed and none were in progress. A three-stage search strategy was then used to identify both published and unpublished studies (see ).

DATA COLLECTION

Our search strategy located 2123 papers, of which 39 were retrieved for further evaluation. We critically appraised seven papers, representing five studies. These were all evaluation studies and, as is typical in this field, comprised a range of study designs and data collection methods. Owing to the diversity of the study types included in the review, we developed a single-appraisal checklist and data-extractiontool which could be applied to all research designs. The tool drew on the Joanna Briggs Institute (JBI) appraisal checklists for experimental studies and interpretive and critical research, and also incorporated specific information and issues which were relevant for our purposes (see ). This extends the thinking outlined in Lyne et al. in which, drawing on Campbell and Stanley's classic paper, the case is made for developing an appraisal tool which is applicable to all types of evaluation, irrespective of study design.In assessing the quality of the papers, we were sympathetic to the methodological challenges of evaluating complex interventions such as ICPs. We were also cognisant of the very real constraints in which service evaluations are frequently undertaken in healthcare contexts. In accordance with the aims of this particular review, we have included studies, which are methodologically weaker than is typical of many systematic reviews because, in our view, in the absence of stronger evidence, they yield useful information.

DATA SYNTHESIS

Given the heterogeneity of the included studies, meta-analysis and/or qualitative synthesis was not possible. A narrative summary of the study findings is presented.

RESULTS

Therefore, we do not know whether the costs of ICP development and implementation are justified by any of the reported benefits.

CONCLUSIONS

Implications for practice There is some evidence that ICPs may support certain elements of service integration in the context of stroke care. This seems to be as a result of their ability to support the timely implementation of clinical interventions and the mobilisation of resources around the patient without incurring additional increases in length of stay. ICPs appear to be most successful in improving service coordination in the acute stroke context where patient care trajectories are predictable. Their value in the context of rehabilitation settings in which recovery pathways are more variable is less clear. There is some evidence that ICPs may be effective in bringing about behavioural changes in contexts where deficiencies in service provision have been identified. Their value in contexts where inter-professional working is well established is less clear. While earlier before and after studies show a reduction in length of stay in ICP-managed care, this may reflect wider healthcare trends, and the failure of later studies to demonstrate further reductions suggests that there may be limits as to how far this can continue to be reduced. There is some evidence to suggest that ICPs bring about improvements in documentation, but we do not know how far documented practice reflects actual practice. It is unclear how ICPs have their effects and the relative importance of the process of development and the artefact in use. As none of the studies reviewed included an economic evaluation, moreover, it remains unclear whether the benefits of ICPs justify the costs of their implementation.

Are the outcomes of clinical pathways evidence-based? A critical appraisal of clinical pathway evaluation research

AIM AND OBJECTIVE

To evaluate the validity of study outcomes of published papers that report the effects of clinical pathways (CP).

METHOD

Systematic review based on two search strategies, including searching Medline, CINAHL, Embase, Psychinfo and Picarta from 1995 till 2005 and ISI Web of Knowledge SM. We included randomized controlled or quasi-experimental studies evaluating the efficacy of clinical pathway application. Assessment of the methodological quality of the studies included randomization, power analysis, selection bias, validity of outcome indicators, appropriateness of statistical tests, direct (matching) and indirect (statistical) control for confounders. Outcomes included length of stay, costs, readmission rate and complications. Two reviewers independently assessed the methodological quality of the selected papers and recorded the findings with an evaluation tool developed from a set of items for quality assessment derived from the Cochrane Library and other publications.

RESULTS

The study sample comprised of 115 publications. A total of 91.3% of the studies comprised of retrospective studies and 8.7% were randomized controlled studies. Using a quality-scoring assessment tool, 33% of the papers were classified as of good quality, whereas 67% were classified as of low quality. Of the studies, 10.4% controlled for confounding by matching and 59.1% adopted parametric statistical tests without testing variables on normal distribution. Differences in outcomes were not always statistically tested.

CONCLUSION

Readers should be cautious when interpreting the results of clinical pathway evaluation studies because of the confounding factors and sources of contamination affecting the evidence-based validity of the outcomes.

Re-mapping client journeys and professional identities: a review of the literature on clinical pathways

OBJECTIVES

To explore the growing use of clinical pathways by nurses and midwives, their impact on client care, and the potential consequences of widespread pathway utilisation for the professional identity and knowledge base of nursing and midwifery.

METHODS

A keyword search was performed within CINAHL and PubMed for the period 1995-2006 to identify relevant material, and article bibliographies were examined to identify relevance references. Thirty-nine publications were selected for inclusion in the analysis on the basis that they offered the most original account of the development of pathways or their effectiveness, or because they provided useful theoretical concepts. A thematic analysis of the selected articles was undertaken.

RESULTS

The review identified four main themes: the multiple aims of clinical pathways; the process of initial development; pathway implementation in practice, and the impacts of pathways on client care, professional identities, and the nature of written documentation. Clinical pathways have multiple aims, including standardising practice, levering external evidence into local health care work, and improving interprofessional co-ordination. The review found limited evidence of pathways' impact on client care, but the existing research suggests that they may be most suitable for predictable, routinised surgical procedures. Key concepts, such as variance and audit were found to be poorly defined. Clinical pathways appear to achieve many of their effects at the development stage and the reshaping of professional interactions.

CONCLUSIONS

Given their widespread adoption and valorisation as tools of evidence-based practice, the dearth of evidence for clinical pathways should raise concerns. Clinical pathways may have significant impacts on nursing and midwifery as professions, both through redrawing professional identities and boundaries, and transforming the ways in which nurses and midwives document care. The impact of standardised pathways on professional ideologies which emphasise individualised care, and clinical autonomy will require long-term programmes of research.

The association between length of post-kidney transplant hospitalization and long-term graft and recipient survival

BACKGROUND

There has been a general trend towards shortened length of post-kidney transplant hospitalization (LOH). The decision regarding patients's discharge from the hospital theoretically may be based on several factors, including, but not limited to, patient well being, insurance status, family situation and other, mostly socio-economic factors, as opposed to hard medical evidence. However, the appropriate LOH in kidney transplant recipients is not well studied regarding long-term outcomes.

METHODS

This study retrospectively analysed the association between LOH and graft and recipient survival based on United States Renal Data System dataset. In total, 100,762 patients who underwent transplant during 1995-2002 were included. Kaplan-Meier survival analysis and Cox models were applied to the whole patient cohort and on sub-groups stratified by the presence of delayed graft function, patient comorbidity index and donor type (deceased or living).

RESULTS

In recipient survival, both short (<4 d) and long (>5 d) LOH showed a significant adverse effect (p < 0.01) on survival times. In the analysis of graft survival, long LOH (>or=2 wk) also showed significant adverse effects (p < 0.001) on survival times. However, short LOH (<4 d) did not reach statistical significance, although it was still associated with adverse effects on graft survival. These observations were consistent across the whole patient cohort and sub-groups stratified by the presence of delayed graft function, patient comorbidity index and donor type.

CONCLUSION

Clinical considerations should be used to make the decision regarding appropriate time of post-kidney transplant recipient discharge. Based on this study, shorter than four d post-kidney transplant hospitalization may potentially be harmful to long-term graft and recipient survival.

Decision tools in health care: focus on the problem, not the solution

Background

Systematic reviews or randomised-controlled trials usually help to establish the effectiveness of drugs and other health technologies, but are rarely sufficient by themselves to ensure actual clinical use of the technology. The process from innovation to routine clinical use is complex. Numerous computerised decision support systems (DSS) have been developed, but many fail to be taken up into actual use. Some developers construct technologically advanced systems with little relevance to the real world. Others did not determine whether a clinical need exists. With NHS investing £5 billion in computer systems, also occurring in other countries, there is an urgent need to shift from a technology-driven approach to one that identifies and employs the most cost-effective method to manage knowledge, regardless of the technology. The generic term, 'decision tool' (DT), is therefore suggested to demonstrate that these aids, which seem different technically, are conceptually the same from a clinical viewpoint.

Discussion

Many computerised DSSs failed for various reasons, for example, they were not based on best available knowledge; there was insufficient emphasis on their need for high quality clinical data; their development was technology-led; or evaluation methods were misapplied. We argue that DSSs and other computer-based, paper-based and even mechanical decision aids are members of a wider family of decision tools. A DT is an active knowledge resource that uses patient data to generate case specific advice, which supports decision making about individual patients by health professionals, the patients themselves or others concerned about them. The identification of DTs as a consistent and important category of health technology should encourage the sharing of lessons between DT developers and users and reduce the frequency of decision tool projects focusing only on technology. The focus of evaluation should become more clinical, with the impact of computer-based DTs being evaluated against other computer, paper- or mechanical tools, to identify the most cost effective tool for each clinical problem.

Summary

We suggested the generic term 'decision tool' to demonstrate that decision-making aids, such as computerised DSSs, paper algorithms, and reminders are conceptually the same, so the methods to evaluate them should be the same.

Critical pathway effectiveness: assessing the impact of patient, hospital care, and pathway characteristics using qualitative comparative analysis

OBJECTIVE

To qualitatively describe patient, hospital care, and critical pathway characteristics that may be associated with pathway effectiveness in reducing length of stay.

DATA SOURCES/STUDY SETTING

Administrative data and review of pathway documentation and a sample of medical records for each of 26 surgical critical pathways in a tertiary care center's department of surgery, 1988-1998.

STUDY DESIGN

Retrospective qualitative study. DATA COLLECTION/ABSTRACTION METHODS: Using information from a literature review and consultation with experts, we developed a list of characteristics that might impact critical pathway effectiveness. We used hypothesis-driven qualitative comparative analysis to describe key primary and secondary characteristics that might differentiate effective from ineffective critical pathways.

PRINCIPAL FINDINGS

" All 7 of the 26 pathways associated with a reduced length of stay had at least one of the following characteristics: (1) no preexisting trend toward lower length of stay for the procedure (71 percent), and/or (2) it was the first pathway implemented in its surgical service (71 percent). In addition, pathways effective in reducing length of stay tended to be for procedures with lower patient severity of illness, as indicated by fewer intensive care days and lower mortality. Effective pathways tended to be used more frequently than ineffective pathways (77 versus 59 percent of medical records with pathway documents present), but high rates of documented pathway use were not necessary for pathway effectiveness.

CONCLUSIONS

Critical pathway programs may have limited effectiveness, and may be effective only in certain situations. Because pathway utilization was not a strong predictor of pathway effectiveness, the mechanism by which critical pathways may reduce length of stay is unclear.

Does a clinical pathway improve the quality of care for sickle cell anemia?

BACKGROUND

Clinical pathways are often implemented to improve care, yet their effect on quality of care and outcomes is often not evaluated. The Johns Hopkins Children's Center instituted a clinical pathway in early 1996 to improve the care for pediatric sickle cell vaso-occlusive crisis (VOC) and used a retrospective before-after study to describe how quality of care and outcomes changed after introduction of the pathway.

RESULTS

Physicians used the pathway in 43% of eligible admissions, with use decreasing over time. Patients on the pathway were more likely to receive each of its required elements than those not on the pathway (odds ratios [OR] 1.15-2.49). After pathway implementation, even patients not on the pathway were more likely to receive incentive spirometry than those admitted before pathway availability (OR 1.40). Pathway use was associated with longer length of stay (LOS) and time to oral pain medication, while readmission rates did not change.

DISCUSSION

Use of a clinical pathway improved quality of care by increasing compliance with specific care elements, with mixed results on outcomes. Pathways may improve care for all patients, including nonpathway-treated patients, by influencing underlying practice patterns. Quality improvement committees must regularly monitor outcomes after pathway implementation to evaluate the need for pathway reinforcement and refinement.

Improving clinical decisions and outcomes with information: a review

The clinical information available to clinicians is expanding rapidly. It can enhance clinical decision-making, but it can also confuse the process. To be most useful, information should be available at the time and place it is needed and be specific to the task at hand. In the new paradigm of medicine, one based on continuous quality improvement, useful information must be relevant to both the processes and outcomes of care. Clinical practice guidelines have become increasingly popular for improving the quality of health care. The field of medical informatics can bring cogent information to the point where decisions are being made to augment quality improvement activities in general, and practice guidelines in particular. However, such innovations are dependent on the type, quantity, and quality of information available. This article discusses when guidelines can enhance the quality and outcomes of care and how medical informatics can help achieve these goals. In particular, the barriers to the broad implementation of electronic medical records in a variety of health care settings are explored.

Critical pathways intervention to reduce length of hospital stay

PURPOSE

Despite their popularity, critical pathways have been evaluated in only a few controlled studies. We evaluated the effectiveness of critical pathways in reducing length of hospital stay.

SUBJECTS AND METHODS

We compared postoperative lengths of stay of patients who underwent coronary artery bypass graft (CABG) surgery, total knee replacement, colectomy, thoracic surgery, or hysterectomy before and after pathway implementation at a university hospital. For three procedures, changes in lengths of stay at neighboring hospitals without pathway programs were assessed for comparison.

RESULTS

A total of 6,796 patients underwent one of the procedures during the study. The percentage of eligible patients managed on a critical pathway ranged from 94% for hysterectomy to 26% for colectomy. For most procedures, the postoperative length of stay was decreasing during the baseline period. After pathway implementation, the length of stay decreased 21% for total knee replacement, 9% for CABG surgery, 7% for thoracic surgery, 5% for hysterectomy, and 3% for colectomy (all P < 0.01). However, similar decreases were seen in the neighboring hospitals that did not have critical pathways or other specific efficiency initiatives.

CONCLUSIONS

Critical pathways were associated with a rapid reduction in postoperative length of stay after all five study procedures. Secular trends at nearby hospitals, however, produced comparable reductions for the three procedures available for comparison. These findings raise questions about the effectiveness of critical pathways in a competitive environment.

Teaching patients about kidney transplantation: documentation

Increasing demands are being placed on transplant nurse coordinators for more precise documentation of their teaching of kidney transplant patients, but the amount of time nurses have for this added documentation remains unchanged or has diminished. After a thorough review of the literature, our transplant team found no patient teaching documentation format that assisted us in overcoming the problem of increased demands. Consequently, following the Joint Commission on Accreditation of Healthcare Organization standards, we developed a Renal Transplant Patient Teaching Record that has assisted our team in documenting the pre- and post-transplant patient teaching that we complete.

Care pathways: an evaluation of their effectiveness

This paper reports on a quasi-experimental case study of two care pathways--a midwifery-led maternity pathway and a breast disease pathway developed within one British National Health Service Trust. Of the aspects evaluated, those reported here are: a comparison of clinical care delivered before (the control group) and after the introduction of the two pathways; a comparison of patient satisfaction levels before (the control group) and after the introduction of the two pathways; and views of staff involved in the development and operation of the two pathways. The results are mixed. In the breast disease pathway five of 12 clinical indicators showed change, but only two of these showed statistically significant changes; three were considered of clinical significance but could not be tested statistically. In the maternity pathway, after allowing for the effect of gravid status, five of 10 indicators showed changes between the pre-pathway and pathway users and of these four showed statistically significant changes. Patient satisfaction levels showed little overall change--only 15% of the questions for breast disease and 9% for maternity showed any statistically significant change. However, both surveys indicated precise areas where a change resulting from the introduction of the pathway could be linked to an increase in satisfaction. The clinical staff interviewed highlighted many positive features of the tool (26/40 comments). The most frequently cited favourable comment was its ability to make staff focus on the clinical care they were providing and how this could be improved. It also highlighted some areas for concern, in particular the introduction of pathway documentation.