Systematic review: indicators to evaluate effectiveness of clinical pathways for gastrointestinal surgery

Use and impact of clinical pathways across various healthcare settings: A protocol for an umbrella review of global evidence

AIM

The proposed umbrella review aims to assess the use and impact of clinical pathways on professional practice, patient outcomes, length of hospital stay, hospital costs, patient satisfaction, and hospital staff satisfaction through a synthesis of existing systematic reviews and meta-analyses.

METHODS

Following PRIOR guidelines, a systematic search will be conducted in MEDLINE, Epistemonikos, and the Cochrane Library to identify relevant systematic reviews and meta-analyses, from inception till March 2024. Two reviewers will independently screen titles and abstracts, with a third resolving any disagreements. Full-text articles considered potentially relevant will be assessed for eligibility by the same process. The data extraction form will cover information about the review methods, characteristics of the included primary studies, the types of interventions evaluated, and the reported outcomes. This standardized data extraction form will be piloted by the review team on five to ten articles to ensure all relevant information is recorded. The quality of included systematic reviews and meta-analyses will be evaluated using AMSTAR 2. PROSPERO registration number is CRD42024529371.

RESULTS

The study will present a narrative synthesis of the findings, addressing the clinical and methodological heterogeneity and assessing the impact of clinical pathways on various healthcare outcomes.

CONCLUSION AND IMPLICATIONS

This umbrella review will provide evidence-based insights into the effectiveness, challenges, and best practices of clinical pathways, guiding healthcare decision-making and identifying areas for future research. Results will be disseminated widely to inform policy and improve healthcare service delivery.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution, as this paper is a protocol of an umbrella review.

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.

End-of-life care in hospital: an audit of care against Australian national guidelines

Objective The aim of this study was to map end-of-life care in acute hospital settings against Elements 1-5 of the Australian Commission on Safety and Quality in Health Care's (ACSQHC) Essential Elements for Safe and High-Quality End-of-Life Care. Methods A retrospective medical record audit of deceased in-patients was conducted from 2016 at one public (n = 320) and one private (n = 132) hospital in Melbourne, Australia. Ten variables, key to end-of-life care according to the ACSQHC's Elements 1-5 were used to evaluate end-of-life care. Results Most patients (87.2%) had a limitation of medical treatment. In 91.97% (P < 0.0001) of cases, a written entry indicating poor prognosis preceded a documented decision to provide end-of-life care, with a documented decision noted in 81.1% of cases (P < 0.0001). Evidence of pastoral care involvement was found in 41.6% of cases (P < 0.0001), with only 33.1% of non-palliative care patients referred to specialist palliative care personnel (P = 0.059). An end-of-life care pathway was used in 51.1% of cases (P < 0.0001). Conclusion There is clear scope for improvement in end-of-life care provision. Health services need to mandate and operationalise Elements 1-5 of the ACSQHC's Essential Elements into care systems and processes, and ensure nationally consistent, high-quality end-of-life care. What is known about the topic? Acute care settings provide the majority of end-of-life care. Despite the ACSQHC's Ten Essential Elements, little is known about whether current end-of-life care practices align with recommendations. What does this paper add? There is room for improvement in providing patient-centred care, increasing family involvement and teamwork, describing and enacting goals of care and using triggers to prompt care. Differences between public and private hospitals may be the result of differences in standard practice or policy and differences in cultural diversity. What are the implications for practitioners? The Essential Elements need to be mandated and operationalised into mainstream care systems and processes as a way of ensuring safe and high-quality end-of-life 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.

The perceived and objectively measured effects of clinical pathways' implementation on medical care in China

Introduction

Substantial resources have been expended on clinical pathways (CPs), but the reported effects of CPs on medical care vary considerably. This study sought to determine the effects of CPs on medical care in Chinese hospitals, including the perceived effects of CPs on medical care and the objectively measured patient outcomes.

Methods

Study data were obtained from 54 public hospitals in three provinces of China in 2015. Hospital questionnaires, employee surveys, and chart reviews were used to collect data related to hospital characteristics, the implementation of CPs and compliance status, perceived effects of CPs, and objectively measured patient outcomes. Logistic regression models and linear regression models were adopted in this study.

Results

The effects of CPs were not highly perceived by the hospitals or by the managers and physicians in China. The relatively low involvement in the implementation of and adherence to CPs resulted in CPs having no significant effects on hospital medical care as a whole. However, a chart review of 5 conditions in Chinese hospitals demonstrated that compliance with national CPs reduced the length of stay (LOS) and inpatient medical costs.

Conclusions

CPs should be implemented widely and followed closely to improve hospital medical care as a whole, and further studies should be conducted to identify the key elements of the effects of CPs on patient clinical outcomes.

Does the Implementation of Clinical Pathways Affect Hierarchical Structures Within a Surgical Department? A Qualitative Study

Objective:

To explore effects of the implementation of clinical pathways (CPs) on hierarchical structures within a surgical department.

Summary of background data:

CPs are care plans stipulating diagnostic and therapeutic measures along a time axis for a given condition or procedure. They are widely used in surgery. There is limited evidence to what extent CP implementation has an effect on hierarchical structures within surgical departments.

Methods:

Semistructured individual interviews were conducted with key members of a CP project team in a large academic surgery department. Interviews were carried out by an external researcher to increase the likelihood of obtaining unbiased opinions. Using an interview guide, it was ensured that respondents provided opinions on various issues related to CP implementation, including hierarchical relationships within the department, but also between caregivers and patients. The transcribed text was independently content analyzed by 2 researchers who converged their findings.

Results:

Clinical pathway implementation changed perceived surgical hierarchy from a top-down to a participatory approach. However, it was acknowledged that some form of hierarchy is required to ensure successful clinical pathway implementation. Respondents felt that clinical pathways changed surgical culture from a largely eminence-based to more evidence-based medicine.

Conclusions:

The implementation of CPs potentially affects several dimensions of surgical hierarchy. It changes “traditional” surgical hierarchy and is associated with perception of increased autonomy and competency in junior staff. The clinical approach appears to shift from eminence- to evidence-based medicine. The knowledge about these changes is important for carrying out CP projects in surgery.

Development of a model care pathway for adults undergoing colorectal cancer surgery: Evidence-based key interventions and indicators

RATIONALE, AIMS, AND OBJECTIVES

During the last decades, perioperative care for patients with colorectal cancer has shifted towards more standardized care, so-called "enhanced recovery after surgery." Those programs aim to optimize interventions in perioperative care to decrease the rate of postoperative complications, improve patients' recovery, and shorten hospital stay. The purpose of this literature review is to identify, summarize, and operationalize the clinical content of both key interventions and clinical indicators to develop an evidence-based model pathway for surgical patients with colorectal cancer.

METHODS

A systematic search in 3 databases was conducted to identify key interventions (KIs) and indicators to measure the effect of implementation of care pathways. The KIs from the enhanced recovery after surgery protocol were listed and used as framework to identify and match KIs used in the included studies. The Clinical Pathway Compass was used to categorize the indicators.

RESULTS

Fifteen studies were included. The number of KI used in the study protocols ranged from 9 to 20. In total, 33 KIs were identified. Little information was available concerning the implementation of and compliance to the protocol. Length of stay and complication rate are the most common used indicators (used in 15/15 and 14/15 of the studies), followed by 21 other measures. All but one of the included studies reported a reduction in length of stay.

CONCLUSION

There is a considerable variation in both number of KIs and indicators as well as operationalization of key interventions, for surgical patients with colorectal cancer documented in literature. Therefore, we summarized the input from different studies and developed an evidence-based model pathway, which can serve as a basis for a local/regional care pathway team to build their own pathway.

Evaluation of the Effect of a Clinical Pathway on the Quality of Simulated Pre-Hospital Cardiopulmonary Resuscitation: Primary Experience from a Chinese Pre-Hospital Care Centre

Objective

The aim of this study was to assess the quality of simulated cardiopulmonary resuscitation (CPR) in local pre-hospital care teams and the improvement achieved by using clinical pathways.

Methods

A prospective observation study. The 2010 American Heart Association Guidelines for CPR, the personnel characteristics of ambulance staff, China's legal system requirements, and the available medical resources were used to design a clinical pathway for pre-hospital care of cardiac arrest. Case simulations were used to evaluate the quality of CPR before and after implementation of the clinical pathway.

Results

The number of teams which successfully implemented electrocardiogram monitoring, endotracheal intubation and intravenous access before training were 8 (17.8%), 5 (11.1%) and 6 (13.3%) respectively. These increased to 45 (100%), 43 (95.6%) and 43 (95.6%), respectively, after training. The number of teams with successful implementation of artificial ventilation, airway management and insertion of oropharyngeal airway before training were 43 (95.6%), 38 (84.4%) and 12 (26.7%) respectively. These increased to 45 (100%), 42 (93.3%) and 43 (95.6%), respectively, after training. Nine (20%) teams decided CPR onsite before training and 35 (77.8%) after training. The average rate of chest compressions before and after training was 120.3 ± 17.9 and 123.2 ± 17.1 compressions per minute, respectively (p>0.05).

Conclusion

Training using established clinical pathway significantly improves the quality of CPR and increases the use of ALS techniques. CPR training requires ongoing validation and optimisation to maintain effectiveness. (Hong Kong j.emerg.med. 2015;22:14-22)

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.

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.

The impact of a clinical pathway on patient postoperative recovery following pancreaticoduodenectomy

BACKGROUND

Pancreaticoduodenectomies (PD) are complex surgical procedures. Clinical pathways (CPW) are surgical process improvement tools that guide postoperative recovery and are associated with high quality care. Our objective was to report the quality of surgical care following implementation of a CPW.

METHODS

We developed and implemented a CPW for patients undergoing PD at a single high volume hepato-pancreato-biliary (HPB) centre. Patient outcomes were collected prospectively during the implementation period. A comparator cohort was selected by identifying patients that underwent a PD prior to CPW development.

RESULTS

122 patients underwent a PD during the CPW implementation period; 83 patients were initiated on the CPW. 74 patients underwent PD during the 12-month period prior to the CPW. The median hospital stay decreased after the implementation of the CPW (11 vs 8 days, p < 0.01) with no significant changes to mortality, morbidity, reoperation, or readmission rates. In-hospital complications were significantly higher in patients that were not initiated on the CPW (54% vs 74%, p = 0.03).

CONCLUSION

Results suggest the CPW reduced variability and allowed a greater proportion of patients to receive all elements of care, resulting in improved quality and efficiency of care based on current best evidence recommendations.

End-of-life care pathways for improving outcomes in caring for the dying

BACKGROUND

This is an updated version of a Cochrane review published in Issue 11, 2013 in the Cochrane Library. In many clinical areas, integrated care pathways are utilised as structured multidisciplinary care plans that detail essential steps in caring for patients with specific clinical problems. In particular, care pathways for the dying have been developed as a model to improve care of patients who are in the last days of life. The care pathways were designed with an aim of ensuring that the most appropriate management occurs at the most appropriate time, and that it is provided by the most appropriate health professional. Since the last update, there have been sustained concerns about the safety of implementing end-of-life care pathways, particularly in the United Kingdom (UK). Therefore, there is a significant need for clinicians and policy makers to be informed about the effects of end-of-life care pathways via a systematic review.

OBJECTIVES

To assess the effects of end-of-life care pathways, compared with usual care (no pathway) or with care guided by another end-of-life care pathway across all healthcare settings (e.g. hospitals, residential aged care facilities, community).In particular, we aimed to assess the effects on symptom severity and quality of life of people who are dying, or those related to the care, such as families, carers and health professionals, or a combination of these.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; Cochrane Library; 2015, Issue 6), MEDLINE, EMBASE, PsycINFO, CINAHL, review articles, trial registries and reference lists of relevant articles. We conducted the original search in September 2009, and the second updated search in July 2015.

SELECTION CRITERIA

All randomised controlled trials (RCTs), quasi-randomised trials or high quality controlled before-and-after studies comparing use versus non-use of an end-of-life care pathway in caring for the dying.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the results of the searches against the predetermined criteria for inclusion, assessed risk of bias, and extracted data. We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We screened 3028 titles, and included one Italian cluster RCT with 16 general medicine wards (inpatient units in hospitals) and 232 carers of cancer patients in this updated review. We judged the study to be at a high risk of bias overall, mainly due to a lack of blinding and rates of attrition. Only 34% of the participants (range 14% to 75% on individual wards) were cared for in accordance with the care pathway as planned. However, these issues were to be expected due to the nature of the intervention and condition. The study population was all cancer patients in their last days of life. Participants were allocated to care using the Liverpool Care Pathway (LCP-I, Italian version of a continuous quality improvement programme of end-of-life care) or to standard care. The primary outcomes of this review were physical symptom severity, psychological symptom severity, quality of life, and any adverse effects. Physical symptom severity was assessed as overall control of pain, breathlessness, and nausea and vomiting. There was very low quality evidence of a difference in overall control of breathlessness that favoured the Liverpool Care Pathway group compared to usual care: the study reported an odds ratio (OR) of 2.0 with 95% confidence intervals (CIs) 1.1 to 3.8. Very low quality evidence of no difference was found for pain (OR 1.3, 95% CI 0.7 to 2.6, P = 0.461) and nausea and vomiting (OR 1.5, 95% CI 0.7 to 3.2, P = 0.252). None of the other primary outcomes were assessed by the study. Limited data on advance care planning were collected by the study authors, making results for this secondary outcome unreliable. None of our other secondary outcomes were assessed by the study.

AUTHORS' CONCLUSIONS

There is limited available evidence concerning the clinical, physical, psychological or emotional effectiveness of end-of-life care pathways.

End-of-life care: pathways and evidence

PURPOSE OF REVIEW

Studies in different countries and settings of care have reported the quality of care for the dying patients as suboptimal. Care pathways have been developed with the aim of ensuring that dying patients and their family members received by health professionals the most appropriate care. This review presents and discusses the evidence supporting the effectiveness of the end-of-life care pathways.

RECENT FINDINGS

Two Cochrane systematic reviews updated at June 2013 did not identify studies that met minimal criteria for inclusion. One randomized cluster trial aimed at assessing the effectiveness of the Liverpool Care Pathway in hospitalized cancer patients was subsequently published. The trial did not find a significant difference in the overall quality of care, the primary end-point, but two out of nine secondary outcomes - respect, dignity, and kindness, and control of breathlessness showed significant improvements. Afterwards, we did not find any other potentially eligible published study.

SUMMARY

The overall amount of evidence supporting the dissemination of end-of-life care pathways is rather poor. One negative randomized trial suggests the pathways have the potential to reduce the gap between hospital and hospices. Further research is needed to understand the potential benefit of end-of-life care pathways.

Could clinical pathways improve the quality of care in patients with gastrointestinal cancer? A meta-analysis

This meta-analysis was performed to assess the implementation effects of clinical pathways in patients with gastrointestinal cancer. A comprehensive search was conducted in the Cochrane Library, PubMed, EMBASE, Web of Science and Chinese Biomedical Literature Database (from inception to May 2014). Selection of studies, assessing risk of bias and extracting data were performed by two reviewers independently. Outcomes were analyzed by fixed-effects and random-effects model meta-analysis and reported as mean difference (MD), standardized mean difference (SMD) and odds ratio (OR) with 95% confidence intervals (CI). The Jadad methodological approach was used to assess the quality of included studies and the meta-analysis was conducted with RevMan 5.1 software. Nine citations (eight trials) involving 642 patients were included. The aggregate results showed that a shorter average length of stay [MD = -4.0; 95% CI (-5.1, -2.8); P < 0.00001] was observed with the clinical pathways as compared with the usual care. A reduction in inpatient expenditure [SMD = -1.5; 95% CI (-2.3, -0.7); P = 0.0001] was also associated with clinical pathways, along with higher patient satisfaction [OR = 4.9; 95% CI (2.2, 10.6); P < 0.0001]. Clinical pathways could improve the quality of care in patients with gastrointestinal cancer, as evidenced by a significant reduction in average length of stay, a decrease in inpatient expenditure and an improvement in patient satisfaction. Therefore, indicators and mechanisms within clinical pathways should be a focus in the future.

Improving quality through process change: a scoping review of process improvement tools in cancer surgery

BACKGROUND

Surgery is a cornerstone of treatment for malignancy. However, significant variation has been reported in patterns and quality of cancer care for important health outcomes, including perioperative mortality. Surgical process improvement tools (SPITs) have been developed that focus on enhancing the processes of care at the point of care, as a means of quality improvement. This study describes SPITs and develops a conceptual framework by synthesizing the available literature on these novel quality improvement tools.

METHODS

A scoping review was conducted based on instruments developed for quality improvement in surgery. The search was executed on electronically indexed sources (MEDLINE, EMBASE, and the Cochrane library) from January 1990 to March 2011. Data were extracted, tabulated and reported thematically using a narrative synthesis approach. These results were used to develop a conceptual framework that describes and classifies SPITs.

RESULTS

232 articles were reviewed for data extraction and analysis. SPITs identified were classified into 3 groups: clinical mapping tools, structure communication tools and error reduction instruments. The dominant instrument reported were clinical mapping tools, including: clinical pathways (113, 48%), fast track (46, 20%) and enhanced recovery after surgery protocols (36, 15%). Outcomes reported included: length of stay (174, 75%), readmission rates (116, 50%), morbidity (116, 50%), mortality (104, 45%), and economic (60, 26%). Many gaps in the literature were recognized.

CONCLUSION

We have developed a conceptual framework of SPITs and identified gaps in current knowledge. These results will guide the design and development of new quality instruments in surgery.

End-of-life care pathways for improving outcomes in caring for the dying

BACKGROUND

This is an updated version of a Cochrane review first published in Issue 1, 2010 of The Cochrane Library. In many clinical areas, integrated care pathways are utilised as structured multidisciplinary care plans that detail essential steps in caring for patients with specific clinical problems. In particular, care pathways for the dying have been developed as a model to improve care of patients who are in the last days of life. The care pathways were designed with an aim of ensuring that the most appropriate management occurs at the most appropriate time and that it is provided by the most appropriate health professional. There have been sustained concerns about the safety of implementing end-of-life care pathways, particularly in the UK. Therefore, there is a significant need for clinicians and policy makers to be informed about the effects of end-of-life care pathways with a systematic review.

OBJECTIVES

To assess the effects of end-of-life care pathways, compared with usual care (no pathway) or with care guided by another end-of-life care pathway across all healthcare settings (e.g. hospitals, residential aged care facilities, community).In particular, we aimed to assess the effects on symptom severity and quality of life of people who are dying; those related to the care such as families, carers and health professionals; or a combination of these.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 6, 2013), MEDLINE, EMBASE, PsycINFO, CINAHL, review articles and reference lists of relevant articles. We conducted the original search in September 2009, and the updated search in June 2013.

SELECTION CRITERIA

All randomised controlled trials (RCTs), quasi-randomised trial or high-quality controlled before-and-after studies comparing use versus non-use of an end-of-life care pathway in caring for the dying.

DATA COLLECTION AND ANALYSIS

Two review authors assessed the results of the searches against the predetermined criteria for inclusion.

MAIN RESULTS

The original review identified 920 titles. The updated search found 2042 potentially relevant titles (including the original 920), but no additional studies met criteria for inclusion in the review update.

AUTHORS' CONCLUSIONS

With sustained concerns about the safety of the pathway implementation and the lack of available evidence on important patient and relative outcomes, recommendations for the use of end-of-life pathways in caring for the dying cannot be made. Since the last version of this review, no new studies met criteria for inclusion in the review update. With recently documented concerns related to the potential adverse effects associated with Liverpool Care Pathway (the most commonly used end-of-life care pathway), we do not recommend decision making based on indirect or low-quality evidence. All health services using end-of-life care pathways are encouraged to have their use of the pathway, to date, independently audited. Any subsequent use should be based on carefully documented evaluations. Large RCTs or other well-designed controlled studies are urgently required for the evaluation of the use of end-of-life care pathways in caring for dying people in various clinical settings. In future studies, outcome measures should include benefits or harms concerning the outcomes of interest in this review in relation to patients, families, carers and health professionals.

Systematic realist review of key factors affecting the successful implementation and sustainability of the Liverpool care pathway for the dying patient

BACKGROUND

The Liverpool Care Pathway (LCP) is recommended internationally as a best practice model for the care of patients and their families at the end of life. However, a recent national audit in the United Kingdom highlighted shortcomings; and understanding is lacking regarding the processes and contextual factors that affect implementation.

AIM

To identify and investigate factors that help or hinder successful implementation and sustainability of the LCP.

METHODS

Electronic databases (Medline, CINAHL, British Nursing Index, Science Direct) and grey literature were searched, supplemented by citation tracking, in order to identify English language papers containing information relevant to the implementation of the LCP. Using a realist review approach, we systematically reviewed all relevant studies that focused on end of life care and integrated care pathway processes and identified theories that explained how the LCP and related programmes worked.

RESULTS

Fifty-eight papers were included in the review. Key factors identified were: a dedicated facilitator, education and training, audit and feedback, organisational culture, and adequate resources.

DISCUSSION

We discuss how these factors change behaviour by influencing the beliefs, attitudes, motivation and confidence of staff in relation to end of life care, and how contextual factors moderate behaviour change.

CONCLUSIONS

The implementation process recommended by the developers of the LCP is necessary but not sufficient to ensure successful implementation and sustainability of the pathway. The key components of the intervention (a dedicated facilitator, education and training, audit and feedback) must be configured to influence the beliefs of staff in relation to end of life care, and increase their motivation and self-efficacy in relation to using the LCP. The support of senior managers is vital to the release of necessary resources, and a dominant culture of cure, which sees every death as a failure, works against effective communication and collaboration in relation to the LCP.

Important variations in the content of care pathway documents for total knee arthroplasty may lead to quality and patient safety problems

AIM

Reducing variations by standardizing the key interventions in clinical processes is an effective tool to minimize the probability of medical errors. Thus, we determined whether variations exist in the key interventions included in care pathway documents (CPDs) of different organizations and in the timing of these interventions during the care process.

METHODS

We invited members of the Belgian Dutch Clinical Pathway Network to send their CPDs for external review. We analysed 19 CPDs for total knee arthroplasty. International guidelines were consulted for definition of key interventions. Documentation of these interventions in the pathway documents was checked.

RESULTS

From the 19 CPDs analysed, we retrieved 18 key interventions. Nine of these key interventions appeared in at least 80% of the care pathways. Only two key interventions appeared in all pathway documents. Nine out of 12 interventions that appeared in at least 80% of the pathway documents showed a variation of 1 day in the timing of care from the median timing.

CONCLUSION

We conclude that important variation exists in the included interventions and in their timing. The results of this study suggest that, before use in daily patient care, CPDs should be reviewed by peers and checked to ensure that all evidence-based key interventions are included and properly planned. Only in this way can pathways documents be used interprofessionally during the entire perioperative period in the search for optimal quality and patient safety.

The effect of care pathways for hip fractures: a systematic review

We performed a systematic review for primary studies on care pathways (CPs) for hip fracture (HF). The online databases MEDLINE-PubMed, Ovid-EMBASE, CINAHL-EBSCO host, and The Cochrane Library (Cochrane Central Register of Clinical Trials, Health Technology Assessment Database, NHS Economic Evaluation Database) were searched. Two researchers reviewed the literature independently. Primary studies that met predefined inclusion criteria were assessed for their methodological quality. A total of 15 publications were included: 15 primary studies corresponding with 12 main investigations. Primary studies were evaluated for clinical outcomes, process outcomes, and economic outcomes. The studies assessed a wide range of outcome measures. While a number of divergent clinical outcomes were reported, most studies showed positive results of process management and health-services utilization. In terms of mortality, the results provided evidence for a positive impact of CPs on in-hospital mortality. Most studies also showed a significantly reduced risk of complications, including medical complications, wound infections, and pressure sores. Moreover, time-span process measures showed that an improvement in the organization of care was achieved through the use of CPs. Conflicting results were observed with regard to functional recovery and mobility between patients treated with CPs compared to usual care. Although our review suggests that CPs can have positive effects in patients with HF, the available evidence is insufficient for formal recommendations. There is a need for more research on CPs with selected process and outcome indicators, for in-hospital and postdischarge management of HF, with an emphasis on well-designed randomized trials.

The impact of care pathways for patients with proximal femur fracture: rationale and design of a cluster-randomized controlled trial

BACKGROUND

Proximal femur fracture (PFF) is associated with considerable morbidity and mortality. The European Quality of Care Pathway (EQCP) study on PFF (NCT00962910) was designed to determine how care pathways (CP) for hospital treatment of PFF affect consistency of care, adherence to evidence-based key interventions, and clinical outcome.

METHODS/DESIGN

An international cluster-randomized controlled trial (cRCT) will be performed in Belgium, Ireland, Italy and Portugal. Based on power analyses, a sample of 44 hospital teams and 437 patients per arm will be included in the study. In the control arm, usual care will be provided. Experimental teams will implement a care pathway which will include three active components: a formative evaluation of quality and organization of the care setting, a set of evidence-based key interventions, and support of the development and implementation of the CP. Main outcome will be the six-month mortality rate.

DISCUSSION

The EQCP study constitutes the first international cRCT on care pathways. The EQCP project was designed as both a research and a quality improvement project and will provide a real-world framework for process evaluation to improve our understanding of why and when CP can really work.

TRIAL REGISTRATION NUMBER

NCT00962910.

Enhanced Recovery after Surgery Program for Elective Abdominal Surgery at Three Victorian Hospitals

The aim of this study was to evaluate the anaesthesia care of an enhanced recovery after surgery (ERAS) program for patients having abdominal surgery in Victorian hospitals. The main outcome measure was the number of ERAS items implemented following introduction of the ERAS program. Secondary endpoints included process of care measures, outcomes and hospital stay. We used a before-and-after design; the control group was a prospective cohort (n=154) representing pre-existing practice for elective abdominal surgical patients from July 2009. The introduction of a comprehensive ERAS program took place over two months and included the education of surgeons, anaesthetists, nurses and allied health professionals. A postimplementation cohort (n=169) was enrolled in early 2010. From a total of 14 ERAS-recommended items, there were significantly more implemented in the post-ERAS period, median 8 (interquartile range 7 to 9) vs 9 (8 to 10), P <0.0001. There were, however, persistent low rates of intravenous fluid restriction (25%) and early removal of urinary catheter (31%) in the post-ERAS period. ERAS patients had less pain and faster recovery parameters, and this was associated with a reduced hospital stay, geometric mean (SD) 5.7 (2.5) vs 7.4 (2.1) days, P=0.006. We found that perioperative anaesthesia practices can be readily modified to incorporate an enhanced recovery program in Victorian hospitals.

Variation in 17 obstetric care pathways: potential danger for health professionals and patient safety?

AIM

To report a study to determine whether or not variations exist in evidence-based key interventions in pathway documents for normal delivery across hospitals.

BACKGROUND

Care pathways are used worldwide to standardize and follow up patient-focused care. Minimal variations in pathway documents increase standardization and patient safety.

DESIGN

A descriptive study design using qualitative methods was used, to examine the various key interventions present in care pathway documents for normal delivery.

METHODS

Between January-March 2009, we evaluated the content of the care pathway document for normal delivery from 17 different hospitals. The key interventions in these pathways were compared with the 40 evidence-based key interventions of Map of Medicine®.

RESULTS

There was much variation in the characteristics and the presence of key interventions in the pathway documents. Only 6 of the 40 evidence-based key interventions (15%) were found in all 17 pathway documents and 20 of the 40 interventions (50%) were found in only 10 pathway documents.

CONCLUSION

If variation already exists among the care pathway documents, this may lead to a high probability of variation in the actual performance of daily care. In this study is shown that, even for highly predictable medical conditions, there are huge differences in the evidence-based content and structure of pathways. Lack of evidence base could potentially endanger both patient safety and the health professional.

Criteria to determine readiness for hospital discharge following colorectal surgery: an international consensus using the Delphi technique

BACKGROUND

Standardized discharge criteria are considered valuable to reduce the risk of premature discharge and avoid unnecessary hospital stays. The most appropriate criteria to indicate readiness for discharge after colorectal surgery are unknown.

OBJECTIVE

The aim of this study is to achieve an international consensus on hospital discharge criteria for patients undergoing colorectal surgery.

DESIGN

Fifteen experts from different countries participated in a 3-round Delphi process. In round 1, experts determined which criteria best indicate readiness for discharge and described specific end points for each criterion. In rounds 2 and 3, experts rated their agreement with the use of a 5-point Likert scale.

MAIN OUTCOME MEASURES

Consensus was defined when criteria and end points were rated as agree or strongly agree by at least 75% of the experts in round 3.

RESULTS

Experts reached consensus that patients should be considered ready for hospital discharge when there is tolerance of oral intake, recovery of lower gastrointestinal function, adequate pain control with oral analgesia, ability to mobilize and self-care, and no evidence of complications or untreated medical problems. Specific end points were defined for each of the criteria. Experts also agreed that after these criteria are achieved, discharge may take place as soon as the patient has adequate postdischarge support and is willing to leave the hospital. If a stoma was constructed, the patient or the patient's family should have received training on stoma care or had outpatient training arranged.

LIMITATIONS

The panel comprised mostly experts from developed countries. This may restrict the applicability of these discharge criteria in countries where there are dissimilar health care resources.

CONCLUSION

This Delphi study has provided substantial consensus on discharge criteria for patients undergoing colorectal surgery. We recommend that these criteria be used in clinical practice to guide decisions regarding patient discharge and applied in future research to increase the comparability of study results.

Reviewing methodologically disparate data: a practical guide for the patient safety research field

This article addresses key questions frequently asked by researchers conducting systematic reviews in patient safety. This discipline is relatively young, and asks complex questions about complex aspects of health care delivery and experience, therefore its studies are typically methodologically heterogeneous, non-randomized and complex; but content rich and highly relevant to practice. Systematic reviews are increasingly necessary to drive forward practice and research in this area, but the data do not always lend themselves to 'standard' review methodologies. This accessible 'how-to' article demonstrates that data diversity need not preclude high-quality systematic reviews. It draws together information from published guidelines and experience within our multidisciplinary patient safety research group to provide entry-level advice for the clinician-researcher new to systematic reviewing, to non-biomedical research data or to both. It offers entry-level advice, illustrated with detailed practical examples, on defining a research question, creating a comprehensive search strategy, selecting articles for inclusion, assessing study quality, extracting data, synthesizing data and evaluating the impact of your review. The article concludes with a comment on the vital role of robust systematic reviews in the continuing advancement of the patient safety field.

Perioperative quality of care is modulated by process management with clinical pathways for fast-track surgery of the colon

PURPOSE

Clinical pathways (CPs) are increasingly used to improve quality of care. However, evidence if such improvements are also feasible in fast-track colorectal surgery is lacking. This study evaluates effects of a CP for fast-track colonic resections with respect to process and outcome quality.

METHODS

We compared 78 consecutive patients undergoing colonic resections in 2008 and being treated with a CP (CP group) with 133 consecutive patients treated without CP between 2006 and 2007 (pre-CP group). Indicators for process quality were epidural catheter placement, postoperative mobilisation, resumption of solid diet, Foley catheter removal and length of stay. Outcome quality was measured through morbidity, mortality, re-operations and readmissions.

RESULTS

In the CP group, patients received epidural analgesia significantly more often (87.2% vs. 75.2%; p =0.04), were mobilized (38.9% vs. 20.6% on the day of surgery; p = 0.03) and resumed a solid diet earlier (60.5% vs. 49.6% on day 1; p = 0.002). Foley catheter removal and length of stay did not differ between the groups. There were no significant differences regarding morbidity (28.2% vs. 32.3%), mortality (1.2% vs. 2.3%), re-operations (6.4% vs. 9.0%) and readmissions (2.6% vs. 3.8%).

CONCLUSIONS

After CP implementation for fast-track surgery of the colon, several indicators of process quality improved while others such as length of stay remained unaltered. There were no significant changes in outcome parameters. CPs are a viable instrument to improve specific aspects of perioperative process management, but their selective benefits have to be critically weighed against the infrastructural and personal efforts required for design and implementation.

Evaluation of a clinical pathway to improve colorectal cancer outcomes

The aims of this preintervention and postintervention study were to monitor and evaluate the clinical pathway (CP) for colorectal cancer (CRC) over a 5-year period and to compare 2 groups of patients (before and after the intervention) with regard to different variables of effectiveness. Group I comprised 68 patients who underwent planned surgery between January 2002 and January 2003. Group II comprised a sample of 202 patients who underwent surgery between January 2004 and December 2008. No significant differences were found in the majority of the parameters measured: postoperative stay, compliance with antibiotic prophylaxis, compliance with the staging study, mortality, rate of infection, and reoperations. The mean length of stay (±standard deviation) for patients without complications was reduced significantly (9.2 ± 3.6 in group I versus 7.7 ± 1.7 in group II, P = .031). The CP for CRC did not achieve most of the objectives for which it was designed.

Surgical intensive care unit - essential for good outcome in major abdominal surgery?

PURPOSE

Surgical intensive care units (ICU) play a pivotal role in perioperative care of patients undergoing major abdominal surgery. Differences in quality of care provided by medical staff in ICUs may be linked to improved outcome. This review aims to elucidate the relationship between quality of care at various ICUs and patient outcome, with the ultimate aim of identifying key measures for achieving optimal outcome.

METHODS

We reviewed the literature in PubMed to identify current ICU structural and process concepts and variations before evaluating their respective impact on quality of care and outcome in major abdominal surgery.

RESULTS

ICU leadership, nurse and physician staffing, and provision of an intermediate care unit are important structural components that impact on patients' outcome. A "mixed ICU" model, with intensivists primarily caring for the patients in close cooperation with the primary physician, seems to be the most effective ICU model. Surgeons' involvement in intensive care is essential, and a close cooperation between surgeons and anesthesiologists is vital for good outcome. Current general process concepts include early mobilization, enteral feeding, and optimal perioperative fluid management. To decrease failure-to-rescue rates, procedure-specific intensive care processes are particularly focused on the early detection, assessment, and timely and consistent treatment of complications.

CONCLUSIONS

Several structures and processes in the ICU have an impact on outcome in major abdominal surgery. ICU structures and care processes connected with optimal outcome could be transmitted to other centers to improve outcome, independent of procedure volume.

Management challenges in care pathways: Conclusions of a qualitative study within 57 health-care organizations

Summary

The objectives of this paper are to study the aim of care pathways, who has decisional power concerning pathways, the actual follow-up, challenges in cross-boundary development and the support provided by information and communication technology (ICT). The study design included a qualitative study using semi-structured interviews with 88 care pathway coordinators and members of the executive board in 57 health-care organizations enrolled in the Belgian- Dutch Clinical Pathway Network. The study revealed that the most important objectives for introducing care pathways are more standardization and quality of care. In 76% of the interviewed organizations, pathways are discussed in a committee. There is a lack of continuous follow-up when care pathways are implemented. Pathways can facilitate cross-boundary care, but are a challenge because of the fragmentation within primary care. There is a need for more ICT support for care pathways. In conclusion, the executive board members and pathway coordinators state that clearly formulated objectives, a special steering committee, a clear follow-up to keep pathways alive, cross-boundary collaboration and ICT support are among the main challenges for the management of an organization.

An overview on the history and concept of care pathways as complex interventions

Care pathways, also known as clinical pathways, critical pathways or integrated care pathways, are used all over the world. Although they are used internationally, there are still a large number of misunderstandings. The goal of this paper is to provide an overview on the history of pathways and how pathways are actually perceived and defined. Pathways are more than just a document in the patient record. They are a concept for making patient-focused care operational and supporting the modelling of patient groups with different levels of predictability. Pathways are a method within the field of continuous quality improvement and are used in daily practice as a product in the patient record. This paper explains these different issues and provides an extensive list of references that should support pathway facilitators, clinicians, managers and policy-makers in their search for excellence.

End-of-life care pathways for improving outcomes in caring for the dying

BACKGROUND

In many clinical areas, integrated care pathways are utilised as structured multidisciplinary care plans which detail essential steps in caring for patients with specific clinical problems. Particularly, care pathways for the dying have been developed as a model to improve the end-of-life care of all patients. They aim to ensure that the most appropriate management occurs at the most appropriate time and that it is provided by the most appropriate health professional. Clinical pathways for end-of-life care management are used widely around the world and have been regarded as the gold standard. Therefore, there is a significant need for clinicians to be informed about the utilisation of end-of-life care pathways with a systematic review.

OBJECTIVES

To assess the effects of end-of-life care pathways, compared with usual care (no pathway) or with care guided by another end-of-life care pathway across all healthcare settings (e.g. hospitals, residential aged care facilities, community).

SEARCH STRATEGY

The Cochrane Register of controlled Trials (CENTRAL), the Pain, Palliative and Supportive Care Review group specialised register, MEDLINE, EMBASE, review articles and reference lists of relevant articles were searched. The search was carried out in September 2009.

SELECTION CRITERIA

All randomised controlled trials (RCTs), quasi-randomised trial or high quality controlled before and after studies comparing use versus non-use of an end-of-life care pathway in caring for the dying.

DATA COLLECTION AND ANALYSIS

Results of searches were reviewed against the pre-determined criteria for inclusion by two review authors.

MAIN RESULTS

The search identified 920 potentially relevant titles, but no studies met criteria for inclusion in the review.

AUTHORS' CONCLUSIONS

Without further available evidence, recommendations for the use of end-of-life pathways in caring for the dying cannot be made. RCTs or other well designed controlled studies are needed for evaluating the use of end-of-life care pathways in caring for dying people.

Is there a future for pathways? Five pieces of the puzzle

In this discussion and opinion paper, the Bureau members of the European Pathway Association present five challenges for the future of care pathways. Pathways will have to be based on the latest available evidence and international databases, and tools will have to be available. If pathways have a future, the organisations should focus on disease-specific oriented care. Evidence-based pathways, which are organised in a disease-specific oriented organisation, can lead to improvement of quality and efficiency but only if we invest in real teamwork. As a fourth challenge, the need for technical support of pathways is presented. The last piece of the future pathway puzzle is the need for patient involvement. Pathways will only lead to continuous improvement if we finally see patients as real partners in care organisation.

The impact of pathways: a significant decrease in mortality

This study was undertaken to determine how care pathways (CPs) in the hospital treatment of heart failure (HF) affected in-hospital mortality, and outcomes at discharge. A two-arm, cluster randomized trial was conducted. Fourteen community hospitals were randomized either to arm 1 (CPs) or to arm 2 (no intervention, usual care). A sample size of 424 patients (212 in each group) was used in order to have 80% of power at the 5% significance level (two-sided). The primary outcome measure was in-hospital mortality. Secondary outcomes were also evaluated. In-hospital mortality was 5.6% in the experimental arm and 15.4% in the controls ( P = 0.001). In CP and usual care groups, the mean rates of unscheduled readmissions were 7.9% and 13.9%, respectively. Adjusting for age, smoking, New York Heart Association (NYHA) score, hypertension and source of referral, patients in the CP group, as compared with controls, had a significantly lower risk of in-hospital death (odds ratio [OR] = 0.18; 95% confidence interval [CI]: 0.07–0.46) and unscheduled readmissions (OR = 0.42; CI = 0.20–0.87). No differences were found between CP and control with respect to the appropriateness of the stay, costs and patient's satisfaction. This paper examines the evaluation of a complex intervention and adds evidence to previous knowledge, indicating that CP should be used to improve the quality of hospital treatment of HF.