Clinical pathway audit tools: a systematic review

Variability in Care Pathways for Hip Fracture Patients in The Netherlands

Background/Objectives: Integrated orthogeriatric care has demonstrated benefits in hip fracture management for older patients. Comprehensive care pathways are essential for effective integrated care delivery, yet local variability in care pathways persists. We assessed the current hip fracture care pathways in the Netherlands, focusing on the variability between these care pathways and the degree of implementation of orthogeriatric care. Methods: A nationwide inventory study was conducted. A survey was sent to all hospitals in the Netherlands to collect the care pathways or local protocols for hip fracture care. All care elements reported in the care pathways and protocols were systematically analyzed by two independent researchers. Furthermore, an assessment was performed to determine which model of orthogeriatric care was applied. Results: All 71 Dutch hospitals were contacted, and 56 hospitals responded (79%), of which 46 (82%) provided a care pathway or protocol. Forty-one care elements were identified in total. In the care pathways and protocols, the variability in the description of these individual care elements ranged from 7% to 87%. Twenty-one hospitals had an integrated care model with shared responsibility, while an equal number followed an orthopedic trauma surgeon-led care model. Conclusions: These findings provide a detailed description of the hip fracture care pathways in the Netherlands. Variations were observed concerning the care elements described in the care pathways, the structure of the care pathway, and the specification of several elements. The implementation of integrated care with shared responsibilities, as recommended by the international literature, has not been achieved nationwide. The clinical implications of the variability between care pathways, such as the influence on the quality of care, need to be further investigated.

Diversity of kidney care referral pathways in national child health systems of 48 European countries

Background

Primary, secondary and tertiary healthcare services in Europe create complex networks covering pediatric subspecialties, sociology, economics and politics. Two surveys of the European Society for Paediatric Nephrology (ESPN) in 1998 and 2017 revealed substantial disparities of kidney care among European countries. The purpose of the third ESPN survey is to further identify national differences in the conceptualization and organization of European pediatric kidney health care pathways during and outside normal working hours.

Methods

In 2020, a questionnaire was sent to one leading pediatric nephrologist from 48 of 53 European countries as defined by the World Health Organization. In order to exemplify care pathways in pediatric primary care nephrology, urinary tract infection (UTI) was chosen. Steroid sensitive nephrotic syndrome (SSNS) was chosen for pediatric rare disease nephrology and acute kidney injury (AKI) was analyzed for pediatric emergency nephrology.

Results

The care pathways for European children and young people with urinary tract infections were variable and differed during standard working hours and also during night-time and weekends. During daytime, UTI care pathways included six different types of care givers. There was a shift from primary care services outside standard working hours to general outpatient polyclinic and hospital services. Children with SNSS were followed up by pediatric nephrologists in hospitals in 69% of countries. Patients presenting with community acquired AKI were admitted during regular working hours to secondary or tertiary care hospitals. During nights and weekends, an immediate shift to University Children's Hospitals was observed where treatment was started by intensive care pediatricians and pediatric nephrologists.

Conclusion

Gaps and fragmentation of pediatric health services may lead to the risk of delayed or inadequate referral of European children with kidney disease to pediatric nephrologists. The diversity of patient pathways outside of normal working hours was identified as one of the major weaknesses in the service chain.

Exploring sustainable care pathways - a scoping review

BACKGROUND

Patients with mental health problems experience numerous transitions into and out of hospital.

AIM

The review studies assessing clinical care pathways between psychiatric hospitalization and community health services.

METHODS

We used publications between 2009-2020 to allow a broad scoping review of the published research. Sixteen review-articles were identified, 12 primary studies were chosen, both on care pathways in the transition between psychiatric hospital and community.

RESULTS

Organizational issues: Systems and procedures to ensure clear responsibilities and transparency at each stage of the pathways of care.

RESOURCES

Information-technology in objectively improving patient outcome. Information/documentation: Providing patients with adequate structured information and documented plans at the appropriate time. Patient/families: Continuous collaborative decision-making. Clinical care and teamwork: Collaboration between mental health and other professionals to guarantee that planned activities meet patient need.

ETHICAL ISSUES

Respectful communication and patient-centred, non-humiliating care.

CONCLUSIONS

System and procedures ensure clear responsibilities and transparency. Information technology support decision-making and referral and objectively improve patient outcomes in care pathways. Collaboration between mental health and other professionals guarantee that planned activities meet patients' needs along with regular meetings sharing key information. Around-the-clock ambulant-teams important to transition success. Informed-shared decision-making between parties, support patient participation and respectful communication.

Influence of the Clinical Nursing Pathway on Nursing Outcomes and Complications of Cervical Carcinoma Patients Undergoing Chemotherapy via PICC

Background

Cervical Carcinoma (CC) is the second most common cause of death in women, with most patients being diagnosed at an advanced stage. The conventional treatment for CC, with a long chemotherapy treatment cycle, is less than satisfactory and will cause serious damage to the patient's blood vessels.

Objective

To analyze the impact of the clinical nursing pathway (CNP) on the incidence of complications and adverse prognosis in patients undergoing chemotherapy for CC via peripherally inserted central catheters (PICC).

Materials and Methods

This study enrolled 157 CC patients who underwent PICC chemotherapy in the Shaanxi Provincial Cancer Hospital between March 2017 and April 2020 and assigned them between the two groups according to different nursing interventions. Ninety-three patients treated with CNP intervention were included in the research group (RG), and sixty-four cases treated with the routine nursing intervention were included in the control group (CG). The self-care ability and intervention satisfaction of patients were assessed using the self-care ability scale and the intervention satisfaction questionnaire, respectively, both developed by our hospital. The complication rate was observed in both cohorts, and the adverse prognosis of patients was statistically analyzed. Finally, an assessment was made on the patients' quality of life (QOL) using the quality of life questionnaire core 30 (QLQ-C30).

Results

Higher scores of self-management information, catheter nursing ability, self-care compliance, and abnormal situation management were determined in RG after the nursing intervention. RG also outperformed CG in the overall incidence rates of complications and poor prognosis. Moreover, RG presented statistically higher nursing satisfaction and QLQ-C30 scores than CG after the nursing intervention.

Conclusion

CNP has a significant nursing effect on patients with CC treated with PICC chemotherapy, which can not only reduce the incidence of postchemotherapy complications but also improve patient prognosis, satisfaction, and life quality, with the value for clinical promotion.

Business Process Model and Notation and openEHR Task Planning for Clinical Pathway Standards in Infections: Critical Analysis

Background

Clinical pathways (CPs) are usually expressed by means of workflow formalisms, providing health care personnel with an easy-to-understand, high-level conceptual model of medical steps in specific patient conditions, thereby improving overall health care process quality in clinical practice. From a standardized perspective, the business process model and notation (BPMN), a widely spread general-purpose process formalism, has been used for conceptual modeling in clinical domains, mainly because of its easy-to-use graphical notation, facilitating the common understanding and communication of the parties involved in health care. However, BPMN is not particularly oriented toward the peculiarities of complex clinical processes such as infection diagnosis and treatment, in which time plays a critical role, which is why much of the BPMN clinical-oriented research has revolved around how to extend the standard to address these special needs. The shift from an agnostic, general-purpose BPMN notation to a natively clinical-oriented notation such as openEHR Task Planning (TP) could constitute a major step toward clinical process improvement, enhancing the representation of CPs for infection treatment and other complex scenarios.

Objective

Our work aimed to analyze the suitability of a clinical-oriented formalism (TP) to successfully represent typical process patterns in infection treatment, identifying domain-specific improvements to the standard that could help enhance its modeling capabilities, thereby promoting the widespread adoption of CPs to improve medical practice and overall health care quality.

Methods

Our methodology consisted of 4 major steps: identification of key features of infection CPs through literature review, clinical guideline analysis, and BPMN extensions; analysis of the presence of key features in TP; modeling of relevant process patterns of catheter-related bloodstream infection as a case study; and analysis and proposal of extensions in view of the results.

Results

We were able to easily represent the same logic applied in the extended BPMN-based process models in our case study using out-of-the-box standard TP primitives. However, we identified possible improvements to the current version of TP to allow for simpler conceptual models of infection CPs and possibly of other complex clinical scenarios.

Conclusions

Our study showed that the clinical-oriented TP specification is able to successfully represent the most complex catheter-related bloodstream infection process patterns depicted in our case study and identified possible extensions that can help increase its adequacy for modeling infection CPs and possibly other complex clinical conditions.

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.

Mind the Differences: How Diagnoses and Hospital Characteristics Influence Coordination in Cancer Patient Pathways

Integrated care pathway (ICP) is a prevailing concept in health care management including cancer care. Though substantial research has been conducted on ICPs knowledge is still deficient explaining how characteristics of diagnose, applied procedures, patient group and organizational context influence specific practicing of ICPs. We studied how coordination takes place in three cancer pathways in four Norwegian hospitals. We identified how core contextual variables of cancer pathways affect complexity and predictability of the performance of each pathway. Thus, we also point at differences in core preconditions for accomplishing coordination of the cancer pathways. In addition, the findings show that three different types of coordination dynamics are present in all three pathways to a divergent degree: programmed chains, consultative hubs and problem-solving webs. Pathway coordination also depends on hierarchical interaction. Lack of corresponding roles in the medical–professional and the administrative–institutional logics presents a challenge for coordination, both within and between hospitals. We recommend that further improvement of specific ICPs by paying attention to what should be standardized and what should be kept flexible, aligning semi-formal and formal structures to pathway processes and identify the professional cancer related background and management style required by the key-roles in pathway management.

Exploring the triggering process of a cancer care reform in three Scandinavian countries

Cancer incidence is increasing, and cancer is a leading cause of death in the Scandinavian countries, and at the same time more efficient but very expensive new treatment options are available. Based on the increasing demand, high expectations and limited resources, crises in public legitimacy of cancer care evolved in the three Scandinavian countries. Similar cancer care reforms were introduced in the period 2007-2015 to address the crisis. In this article we explore processes triggering these reforms in countries with similar and well-developed health care systems. The common objective was the need to reduce time from referral to start treatment, and the tool introduced to accomplish this was integrated care pathways for cancer diagnosis, that is Cancer Patient Pathways. This study investigates the process by drawing on interviews with key actors and public documents. We identified three main logics in play; the economic-administrative, the medical and the patient-related logic and explored how institutional entrepreneurs skillfully aligned these logics. The article contributes by describing the triggering processes on politically initiated similar reforms in the three countries studied and also contributes to a better understanding on the orchestrating of politically initiated health care reforms with the intention to change medical practice in hospitals.

Developing a Data-Driven Approach in Order to Improve the Safety and Quality of Patient Care

Objective: To improve the safety and quality of patient care in hospitals by shaping clinical pathways throughout the patient journey.

Study Setting: A risk model designed for healthcare organizations in the context of the challenges arising from comorbidity and other treatment-related complexities.

Study Design: The core of the model is the patient and his intra-hospital journey, which is analyzed using a data-driven approach. The structure of a predictive model to support organizational and clinical decision-making activities is explained. Data relating to each step of the intra-hospital journey (from hospital admission to discharge) are extracted from clinical records.

Principal Findings: The proposed approach is feasible and can be used effectively to improve safety and quality. It enables the evaluation of clinical risks at each step of the patient journey.

Conclusion: Based on data from real cases, the model can record and calculate, over time, variables and behaviors that affect the safety and quality of healthcare organizations. This provides a greater understanding of healthcare processes and their complexity which can, in turn, advance research relating to clinical pathways and improve strategies adopted by organizations.

Development and implementation of a stroke rehabilitation integrated care pathway in an Italian no profit institution: an observational study

BACKGROUND

To standardize assessment and coordinate processes in stroke rehabilitation, an integrated care pathway (ICP) was developed in an Italian Rehabilitation and Research Institution by a knowledge-translation interdisciplinary process, from evidence-based guidelines to rehabilitation practice. The ICP was implemented in two pilot Tuscan rehabilitation Centers.

AIM

The purpose of this study was to describe ICP development and assess the ICP effects on postacute stroke inpatient rehabilitation outcomes.

DESIGN

Prospective observational study, before and after comparison.

SETTING

Two Tuscan inpatient rehabilitation centers.

POPULATION

Patients accessing either centers for intensive rehabilitation after acute stroke.

METHODS

Two cohorts were prospectively recruited before (2015-2017) and after (2018) implementation of the pathway. The primary outcome was change in activities of daily living disability, assessed by the modified Barthel Index (mBI) from admission to discharge. Secondary outcomes included length of stay (LOS), adverse outcomes, and changes in communication ability, trunk control, pain, ambulation, bladder catheter (Y/N), bedsores (Y/N).

RESULTS

In 2015-2017, 443 postacute stroke patients (mean age 77±11 years, 47% women), while in 2018, 84 patients (mean age 76±13 years, 61% women) were admitted to the two facilities. Comparing the 2018 vs. the 2015-17 cohort, the mean mBI increase was not substantially different (26 vs. 24 points), nor were LOS (37±18 vs. 36±16 days), adverse outcomes, discharge destination, and improvement of ambulation, pain, and communication (P>0.05). Instead, a significantly higher improvement of trunk control (trunk control test: 69.6±33.2 vs. 79.0±31.3, P=0.019), and a higher percentage of bedsore resolution (13% vs. 5%, P=0.033), and bladder catheter removal (37% vs. 17% P<0.001) were observed in 2018 vs. 2015-2017.

CONCLUSIONS

Compared to prior practice, ICP was associated to improvement of trunk control recovery, bladder catheter removal, and bedsores resolution. Further ICP implementation on a larger scale is needed to verify improvements of stroke inpatient rehabilitation outcomes.

CLINICAL REHABILITATION IMPACT

An evidence-based stroke rehabilitation ICP was interdisciplinary developed and implemented in two rehabilitation centers of a multicenter Italian health group. ICP implementation as to inpatient intensive postacute stroke rehabilitation was associated to improved trunk control recovery, bladder catheter removal, and bedsore resolution. Further ICP implementation will allow multicenter studies and quality benchmarking.

Early path nursing improves neurological function recovery in patients with intracerebral hemorrhage: Protocol for a randomized controlled trial

BACKGROUND

To explore the influence of the early path nursing on life quality and the neurological function recovery in the intracerebral hemorrhage (ICH) patients.

METHODS

The experiment was implemented from January 2018 to October 2020 at the First Affiliated Hospital of Soochow University. The experiment was granted through the Research Ethics Committee of the First Affiliated Hospital of Soochow University (2017033). In this experiment, the criteria for inclusion includes: hemorrhagic stroke diagnosed via the MRI or head CT; over 18 years of age; patients with motor dysfunction; The Glasgow Coma Scale > 12. The patients with these symptoms will be excluded: severe cognitive impairment; ischemic stroke; onset time > 3 days; and severe complications. The scale used for the evaluation the neurological function is the American Stroke Scale. This scale contains a total of eleven items, that is, the movements of upper and lower limb, the consciousness level, gaze, visual field, etc. Other outcomes include patient satisfaction and complications.

RESULTS

Evaluation the neurological function and quality of life will be shown in Table 1.

CONCLUSION

The early path nursing can promote the neurological function recovery in the ICH patients.

TRIAL REGISTRATION NUMBER

researchregistry6327.

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.

Towards standardisation of evidence-based clinical care process specifications

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

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

Introduction

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

Methods

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

Results

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

Conclusion and discussion

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

An integrative approach to improving patient care pathways

PURPOSE

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

DESIGN/METHODOLOGY/APPROACH

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

FINDINGS

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

RESEARCH LIMITATIONS/IMPLICATIONS

The authors provide a conceptual framework that requires empirically testing.

PRACTICAL IMPLICATIONS

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

ORIGINALITY/VALUE

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

Patient and Health Care Professional Perspectives: A Case Study of the Lung Cancer Integrated Care Pathway

Introduction:

The purpose of this study was to evaluate the perception of the quality of care, considering both patient experience and health care professionals’ perceptions as well as patient outcome measures of an integrated lung cancer pathway.

Methods:

A cross-sectional study was conducted in 2016 at Ferrara University Hospital, Italy. OPportunity for Treatment In ONcology (OPTION) questionnaires were administered to 77 patients, and the Care Process Self-Evaluation Tool (CPSET) questionnaires were given to 38 health care professionals. The effectiveness of the pathway was evaluated by analysing the tool’s positive impact on lung cancer surgery volume and 30-day mortality.

Results:

Seventy-seven patients were enrolled, and 38 health care professionals assessed the CPSET questionnaire. The highest scores were related to “respect” (100%), “satisfaction” (98.7%), and “trust” (97.4%) on the OPTION and to “patient-focused vision” (97.2%) and “patient engagement” (94.4%) on the CPSET. The lowest scores were related to “information” (26%) and “cooperation with general practitioner” (17.6%) on the OPTION and “cooperation between the hospital and primary care” (23.5%) for the CPSET. The outcomes analysis shows an increase in the volume of activity and a decrease in 30-day mortality after pathway implementation.

Discussion:

The lung cancer pathway is a patient-centred intervention that enables care to be shaped for patient needs in order to improve the quality and efficiency of service and clinical outcome.

Care pathways in the transition of patients between district psychiatric hospital centres (DPCs) and community mental health services

RATIONALE AIMS AND OBJECTIVES

Patients with mental health problems experience numerous transitions into and out of hospital. Primary care providers have mixed success in identifying and managing patients' needs. This study explores health personnel's experience of care pathways in patient transition between inpatient and community mental health services.

METHODS

A descriptive qualitative design was chosen. Four focus group interviews with 12 informants from 7 different communities were conducted. Interviews were analyzed thematically.

RESULTS

Two main themes were identified: integrated care and patient activation. The participants shared their experiences on topics that can affect smooth care pathways in mental health. Six promoting factors were identified for successful patient transition: opportunities for information sharing, implementation of systematic plans, use of e-messages, around-the-clock care, designating one responsible health person in each system for each patient, and the involvement of patients and their families. The following barriers were all found to impede the patients' transition between levels of care: the lack of a single responsible person at each health care level, insufficient meetings, the absence of systematic plans, difficulties in identifying the right staff at different levels, delays in information sharing, and the complexity of welfare systems negatively affecting patient dignity.

CONCLUSIONS

Systems and procedures should be developed to ensure clear responsibilities and transparency at each stage of the pathways of care. A single person should take charge of ensuring sufficient connection and communication between inpatient and community mental health services. Finally, both patient and staff in community services should be linked through a direct telephone number with around-the-clock availability.

Development of a clinical transition pathway for adolescents in the Netherlands

AIMS

To explore how young people with juvenile-onset rheumatic and musculoskeletal diseases (jRMDs) and their parent(s) experience care during preparation for the upcoming transfer to adult services, and to develop a clinical transition pathway.

METHOD

A survey was conducted with 32 young people aged between 14 and 20 years with jRMDs, and their parents ( n =33), treated at the department of paediatric rheumatology in a tertiary care children's hospital in the Netherlands.

RESULTS

More than 30% of young people would have liked to discuss topics such as educational and vocational choices in a clinic, but did not get the opportunity. Preparation for transition was poor as was training in self-management skills. One third of parents had feelings of anxiety about the upcoming transfer. Results from the survey and evidence-based principles of transitional care were used to develop the clinical transition pathway. The pathway focuses on starting transition early, developing self-management skills, joint consultations and supporting parents in giving young people control of their clinical care.

CONCLUSION

Care does not currently meet the needs of young people in the process of transition to adult rheumatology services. The clinical transition pathway developed as a result of the study is a tool that may improve this process.

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

AIMS AND OBJECTIVES

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

BACKGROUND

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

DESIGN

Prospective, quasi-experimental design.

METHODS

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

RESULTS

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

CONCLUSION

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

RELEVANCE TO CLINICAL PRACTICE

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

Discovering health-care processes using DeciClareMiner

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

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

Introduction

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

Methods

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

Results

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

Conclusion

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

Making care organizations great again? A comparison of Care Pathways, Lean Thinking, Relational Coordination, and Modern Sociotechnical Design

Introduction

Care organizations are often not well equipped to the increasing complexity and chronicity of diseases. Several organizational redesign models propose interventions that may help organizations adapt to this new reality. The objective of this study is to describe the redesign models in a uniform manner and to offer conceptual clarity.

Methods

This study presents a systematic comparison of the problem definition and proposed interventions of four redesign models: Care Pathways, Lean Thinking, Relational Coordination, and Modern Sociotechnical Design. Data were collected through a critical and thematic review of selected literature. Data were analyzed using a priori deducted coding derived from a theoretical framework based on Mintzberg. The COREQ checklist was used to minimize bias.

Results

Twenty conceptual documents and practical guidelines were included for data analysis. The problem definition of the four redesign models is largely similar and suggests that fragmented task division and centralized coordination hinder the delivery of complex and chronic care. The proposed interventions differ between the redesign models, but in general more attention is given to the coordination of tasks than to task division, and interventions are mainly situated at the micro (workplace) and meso (work unit) levels of the organization.

Discussion

The systematic comparison clarifies the similarities and differences between the analyzed redesign models, which can be useful for improving studies on redesign model effectiveness. Additionally, systematic comparison supports care organizations in selecting appropriate redesign models. Future studies may involve a larger selection of redesign models as well as the redesign of inter-organizational networks.

Validation of descriptive clinical pathway criteria in the systematic identification of publications in emergency medicine

Background

Heterogeneity in both the definition and terminology of clinical pathways presents a challenge to the systematic identification of primary studies for review purposes. Recently developed clinical pathway identification criteria may facilitate both the identification and assessment of clinical pathway studies. The goal of this publication is the validation of these five criteria in a descriptive systematic review of actively implemented clinical pathway studies in the emergency department setting. The main outcome measure is the inter-rater agreement of investigators using the clinical pathway criteria.

Methods

We performed a systematic literature search from 2006 to 2015 using MEDLINE, EMBASE, CENTRAL, and CINAHL. All types of prospective trial designs were eligible. We identified relevant publications using the above-mentioned clinical pathway criteria. Two reviewers independently collected data using a piloted data abstraction tool.

Results

We identified 5947 publications, with 472 potentially relevant full text publications retrieved. Of these, 357 did not meet preliminary study inclusion criteria, leaving 115 publications where the clinical pathway criteria were applied. Ultimately, 44 publications were included. The inter-rater agreement of the criteria was very good (κ = 0.81, 95% Confidence Interval = 0.70–0.92). The vast majority of studies were excluded because the intervention did not meet the criterion of being multidisciplinary in nature.

Conclusion

These criteria are a useful instrument to reliably identify clinical pathway publications for systematic review purposes in an emergency department setting. Future modification of these criteria may improve their usefulness. Particular attention should be placed on clarifying what is meant by multidisciplinary involvement within the context of clinical pathway interventions, with specific emphasis placed on delineating the level of involvement of each discipline and their decision-making responsibility.

Improving care coordination using organisational routines

PURPOSE

The purpose of this paper is to systematically apply theory of organisational routines to standardised care pathways. The explanatory power of routines is used to address open questions in the care pathway literature about their coordinating and organising role, the way they change and can be replicated, the way they are influenced by the organisation and the way they influence health care professionals.

DESIGN/METHODOLOGY/APPROACH

Theory of routines is systematically applied to care pathways in order to develop theoretically derived propositions.

FINDINGS

Care pathways mirror routines by being recurrent, collective and embedded and specific to an organisation. In particular, care pathways resemble standard operating procedures that can give rise to recurrent collective action patterns. In all, 11 propositions related to five categories are proposed by building on these insights: care pathways and coordination, change, replication, the organisation and health care professionals. Research limitations/implications - The paper is conceptual and uses care pathways as illustrative instances of hospital routines. The propositions provide a starting point for empirical research.

PRACTICAL IMPLICATIONS

The analysis highlights implications that health care professionals and managers have to consider in relation to coordination, change, replication, the way the organisation influences care pathways and the way care pathways influence health care professionals. Originality/value - Theory on organisational routines offers fundamental, yet unexplored, insights into hospital processes, including in particular care coordination.

HIV Clinical Pathway: A New Approach to Combine Guidelines and Sustainability of Anti-Retroviral Treatment in Italy

The present article describes the case study of a “real world” HIV practice within the debate concerning the strategic role of Clinical Governance (CG) tools in the management of a National Healthcare System’s sustainability. The study aimed at assessing the impact of a Clinical Pathway (CP) implementation, required by the Regional Healthcare Service, in terms of effectiveness (virological and immunological conditions) and efficiency (economic resources absorption), from the budget holder perspective. Data derived from a multi-centre cohort of patients treated in 6 Hospitals that provided care to approximately 42% of the total HIV+ patients, in Lombardy Region, Italy. Two phases were compared: Pre-CP (2009–2010) vs. Post-CP implementation (2011–2012). All HIV infected adults, observed in the participating hospitals during the study periods, were enrolled and stratified into the 3 categories defined by the Regional CP: first-line, switch for toxicity/other, and switch for failure. The study population was composed of 1,284 patients (Pre-CP phase) and 1,135 patients (Post-CP phase). The results showed that the same level of virological and immunological effectiveness was guaranteed to HIV+ patients: 81.2% of Pre-CP phase population and 83.2% of Post-CP phase population had undetectable HIV-RNA (defined as <50 copies/mL) at 12-month follow up. CD4⁺ cell counts increased by 28 ± 4 cells/mm³ in Pre-CP Phase and 39 ± 5 cells/mm³ in Post-CP Phase. From an economic point of view, the CP implementation led to a substantial advantage: the mean total costs related to the management of the HIV disease (ART, hospital admission and laboratory tests) decreased (-8.60%) in the Post-CP phase (p-value < 0.0001). Results confirmed that the CP provided appropriateness and quality of care, with a cost reduction for the budget holder.

Operational antecedents of integrated patient planning in hospitals

Purpose

– Hospitals struggle to integrate the planning from different departments; resulting in unacceptable waiting times for patients. The literature mainly addresses general, organizational factors inhibiting or enabling integration and omits important factors stemming from the care delivery process. Therefore, the purpose of this paper is to uncover operational antecedents and to assess their effect on the integration of hospital planning.

Design/methodology/approach

– The study is based on a three-hospital multi-case study. The main findings stem from over 40 in-depth interviews with specialists, nurses, planners, and managers of four specialties that are all involved in the orthopedic internal supply chain.

Findings

– This study identifies five critical operational antecedents: performance management, shared resources, information technology, process visibility, and uncertainty/variability. The latter two are of specific importance in a healthcare context. Three distinctive roles are identified; initiating (performance management and process visibility), facilitating (information technology), and inhibiting (shared resources and uncertainty/variability).

Practical implications

– The authors address how integration can be achieved, rather than merely prescribing integration as a means to improve performance. The identification of specific operational antecedents and their role help managers to find tangible ways to effectively integrate hospital planning which increases hospital performance.

Originality/value

– First, the identified operational antecedents are essential supplementary factors to more common organizational and behavioral antecedents. Second, in contrast to earlier contributions the authors show the effects of antecedents on three different stages of integration, rather than on integration in general.

Psychometric properties of the Norwegian version of the Care Process Self-Evaluation Tool

The Care Process Self-Evaluation Tool (CPSET) assesses key characteristics of well-organised care processes in hospitals from an interprofessional team perspective. The present study investigated the psychometric properties of the CPSET in terms of factor structure, convergent and discriminant validity, and reliability in Norwegian language and context. After a pilot test, the Norwegian version of the questionnaire was administered as a web form to 501 health professionals in public general hospitals and mental health specialist services; 301 completed forms (response rate 60%) were returned, and 268 (54%) forms representing 27 care processes (19 from somatic care and 8 from mental healthcare) were included in the valid sample. A confirmatory factor analysis (CFA) confirmed the original five-factor structure. All model fit indices, including the standardised root mean square residual (SRMR), which is independent of the χ²-test, met the criteria for an acceptable model fit. Internal consistencies within sub-scales as measured by Cronbach's alpha were high (range 0.83-0.94). As expected, some redundancy between factors existed (in particular among the PO (Patient-focused organisation), COR (Coordination of the care process), COM (Communication with patient and family), and PO (Follow-up of the care process) factors). In conclusion, the Norwegian CPSET scale showed acceptable psychometric properties in terms of convergent validity and reliability, and fit indices from the CFA confirmed the original factor structure. Based on these findings, we recommend the Norwegian version of the CPSET for use in the assessment of interprofessional teamwork in care processes in specialist healthcare.

Management by geographical area or management specialised by disorder? A mixed-methods evaluation of the effects of an organisational intervention on secondary mental health care for common mental disorder

Background

In 2010, South London and Maudsley NHS Foundation Trust (SLaM) established a programme replacing the borough directorates responsible for adult mental health services with three Clinical Academic Groups (CAGs), each of which took on a subset of adult services straddling all four boroughs. Care pathways were also introduced. We studied the Mood Anxiety and Personality CAG, which took on assessment and treatment teams and psychotherapy services.

Objectives

We aimed (1) to understand the CAG programme using realistic evaluation and (2) to assess whether or not it led to changes in activity and health-care quality.

Methods

Qualitative analysis was based on interviews and project documents. Quantitative analyses were based on electronic patient records and compared care in community mental health teams (CMHTs) and psychotherapy teams before and after CAG implementation. Analyses of activity covered caseload, counts of new episodes, episode length and number of contacts per episode. We also looked at CMHT costs. Analyses of effectiveness covered processes (pharmacological and psychological treatment of depression in CMHTs) and outcomes (effect on the Health of the Nation Outcome Scales total score or the Clinical Outcomes in Routine Evaluation 10-item version total score). Analyses of safety examined the rates of self-harm among current or recent CMHT patients. Patient centredness was represented by waiting time.

Results

The first core component of SLaM’s CAG programme was the CAG restructuring itself. The second was the promotion of care pathways; interpreted as ‘high level pathways’, these schematised processes of referral, assessment, treatment, reassessment and discharge, but abstracted from the details of treatment. The three mechanisms of the CAG restructuring were increasing oversight, making teams fit the template of team types defined for each CAG (‘CAG compliance’) and changing financial accounts by grouping services in new ways; these mechanisms resulted in further reconfigurations. The use of high-level pathways supported service redesign and performance management. In CMHTs and psychotherapy teams activity tended to decrease, but this was probably not because of the CAG programme. CMHT costs were largely unchanged. There was no evidence that the CAG programme altered effectiveness or safety. Effects on waiting times varied but these were reduced in some cases. Overall, therefore, the CAG programme appeared to have had few effects on quality. We attributed this to the limited effect of the programme on individual treatment.

Conclusions

SLaM’s CAG programme had clear effects on service reconfiguration at team level, with high-level pathways changing the ways that managers conceptualised their work. However, our quantitative work indicated no clear effects on quality. Thinking about how to use care pathways in ways that complement ‘high-level’ pathways by supporting the delivery of evidence-based treatments is a strategy that could help SLaM and other providers. Future research should look at the genesis of organisational change and how this is altered through implementation; it should also look at the effectiveness of care pathways in mental health services.

Funding

The research was supported by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and was performed using infrastructure provided by the NIHR South London and Maudsley and Institute of Psychiatry Biomedical Research Centre.

What is a clinical pathway? Refinement of an operational definition to identify clinical pathway studies for a Cochrane systematic review

Clinical pathways (CPWs) are a common component in the quest to improve the quality of health. CPWs are used to reduce variation, improve quality of care, and maximize the outcomes for specific groups of patients. An ongoing challenge is the operationalization of a definition of CPW in healthcare. This may be attributable to both the differences in definition and a lack of conceptualization in the field of clinical pathways. This correspondence article describes a process of refinement of an operational definition for CPW research and proposes an operational definition for the future syntheses of CPWs literature. Following the approach proposed by Kinsman et al. (BMC Medicine 8(1):31, 2010) and Wieland et al. (Alternative Therapies in Health and Medicine 17(2):50, 2011), we used a four-stage process to generate a five criteria checklist for the definition of CPWs. We refined the operational definition, through consensus, merging two of the checklist's criteria, leading to a more inclusive criterion for accommodating CPW studies conducted in various healthcare settings. The following four criteria for CPW operational definition, derived from the refinement process described above, are (1) the intervention was a structured multidisciplinary plan of care; (2) the intervention was used to translate guidelines or evidence into local structures; (3) the intervention detailed the steps in a course of treatment or care in a plan, pathway, algorithm, guideline, protocol or other 'inventory of actions' (i.e. the intervention had time-frames or criteria-based progression); and (4) the intervention aimed to standardize care for a specific population. An intervention meeting all four criteria was considered to be a CPW. The development of operational definitions for complex interventions is a useful approach to appraise and synthesize evidence for policy development and quality improvement.

Unpacking the key components of a programme to improve the timeliness of hip-fracture care: a mixed-methods case study

Background

Delay to surgery for patients with hip fracture is associated with higher incidence of post-operative complications, prolonged recovery and length of stay, and increased mortality. Therefore, many health care organisations launch improvement programmes to reduce the wait for surgery. The heterogeneous application of similar methods, and the multifaceted nature of the interventions, constrain the understanding of which method works, when, and how. In complex acute care settings, another concern is how changes for one patient group influence the care for other groups. We therefore set out to analyse how multiple components of hip-fracture improvement efforts aimed to reduce the time to surgery influenced that time both for hip-fracture patients and for other acute surgical orthopaedic inpatients.

Methods

This study is an observational mixed-methods single case study of improvement efforts at a Swedish acute care hospital, which triangulates control chart analysis of process performance data over a five year period with interview, document, and non-participant observation data.

Results

The improvement efforts led to an increase in the monthly percentage of hip-fracture patients operated within 24 h of admission from an average of 47 % to 83 %, with performance predictably ranging between 67 % and 98 % if the process continues unchanged. Meanwhile, no significant changes in lead time to surgery for other acute surgical orthopaedic inpatients were observed. Interview data indicated that multiple intervention components contributed to making the process more reliable. The triangulation of qualitative and quantitative data, however, indicated that key changes that improved performance were the creation of a process improvement team and having an experienced clinician coordinate demand and supply of surgical services daily and enhance pre-operative patient preparation.

Conclusions

Timeliness of surgery for patients with hip fracture in a complex hospital setting can be substantially improved without displacing other patient groups, by involving staff in improvement efforts and actively managing acute surgical procedures.

Evaluating the Liverpool Care Pathway for care of the terminally ill in rural Australia

PURPOSE

This study evaluates a pilot implementation of the Liverpool Care Pathway (LCP), a clinical tool used to guide the care of dying patients in the last days of life, on the end-of-life care for dying patients in three regions in rural Australia.

METHODS

The LCP was implemented at 13 participating sites: nine hospitals (general wards), one community-based palliative care service, and three in-hospital palliative care units. To evaluate the implementation of the LCP, 415 eligible patient records were examined: 223 pre-implementation and 192 post-implementation (116 on the LCP and 76 receiving usual care). The primary analysis compared all patients pre-implementation of the LCP versus all patients post-implementation.

RESULTS

Increases were found post-implementation for communication with other health professionals and with patients or family (pre-69 %, post-87 %; p ≤ 0.000), use of palliative medications (pre-87 %, post-98 %; p ≤ 0.000) and frequency of symptom assessments (pre-66 %, post-82 %; p ≤ 0.000). Fewer blood and radiological investigations were conducted and venous access devices used in the post-implementation groups than in the pre-implementation period.

CONCLUSIONS

This study suggests that when rigorously implemented, the LCP improves important components of end-of-life care for dying patients and their families.

The importance of clinical pathways and protocols in pediatric nephrology

Modern clinical practice is increasingly delivered by teams of individuals working within an environment of rising complexity and daunting patient care loads. Clinical pathways, protocols and checklists offer a way to assure coordination, efficiency, quality and safety in this chaotic environment. In this review, we discuss some of the principal characteristics of these clinical tools, some of the challenges involved with introducing them into clinical practice and the evidence that they can positively affect patient and system outcomes. We believe pediatric nephrology, as a discipline, is ready for the widespread introduction of these important quality tools.

Evaluation of the impact of a clinical pathway on the organization of a multidisciplinary dental sleep clinic

PURPOSE

Clinical pathways are used to organize complex care processes by providing structure and standardization. The multidisciplinary approach of oral appliance (OA) therapy for sleep-disordered breathing (SDB) is a complex and dynamic process suitable for such a structured pathway approach.

METHODS

A clinical pathway for patients referred for OA therapy was developed and implemented. The aim of this study was to evaluate the impact of this clinical pathway on the time to delivery of the OA and the organization of the multidisciplinary dental sleep clinic (MDSC). The latter was achieved using the care process self-evaluation tool (CPSET).

RESULTS

First, development and implementation of the clinical pathway gave structure and shortened the mean time to delivery by 102 days (240 ± 70 vs. 138 ± 33 days) (Mann-Whitney U: P < 0.001). Second, the CPSET scores were obtained in a cohort of 49 healthcare professionals involved in the pathway. Overall, patient-focused organization received the highest scores (80.5 ± 9.0%), whereas cooperation with primary care received the lowest score (66.7 ± 12.4%).

CONCLUSIONS

This is the first project on clinical pathways in OA therapy for SDB. The implementation of the pathway in our MDSC has created a significant shortening of the time to delivery. A first evaluation of the clinical pathway using the CPSET scores indicates that all disciplines involved should be thoroughly informed in an ongoing approach.

Systematic review of the effectiveness of integrated care pathways: what works, for whom, in which circumstances?

Aim  Integrated care pathways (ICP) are management technologies which formalise multidisciplinary team-working and enable professionals to examine their roles and responsibilities. ICPs are now being implemented across international healthcare arena, but evidence to support their use is equivocal. The aim of this study was to identify the circumstances in which ICPs are effective, for whom and in what contexts. Methods  A systematic review of high-quality randomised controlled trials published between 1980 and 2008 (March) evaluating ICP use in child and adult populations in the full range of healthcare settings.

RESULTS

1 For relatively predictable trajectories of care ICPs can be effective in supporting proactive care management and ensuring that patients receive relevant clinical interventions and/or assessments in a timely manner. This can lead to improvements in service quality and service efficiency without adverse consequences for patients. 2 ICPs are an effective mechanism for promoting adherence to guidelines or treatment protocols thereby reducing variation in practice. 3 ICPs can be effective in improving documentation of treatment goals, documentation of communication with patients, carers and health professionals. 4 ICPs can be effective in improving physician agreement about treatment options. 5 ICPs can be effective in supporting decision-making when they incorporate a decision-aide. 6 The evidence considered in this review indicates that ICPs may be particularly effective in changing professional behaviours in the desired direction, where there is scope for improvement or where roles are new. 7 Even in contexts in which health professionals are already experienced with a particular pathway, ICP use brings additional beneficial effects in directing professional practice in the desired direction. 8 ICPs may be less effective in bringing about service quality and efficiency gains in variable patient trajectories. 9 ICPs may be less effective in bringing about quality improvements in circumstances in which services are already based on best evidence and multidisciplinary working is well established. 10 Depending on their purpose, the benefits of ICPs may be greater for certain patient subgroups than others. 11 We do not know whether the costs of ICP development and implementation are justified by any of their reported benefits. 12 ICPs may need supporting mechanisms to underpin their implementation and ensure their adoption in practice, particularly in circumstances in which ICP use is a significant change in organisational culture. 13 ICP documentation can introduce scope for new kinds of error. Conclusions  ICPs are most effective in contexts where patient care trajectories are predictable. Their value in settings in which recovery pathways are more variable is less clear. ICPs are most effective in bringing about behavioural changes where there are identified deficiencies in services; their value in contexts where inter-professional working is well established is less certain. None of the studies reviewed included an economic evaluation and thus it is not known whether their benefits justify the costs of their implementation.

Effects of care pathways on the in-hospital treatment of heart failure: a systematic review

BACKGROUND

Care pathways have become a popular tool to enhance the quality of care by improving patient outcomes, promoting patient safety, increasing patient satisfaction, and optimizing the use of resources. We performed a disease specific systematic review to determine how care pathways in the hospital treatment of heart failure affect in-hospital mortality, length of in-hospital stay, readmission rate and hospitalisation cost when compared with standard care.

METHODS

Medline, Cinahl, Embase and the Cochrane Central Register of Controlled Trials were searched from 1985 to 2010. Each study was assessed independently by two reviewers. Methodological quality of the included studies was assed using the Jadad methodological approach for randomised controlled trials, controlled clinical trials and the New Castle Ottawa Scale for case-control studies, cohort studies and time interrupted series.

RESULTS

Seven studies met the study inclusion criteria and were included in the systematic review with a total sample of 3,690 patients. The combined overall results showed that care pathways have a significant positive effect on mortality and readmission rate. A shorter length of hospital stay was also observed compared with the standard care group. No significant difference was found in the hospitalisation costs. More positive results were observed in controlled trials compared to randomized controlled trials.

CONCLUSION

By combining all possible results, it can be concluded that care pathways for treatment of heart failure decrease mortality rates and length of hospital stay, but no statistically significant difference was observed in the readmission rates and hospitalisation costs. However, one should be cautious with overall conclusions: what works for one organization may not work for another because of the subtle differences in processes and bottlenecks.

A systematic integrated literature review of systematic integrated literature reviews in nursing

As faculty members, we frequently find that first-year doctoral students in nursing are confused about how to conduct a systematic integrated literature review. This could be due to its vague definition and a lack of recent literature that provides directions for conducting a systematic integrated literature review. This article aims to provide directions for conducting a systematic integrated literature review by identifying the essential components of published literature reviews in nursing. To achieve this goal, the literature was searched by using the keywords nursing, systematic, and review in multiple databases. A total of 267 articles were selected and are included in this systematic integrated literature review. The articles were then sorted by study design and analyzed in six areas of interests. Finally, a practical guideline for conducting systematic integrated literature reviews is proposed based on the analysis of the literature.

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

OBJECTIVE

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

DESIGN

 Cluster randomised controlled trial.

SETTING

  Six rural Victorian emergency departments participated.

INTERVENTION

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

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.

[Development of an internet-based clinical pathway exemplified by the fibromyalgia syndrome]

Clinical pathways (CP) are considered to be a tool of clinical process management describing the optimal route for diagnostic and therapeutic medical treatment of a specified patient. Apart from economic aspects CPs can make a contribution to optimization of health quality management as well as to improvement of medical staff and both patient satisfaction and patient safety whereas the feasibility and acceptance of evidence-based medicine guidelines are often found to be low. In order to stimulate critical discussion by offering the opportunity to easily gain first practical experience, a free web-based clinical pathway system for diagnosis and treatment for patients with fibromyalgia syndrome (FMS) will be presented.

Cost effectiveness of total knee arthroplasty from a health care providers' perspective before and after introduction of an interdisciplinary clinical pathway--is investment always improvement?

Background

Total knee arthroplasty (TKA) is an effective, but also cost-intensive health care intervention for end stage osteoarthritis. This investigation was designed to evaluate the cost-effectiveness of TKA before versus after introduction of an interdisciplinary clinical pathway from a University Orthopedic Surgery Department's cost perspective as an interdisciplinary full service health care provider.

Methods

A prospective trial recruited two sequential cohorts of 132 and 128 consecutive patients, who were interviewed by means of the WOMAC questionnaire. Direct process costs from the health care providers' perspective were estimated according to the German DRG calculation framework. The health economic evaluation was based on margiual cost-effectveness ratios (MCERs); an individual marginal cost effectiveness relation ≤ 100 € per % WOMAC index increase was considered as primary endpoint of the confirmatory cohort comparison. The interdisciplinary clinical pathway under consideration primarily consisted of a voluntary preoperative personal briefing of patients concerning postoperatively expectable progess in health status and optimum use of walking aids after surgery. All patients were supplied with written information on these topics, attendance of the personal briefing also included preoperative training for postoperative mobilisation by the Department's physiotherapeutic staff.

Results

An individual marginal cost effectiveness relation ≤ 100 €/% WOMAC index increase was found in 38% of the patients in the pre pathway implementation cohort versus in 30% of the post pathway implementation cohort (Fisher p = 0.278). Both cohorts showed substantial improvement in WOMAC scores (39 versus 35% in median), whereas the cohort did not differ significantly in the median WOMAC score before surgery (41% for the pre pathway cohort versus 44% for the post pathway cohort). Despite a locally significant decrease in costs (4303 versus 4194 € in median), the individual cost/benefit relation became worse after introduction of the pathway: for the first cohort the MCER was estimated 108 € per gained % WOMAC index increase (86 - 150 €/%) versus 118 €/% WOMAC gain (93 - 173 €/%) in the second cohort after pathway implementation. In summary, the proposed critical pathway for TKA could be shown to be significantly cost efficient, but not cost effective concerning functional outcome, when the above individual marginal cost effectiveness criterion was concentrated on.

Conclusions

The introduction of an interdisciplinary clinical pathway does not necessarily improve patient related outcomes. On the contrary, cost effectiveness from the health care providers' perspective may even turn out remarkably reduced in the setting considered here (functional outcome assessment after treatment by a full service health care provider).

Knowledge Management of Healthcare by Clinical-Pathways

Healthcare is a knowledge-intensive service provided by professionals, such as medical doctors, nurses, and pharmacists. Clinical-pathways are used by many healthcare organisations (HCOs) as a tool for performing the healthcare process, sharing and utilising knowledge from different professionals. In this paper, case studies were performed at two HCOs that use clinical-pathways actively in the healthcare process. Theoretical model construction, sharing, utilisation, and creation of the knowledge by different professionals, were tested by the case study of two HCOs which use clinical pathways actively. The theoretical model was a knowledge creation model which creates new knowledge continuously. In this theoretical model, clinical-pathways are suggested to be an effective tool for knowledge management in healthcare.

[Clinical pathway for total knee arthroplasty. I: Pathway conception and effect on functional quality of results]

PURPOSE

The aim of the current study was to evaluate patient-centred and economic outcomes after introduction of a clinical pathway for total knee arthroplasty.

METHODS

In a prospective trial two sequential cohorts of patients undergoing total knee arthroplasty were recruited. Baseline treatment was surveyed in cohort I and the clinical pathway was developed and evaluated in cohort II. Data from WOMAC, EQ-5D as well as partial cost data were collected. The study design was ratified by the local Independent Ethics Committee.

RESULTS

There was an increase in WOMAC score of 39% for cohort I and 35% for cohort II in 3 months follow-up. Similar results were found for ED-5D with an increase of 30% for cohort I and 25% for cohort II. Partial cost rates could be lowered from 4303 EUR to 419 EUR. Despite this significant cost saving we were not able to improve the ratio of improvement in quality of life to costs.

CONCLUSION

With the aid of a clinical pathway the process for implementation of a total knee arthroplasty was improved and treatment quality assured.

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.

The utility of clinical care pathways in determining perinatal outcomes for women with one previous caesarean section; a retrospective service evaluation

Background

The rising rates of primary caesarean section have resulted in a larger obstetric population with scarred uteri. Subsequent pregnancies in these women are risk-prone and may complicate. Besides ensuring standardised management, care pathways could be used to evaluate for perinatal outcomes in these high risk pregnancies. We aim to demonstrate the use of a care pathway for vaginal birth after caesarean section as a service evaluation tool to determine perinatal outcomes.

Methods

A retrospective service evaluation by review of delivery case notes and records was undertaken at the Aga Khan University Hospital, Nairobi, Kenya between January 2008 and December 2009

Women with ≥2 previous caesarean sections, previous classical caesarean section, multiple gestation, breech presentation, severe pre-eclampsia, transverse lie, placenta praevia, conditions requiring induction of labour and incomplete records were excluded. Outcome measures included the proportion of eligible women who opted for test of scar (ToS), success rate of vaginal birth after caesarean section (VBAC); proportion on women opting for elective repeat caesarean section (ERCS) and their perinatal outcomes.

Results

A total of 215 women with one previous caesarean section were followed up using a standard care pathway. The median parity (minimum-maximum) was 1.0[1-4]. The other demographic characteristics were comparable. Only 44.6% of eligible mothers opted to have a ToS. The success rate for VBAC was 49.4% with the commonest (31.8%) reason for failure being protracted active phase of labour. Maternal morbidity was comparable for the failed and successful VBAC group. The incidence of hemorrhage was 2.3% and 4.4% for the successful and failed VBAC groups respectively. The proportion of babies with acidotic arterial PH (< 7.10) was 3.1% and 22.2% among the successful and failed VBAC groups respectively. No perinatal mortality was reported.

Conclusions

Besides ensuring standardised management, care pathways could be objective audit and service evaluation tools for determining perinatal outcomes.

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.

What is a clinical pathway? Development of a definition to inform the debate

BACKGROUND

Clinical pathways are tools used to guide evidence-based healthcare that have been implemented internationally since the 1980s. However, there is widespread lack of agreement on the impact of clinical pathways on hospital resources and patient outcomes. This can be partially attributed to the confusion for both researchers and healthcare workers regarding what constitutes a clinical pathway. This paper describes efforts made by a team of Cochrane Review authors to develop criteria to assist in the objective identification of clinical pathway studies from the literature.

METHODS

We undertook a four-stage process aiming to develop criteria to define a clinical pathway: (1) identify publications exploring the definition of a clinical pathway; (2) derive draft criteria; (3) pilot test the criteria; and (4) modify criteria to maximise agreement between review authors.

RESULTS

Previous literature and liaison with the European Pathways Association resulted in five criteria being used to define a clinical pathway: (1) the intervention was a structured multidisciplinary plan of care; (2) the intervention was used to translate guidelines or evidence into local structures; (3) the intervention detailed the steps in a course of treatment or care in a plan, pathway, algorithm, guideline, protocol or other 'inventory of actions'; (4) the intervention had timeframes or criteria-based progression; and (5) the intervention aimed to standardise care for a specific clinical problem, procedure or episode of healthcare in a specific population. After pilot testing it was decided that if an intervention met the first criteria (a structured multidisciplinary plan of care) plus three out of the other four criteria then it was included as a clinical pathway for the purposes of this review. In all, 27 studies were included in the final review. The authors of the included studies referred to these interventions as 'clinical pathways', 'protocols', 'care model', 'care map', 'multidisciplinary care', evidence-based care' and 'guideline'.

CONCLUSIONS

The criteria used for the identification of relevant studies for this Cochrane Review can be used as a foundation for the development of a standardised, internationally accepted definition of a clinical pathway.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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