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Hooper J, Jervis N, Morgan L, Beckett V, Hand P, Higgs K, Munir A, Prinn J, Pritchard DM, Sarker D, Srirajaskanthan R, Ellis CB. Neuroendocrine neoplasms: Consensus on a patient care pathway. J Neuroendocrinol 2024; 36:e13380. [PMID: 38471798 DOI: 10.1111/jne.13380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 01/30/2024] [Accepted: 02/22/2024] [Indexed: 03/14/2024]
Abstract
People with neuroendocrine neoplasms (NENs) face a multitude of challenges, including delayed diagnosis, low awareness of the cancer among healthcare professionals and limited access to multidisciplinary care and expert centres. We have developed the first patient care pathway for people living with NENs in England to guide disease management and help overcome these barriers. The pathway was developed in two phases. First, a pragmatic review of the literature was conducted, which was used to develop a draft patient care pathway. Second, the draft pathway was then updated following semi-structured interviews with carefully selected expert stakeholders. After each phase, the pathway was discussed among a multidisciplinary, expert advisory group (which comprised the authors and the Deputy Chief Operating Officer, West Suffolk NHS Foundation Trust), who reached a consensus on the ideal care pathway. This article presents the outputs of this research. The pathway identified key barriers to care and highlighted how these may be addressed, with many of the findings relevant to the rest of the UK and international audiences. NENs are increasing in incidence and prevalence in England, compounding pre-existing inequities in diagnosis and disease management. Effective integration of this pathway within NHS England will help achieve optimal, equitable care provision for all people with NENs, and should be feasible within the existing expert multidisciplinary teams across the country.
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Affiliation(s)
| | | | | | - Vivienne Beckett
- Advanced Accelerators Applications (UK & Ireland) Ltd, a Novartis Company, London, UK
| | - Philippa Hand
- London North West University Healthcare NHS Trust, London, UK
| | | | - Alia Munir
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield Teaching Hospitals European Neuroendocrine Tumor Society Center of Excellence, Sheffield, UK
| | | | - D Mark Pritchard
- University of Liverpool and Liverpool University Hospitals NHS Foundation Trust, Liverpool Regional NET Service (European Neuroendocrine Tumor Society Center of Excellence), Liverpool, UK
| | - Debashis Sarker
- Guy's, St Thomas' and King's College Hospitals, King's Health Partners NET Centre (European Neuroendocrine Tumor Society Center of Excellence), London, UK
| | - Raj Srirajaskanthan
- King's College Hospital NHS Foundation Trust, King's Health Partners NET Centre (European Neuroendocrine Tumor Society Center of Excellence), London, UK
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James CA, Lewis PS, Moore MB, Wong K, Rader EK, Roberson PK, Ghaleb NA, Jensen HK, Pezeshkmehr AH, Stroud MH, Ashton DJ. Efficacy of standardizing fibrinolytic therapy for parapneumonic effusion. Pediatr Radiol 2022; 52:2413-2420. [PMID: 35451632 PMCID: PMC9023697 DOI: 10.1007/s00247-022-05365-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 12/15/2021] [Accepted: 03/21/2022] [Indexed: 10/25/2022]
Abstract
BACKGROUND While chest tube placement with pleural fibrinolytic medication is the established treatment of pediatric empyema, treatment failure is reported in up to 20% of these children. OBJECTIVE Standardizing fibrinolytic administration among interventional radiology (IR) physicians to improve patient outcomes in pediatric parapneumonic effusion. MATERIALS AND METHODS We introduced a hospital-wide clinical pathway for parapneumonic effusion (1-2 mg tissue plasminogen activator [tPA] twice daily based on pleural US grade); we then collected prospective data for IR treatment May 2017 through February 2020. These data included demographics, co-morbidities, pediatric intensive care unit (PICU) admission, pleural US grade, culture results, daily tPA dose average, twice-daily dose days, skipped dose days, pleural therapy days, need for chest CT/a second IR procedure/surgical drainage, and length of stay. We compared the prospective data to historical controls with IR treatment from January 2013 to April 2017. RESULTS Sixty-three children and young adults were treated after clinical pathway implementation. IR referrals increased (P = 0.02) and included higher co-morbidities (P = 0.005) and more PICU patients (P = 0.05). Mean doses per day increased from 1.5 to 1.9 (P < 0.001), twice-daily dose days increased from 38% to 79% (P < 0.001) and median pleural therapy days decreased from 3.5 days to 2.5 days (P = 0.001). No IR patients needed surgical intervention. No statistical differences were observed for gender/age/weight, US grade, need for a second IR procedure or length of stay. US grade correlated with greater positive cultures, need for chest CT/second IR procedure, and pleural therapy days. CONCLUSION Interventional radiology physician standardization improved on a clinical pathway for fibrinolysis of parapneumonic effusion. Despite higher patient complexity, pleural therapy duration decreased. There were no chest tube failures needing surgical drainage.
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Affiliation(s)
- Charles A James
- Radiology Department, Arkansas Children's Hospital and University of Arkansas for Medical Sciences, Slot 105, 1 Children's Way, Little Rock, AR, 72202, USA.
| | - P Spencer Lewis
- Radiology Department, Arkansas Children's Hospital and University of Arkansas for Medical Sciences, Slot 105, 1 Children's Way, Little Rock, AR, 72202, USA
| | - Mary B Moore
- Radiology Department, Arkansas Children's Hospital and University of Arkansas for Medical Sciences, Slot 105, 1 Children's Way, Little Rock, AR, 72202, USA
| | - Kevin Wong
- Radiology Department, Arkansas Children's Hospital and University of Arkansas for Medical Sciences, Slot 105, 1 Children's Way, Little Rock, AR, 72202, USA
| | - Emily K Rader
- Quality, Risk, and Safety Department, Arkansas Children's Hospital, Little Rock, AR, USA
| | - Paula K Roberson
- Biostatistics Department, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Nancy A Ghaleb
- Anesthesia Department, Detroit Medical Center and Wayne State University, Detroit, MI, USA
| | - Hanna K Jensen
- Radiology Department, Arkansas Children's Hospital and University of Arkansas for Medical Sciences, Slot 105, 1 Children's Way, Little Rock, AR, 72202, USA
| | - Amir H Pezeshkmehr
- Radiology Department, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Michael H Stroud
- Pediatrics Department, Arkansas Children's Hospital and University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Daniel J Ashton
- Radiology Department, Arkansas Children's Hospital and University of Arkansas for Medical Sciences, Slot 105, 1 Children's Way, Little Rock, AR, 72202, USA
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Erjavec K. Team Members and Patients’ Views on Cost-effectiveness of (Integrated) Clinical Pathway. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.8049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: Integrated clinical pathways (ICPs), which have particularly enhanced existing clinical pathways (CPs) through the work of multifunctional teams, have become an important tool to enable informed decision-making and provide more efficient, cost-effective, and value-based care.
AIM: In the absence of studies on the cost-effectiveness of ICPs, the aim of this study was to determine the opinion of team members treating patients with total hip arthroplasty and their patients on the practice of cost-effectiveness of the existing CP and ICP that might be introduced in the future.
METHODS: A mixed descriptive quantitative and qualitative approach was used. A survey of 61 team members of CP for total hip arthroplasty was conducted, as well as in-depth interviews (n = 12) and focus groups (n = 11). In addition, in-depth interviews were performed with 20 patients who had undergone total hip arthroplasty at CP in a typical Slovenian general hospital.
RESULTS: The results showed that participants occasionally prioritized cost-effectiveness over quality of health care. They frequently used CP to reduce the cost and time of patient care. Nurses with secondary education were statistically significantly more likely to prioritize cost-effectiveness of health care over quality of health care than nurses with higher education, physicians, and others. Team members and patients evaluated positively the cost-effectiveness of ICP for total hip arthroplasty, but patients also pointed out that staff, especially nurse had too little contact with patients.
CONCLUSION: Both team members treating patients with total hip arthroplasty and their patients have a positive attitude toward the cost-effectiveness of ICP. The nursing staff has too little contact with the patients due to staff shortages.
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Seys D, Coeckelberghs E, Sermeus W, Van Zelm R, Panella M, Babu Payedimarri A, Vanhaecht K. Overview on the target population and methods used in care pathway projects: A narrative review. Int J Clin Pract 2021; 75:e14565. [PMID: 34165865 DOI: 10.1111/ijcp.14565] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 06/23/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND There is evidence that the efficiency and effectiveness of care processes can be improved in all countries. Care pathways (CPs) are proposed as a method to improve the quality of care by reducing variation. During the last decades, CPs have been intensively used in practice. The objective of this study is to examine the study designs for investigating CPs, for which pathologies CPs are used and what the reported indicators to measure the impact of CPs are. METHODS A narrative review of the literature published from 2015 to 2019 was performed. RESULTS We identified 286 studies, of which 207 evaluated the impact of CPs, 33 were review articles, 29 studies described the development of a CP, 12 were study protocols and 5 opinion papers. The most frequently reported study design for studying the impact of a CP is pre-posttest (n = 82), followed by cross-sectional studies (n = 50). Oncology, cardiovascular disease and abdominal surgery are the domains with the highest numbers of studies evaluating the impact of CPs. Financial (n = 86), process (n = 76) and clinical indicators (n = 74) are the most frequently reported indicators while service (n = 12) and team indicators (n = 6) are less reported. CONCLUSIONS Based on the relative low number of identified studies compared with the number of CP projects in organisations, we conclude that the CP knowledge is not only found in the literature. We, therefore, argue that (inter)national scientific societies should not only focus on searching and spreading evidence on the content of care but also enhance their knowledge sharing initiatives on the organisation of care processes.
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Affiliation(s)
- Deborah Seys
- Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven, Leuven, Belgium
| | - Ellen Coeckelberghs
- Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven, Leuven, Belgium
| | - Walter Sermeus
- Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven, Leuven, Belgium
| | - Ruben Van Zelm
- Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven, Leuven, Belgium
| | - Massimiliano Panella
- Department of Translational Medicine, University of Eastern Piedmont Amedeo Avogadro, Novara, Italy
| | - Anil Babu Payedimarri
- Department of Translational Medicine, University of Eastern Piedmont Amedeo Avogadro, Novara, Italy
| | - Kris Vanhaecht
- Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven, Leuven, Belgium
- Department of Quality Management, University Hospitals Leuven, Leuven, Belgium
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Logan AM, Landera MA. Clinical Practices in Head and Neck Cancer: A Speech-Language Pathologist Practice Pattern Survey. Ann Otol Rhinol Laryngol 2021; 130:1254-1262. [PMID: 33733876 DOI: 10.1177/00034894211001065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Clinical practices of speech-language pathologists (SLP) treating head and neck cancer (HNC) patients range widely despite literature trending toward best practices. This survey study was designed to identify current patterns and assess for gaps in clinical implementation of research evidence. METHOD A web-based survey was distributed to SLPs via listserv and social media outlets. Descriptive statistics and group calculations were completed to identify trends and associations in responses. RESULTS Of 152 received surveys, the majority of respondents were hospital-based (86%) and had greater than 5 years of experience (65%). There was group consensus for the use of prophylactic exercise programs (95%), recommendations for SLP intervention during HNC treatment (75%), and use of maintenance programs post-treatment (97%). Conversely, no group consensus was observed for use of pre-treatment swallow evaluations, frequency of service provision, and content of therapy sessions. Variation in clinical decision making was noted in use of prophylactic feeding tubes and number of patients taking nothing by mouth during treatment. No associations were found between years of experience and decision-making practices, nor were any associations found between practice setting and clinical decision making. CONCLUSION Despite the growing body of literature outlining evidence-based treatment practices for HNC patients, clinical practice patterns among SLPs continue to vary widely resulting in inconsistent patient care across practice settings. As compared to prior similar data, increased alignment with best practices was observed relative to early referrals, implementation of prophylactic intervention programs, and intervention with the SLP during the period of HNC treatment.
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Affiliation(s)
- Ashley M Logan
- Dr. Pallavi Patel College of Health Care Sciences, Nova Southeastern University, Fort Lauderdale, FL, USA.,Department of Otolaryngology-Head and Neck Surgery, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Mario A Landera
- Dr. Pallavi Patel College of Health Care Sciences, Nova Southeastern University, Fort Lauderdale, FL, USA.,Department of Otolaryngology, University of Miami School of Medicine, Miami, FL, USA
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McLachlan S, Kyrimi E, Dube K, Hitman G, Simmonds J, Fenton N. Towards standardisation of evidence-based clinical care process specifications. Health Informatics J 2020; 26:2512-2537. [DOI: 10.1177/1460458220906069] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
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.
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Affiliation(s)
- Scott McLachlan
- Health informatics and Knowledge Engineering Research Group (HiKER), New Zealand; Queen Mary University of London, UK
| | | | - Kudakwashe Dube
- Health informatics and Knowledge Engineering Research Group (HiKER), New Zealand; Massey University, New Zealand
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Abstract
PurposeThe reduction of costs has a more and more relevant role in the healthcare context, therefore, a large effort is done by health providers to this aim, for example, by reducing the length of hospital stay (LOS) of patients undergoing surgery. Fast track surgery fits perfectly this issue and was applied to patients undergoing knee replacement surgery due to Osteoarthritis, one of the most common diseases of aged population. The paper aims to discuss these issues.Design/methodology/approachLean six sigma was applied to analyze the implementation of fast track surgery through the define, measure, analyze, improve, control roadmap, used as a typical problem-solving approach. It is characterized by five operational phases, which make possible the achievement of fixed goals through a rigorous process of defining, measuring, analyzing, improving and controlling business problems.FindingsThe corrective action, consisting in the application of fast track surgery, improved both effectiveness and efficiency of the process of care. The average length of hospital stay (LOS) was reduced from 8.34 to 6.68 days (–19.9 percent) and its standard deviation from 2.41 to 1.99 days (–17.1 percent). The statistical significance of this decrease was verified by means of proper tests. Moreover, some variables influencing the LOS were identified.Research limitations/implicationsThe follow up and the satisfaction of patients were not analyzed and could be a future development of this study.Practical implicationsPatients will experience a faster recovery while the hospital will benefit from a rise of available beds. The effect is a general improvement of hospital management.Originality/valueThe introduction of fast track surgery for patients undergoing knee replacement surgery made significantly reduce LOS and, consequently, costs’ with a money saving of more than 50,000 euro per year.
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Vanhaecht K, de Witte K, Sermeus W. The Care Process Organization Triangle: A Framework to Better Understand how Clinical Pathways Work. ACTA ACUST UNITED AC 2019. [DOI: 10.1177/205343450701100202] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Clinical pathways, also known as care pathways or integrated care pathways, are used worldwide to make care processes transparent and organize care around patient needs. Although this is in international use, it is still unclear why pathways sometimes work and sometimes do not. To better understand how pathways work, there is a growing need for paradigms or organizing concepts. Different quality and health-care management gurus have developed frameworks to better understand how certain processes or methods work. This paper will provide an overview of several frameworks and integrate them into Donabedian's Structure–Process–Outcome configuration. In view of this configuration, the care process organization triangle was developed. In this paper, we will describe the three cornerstones of this triangle by integrating the literature on clinical pathways. The care process organization triangle is only one model, but as Deming described it: ‘Some models can be quite useful’.
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Affiliation(s)
- Kris Vanhaecht
- Center for Health Services and Nursing Research, Catholic University Leuven, Leuven
- Belgian Dutch Clinical Pathway Network, Leuven
- European Pathway Association, Leuven
| | - Karel de Witte
- Belgian Dutch Clinical Pathway Network, Leuven
- Center for Organisation and Personnel Psychology, Catholic University Leuven, Leuven, Belgium
| | - Walter Sermeus
- Center for Health Services and Nursing Research, Catholic University Leuven, Leuven
- Belgian Dutch Clinical Pathway Network, Leuven
- European Pathway Association, Leuven
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Ricciardi C, Fiorillo A, Valente AS, Borrelli A, Verdoliva C, Triassi M, Improta G. Lean Six Sigma approach to reduce LOS through a diagnostic-therapeutic-assistance path at A.O.R.N. A. Cardarelli. TQM JOURNAL 2019. [DOI: 10.1108/tqm-02-2019-0065] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
The rise of the mean age incremented the occurrence of femur fractures with respect to the past, leading thus to serious consequences, as regards morbidity and socio-economic impact. The direction of the A.O.R.N. Cardarelli of Naples has introduced a DTAP whose aim was the reduction of LOS. The paper aims to discuss this issue.
Design/methodology/approach
The aim of this paper is to analyze the introduction of DTAP, employing Lean Thinking and Six Sigma methodology based on the DMAIC cycle. To evaluate the effectiveness of DTAP, two groups of patients have been observed for 14 months (before and after the implementation of DTAP).
Findings
Statistical tests were performed on the groups and graphics were provided to visualize the decrease of LOS (29.9 per cent). The overall population was also divided in subgroups according to six variables potentially influencing LOS.
Research limitations/implications
Authors considered six variables of influences; yet, others could be taken into account in the future.
Practical implications
The decrease of costs due to the management of elderly patients with femur fracture, the optimization of care processes in hospitals and a faster recovery for patients is the tangible contribute of DTAP.
Originality/value
The implementation of DTAP allowed the hospital to obtain a significant reduction of LOS with a consequently decrease of costs alleviating the hospital and the society from the socio-economic burden and the morbidity of this pathology.
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Szelągowski M, Berniak-Woźny J. A Process-Centered Approach to the Description of Clinical Pathways-Forms and Determinants. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16152638. [PMID: 31344806 PMCID: PMC6695712 DOI: 10.3390/ijerph16152638] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 07/17/2019] [Accepted: 07/22/2019] [Indexed: 11/16/2022]
Abstract
The aim of the study is to indicate the need for variability in the presentation of clinical pathways, in various phases of their implementation, and to define the forms of presentation of clinical pathways required by physicians in both the Hospital Information Systems (HIS) and Electronic Medical Records (EMR) Systems, as well as the determinants of the selection of the forms of description, in relation to the performed medical actions. The results of the study are a significant lead-in towards further research on the required form of the user interface in systems supporting dynamic business process management (dynamic BPM). The research is a pilot of a survey study, conducted to ascertain the usefulness and feasibility of the adopted methodology, for a wider project on the determinants of the form of description of clinical pathways. An exploratory pilot survey, in a large multi-specialization hospital in Poland, was conducted. The survey sample consisted of 28 purposely selected heads of all hospital departments, and the medical team of the pediatric ward. Descriptive analysis was carried out on the data collected. The results of the study have unambiguously supported the claim that physicians require the form of presentation of clinical pathways to change, depending on the particular phase of the diagnostic–therapeutic process, as well as establishing the main determinants thereof. This pilot study is one of the first attempts to establish the factors determining the choice of clinical pathway presentation in HIS/EMR systems. While not conclusively decisive in terms of the forms of presentation or the determinants of their choice, it indicates the directions of further research, both from the point of view of ergonomics and the usability of HIS/EMR systems, as well as the management of medical knowledge, as part of the dynamic management of clinical pathways.
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Affiliation(s)
- Marek Szelągowski
- Systems Research Institute, Polish Academy of Sciences, 00-001 Warsaw, Poland
| | - Justyna Berniak-Woźny
- Faculty of Business and International Relations, Vistula University, 02-787 Warsaw, Poland.
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Abstract
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.
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Affiliation(s)
- Sharon Williams
- College of Human and Health Sciences, Swansea University , Swansea, UK
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Jabbour M, Newton AS, Johnson D, Curran JA. Defining barriers and enablers for clinical pathway implementation in complex clinical settings. Implement Sci 2018; 13:139. [PMID: 30419942 PMCID: PMC6233585 DOI: 10.1186/s13012-018-0832-8] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 10/22/2018] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND While clinical pathways have the potential to improve patient outcomes and reduce healthcare costs, their true impact has been limited by variable implementation strategies and suboptimal research designs. This paper explores a comprehensive set of factors perceived by emergency department staff and administrative leads to influence clinical pathway implementation within the complex and dynamic environments of community emergency department settings. METHODS This descriptive, qualitative study involved emergency health professionals and administrators of 15 community hospitals across Ontario, Canada. As part of our larger cluster randomized controlled trial, each site was in the preparation phase to implement one of two clinical pathways: pediatric asthma or pediatric vomiting and diarrhea. Data were collected from three sources: (i) a mediated group discussion with site champions during the project launch meeting; (ii) a semi-structured site visit of each emergency department; and (iii) key informant interviews with an administrative lead from each hospital. The Theoretical Domains Framework (TDF) was used to guide the interviews and thematically analyze the data. Domains within each major theme were then mapped onto the COM-B model-capability, opportunity, and motivation-of the Behaviour Change Wheel. RESULTS Seven discrete themes and 58 subthemes were identified that comprised a set of barriers and enablers relevant to the planned clinical pathway implementation. Within two themes, three distinct levels of impact emerged, namely (i) the individual health professional, (ii) the emergency department team, and (iii) the broader hospital context. The TDF domains occurring most frequently were Memory, Attention and Decision Processes, Environmental Context and Resources, Behavioural Regulation, and Reinforcement. Mapping these barriers and enablers onto the COM-B model provided an organized perspective on how these issues may be interacting. Several factors were viewed as both negative and positive across different perspectives. Two of the seven themes were limited to one component, while four involved all three components of the COM-B model. CONCLUSIONS Using a theory-based approach ensured systematic and comprehensive identification of relevant barriers and enablers to clinical pathway implementation in ED settings. The COM-B system of the Behaviour Change Wheel provided a useful perspective on how these factors might interact to effect change. TRIAL REGISTRATION ClinicalTrials.gov, NCT01815710 .
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Affiliation(s)
- Mona Jabbour
- Department of Pediatrics, Division of Emergency Medicine, Children's Hospital of Eastern Ontario, 401 Smyth Road, Room W1415, Ottawa, ON, K1H 8L1, Canada.
- University of Ottawa, Ottawa, ON, Canada.
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada.
| | - Amanda S Newton
- Department of Pediatrics, Division of General Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - David Johnson
- Departments of Pediatrics and Emergency Medicine, University of Calgary, Calgary, AB, Canada
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
| | - Janet A Curran
- School of Nursing, Faculty of Health Professions, Dalhousie University, Halifax, NS, Canada
- Department of Emergency Medicine, IWK Health Centre, Halifax, NS, Canada
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Patient and Health Care Professional Perspectives: A Case Study of the Lung Cancer Integrated Care Pathway. Int J Integr Care 2018; 18:7. [PMID: 30473645 PMCID: PMC6234416 DOI: 10.5334/ijic.3972] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
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.
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Vanhaecht K, Bollmann M, Bower K, Gallagher C, Gardini A, Guezo J, jansen U, Massoud R, Moody K, Sermeus W, Van Zelm R, Whittle C, Yazbeck AM, Zander K, Panella M. Prevalence and use of clinical pathways in 23 countries – an international survey by the European Pathway Association. ACTA ACUST UNITED AC 2018. [DOI: 10.1177/205343540601000106] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives To give an overview on the use and prevalence of clinical pathways. Design Cross-sectional descriptive study. Study participants European Pathway Association (E-P-A) contact persons in 23 countries. Results Clinical pathways, also known as critical pathways or integrated care pathways, have been used in health care for 20 years. Although clinical pathways are well established, little information exists on their use and dissemination around the world. The E-P-A has performed their first international survey on the use and dissemination of clinical pathways in 23 countries. At present, pathways are used with a minority of patients, mainly in acute hospital trusts. Our survey showed that clinical pathways were predominantly viewed as a multidisciplinary tool to improve the quality and efficiency of evidence-based care. Pathways were also used as a communication tool between professionals to manage and standardize outcome-oriented care. Conclusions There is a future for the use of clinical pathways, but there is a need for international benchmarking and knowledge sharing with regard to their development, implementation and evaluation.
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Affiliation(s)
- Kris Vanhaecht
- Centre for Health Services and Nursing Research, Catholic University Leuven, Leuven, Belgium
- European Pathway Association, Kapucijnenvoer 35, 4th floor, 3000 Leuven, Belgium
| | - Marcus Bollmann
- SANA Kliniken, Munich, Germany
- European Pathway Association, Kapucijnenvoer 35, 4th floor, 3000 Leuven, Belgium
| | - Kathy Bower
- Centre for Case Management, Boston, USA
- European Pathway Association, Kapucijnenvoer 35, 4th floor, 3000 Leuven, Belgium
| | - Clare Gallagher
- Patient Concern & Healthcare Events, London, England, UK
- European Pathway Association, Kapucijnenvoer 35, 4th floor, 3000 Leuven, Belgium
| | - Andrea Gardini
- International Society for Quality in Healthcare, Ancona, Italy
- European Pathway Association, Kapucijnenvoer 35, 4th floor, 3000 Leuven, Belgium
| | - Jen Guezo
- Board of Health, Castel, Guernsey
- European Pathway Association, Kapucijnenvoer 35, 4th floor, 3000 Leuven, Belgium
| | - Uwe jansen
- KISS Project & General practitioners part, County of Sønderjylland, Denmark
- European Pathway Association, Kapucijnenvoer 35, 4th floor, 3000 Leuven, Belgium
| | - Rashad Massoud
- Institute for Healthcare Improvement, Boston, USA
- European Pathway Association, Kapucijnenvoer 35, 4th floor, 3000 Leuven, Belgium
| | - Karen Moody
- Integrated Care Pathway User Group, Glasgow, Scotland, UK
- European Pathway Association, Kapucijnenvoer 35, 4th floor, 3000 Leuven, Belgium
| | - Walter Sermeus
- Centre for Health Services and Nursing Research, Catholic University Leuven, Leuven, Belgium
- European Pathway Association, Kapucijnenvoer 35, 4th floor, 3000 Leuven, Belgium
| | - Ruben Van Zelm
- Institute for Healthcare Improvement CBO, Utrecht, The Netherlands
- European Pathway Association, Kapucijnenvoer 35, 4th floor, 3000 Leuven, Belgium
| | - Claire Whittle
- School of Health Sciences, Birmingham University, Birmingham, England, UK
- European Pathway Association, Kapucijnenvoer 35, 4th floor, 3000 Leuven, Belgium
| | - Anne-Marie Yazbeck
- Ministry of Health, Department for Quality, Ljubljana, Slovenia
- European Pathway Association, Kapucijnenvoer 35, 4th floor, 3000 Leuven, Belgium
| | - Karen Zander
- Centre for Case Management, Boston, USA
- European Pathway Association, Kapucijnenvoer 35, 4th floor, 3000 Leuven, Belgium
| | - Massimiliano Panella
- University of Eastern Piedmont ‘Amedeo Avogadro’, Novara, Italy
- European Pathway Association, Kapucijnenvoer 35, 4th floor, 3000 Leuven, Belgium
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15
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Chen S, Awan S, Rajji T, Abdool P, George TP, Collins A, Kidd SA. Integrated Care Pathways for Schizophrenia: A Scoping Review. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2018; 43:760-767. [PMID: 26512011 DOI: 10.1007/s10488-015-0696-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
This paper summarizes the existing evidence for integrated care pathways (ICPs) for the treatment of schizophrenia. Scoping review methods following PRISMA guidelines were employed due to the variable nature of the evidence in this area. The review identified 13 papers. Of these papers, 7 focused on describing ICP content and process-related data and 6 examined clinical outcomes. Of the 6 studies providing outcome data, 2 reported improved outcomes associated with ICPs. Conceptually, ICPs hold great promise for improving the quality of schizophrenia care. However, in contrast with other specialty healthcare domains, the schizophrenia ICP evidence base is very limited and has not fulsomely begun to address ICPs for effectiveness.
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Affiliation(s)
- Sheng Chen
- Complex Mental Illness Program, Toronto Centre for Addiction and Mental Health, 1001 Queen St. W., Unit 2-1, #161, Toronto, ON, M6J 1H1, Canada
| | - Saima Awan
- ICP Program, Toronto Centre for Addiction and Mental Health, Toronto, Canada
| | - Tarek Rajji
- Department of Psychiatry, Toronto Centre for Addiction and Mental Health, University of Toronto, Toronto, Canada
| | - Petal Abdool
- Department of Psychiatry, Toronto Centre for Addiction and Mental Health, University of Toronto, Toronto, Canada
| | - Tony P George
- Department of Psychiatry, Toronto Centre for Addiction and Mental Health, University of Toronto, Toronto, Canada
| | - April Collins
- Complex Mental Illness Program, Toronto Centre for Addiction and Mental Health, 1001 Queen St. W., Unit 2-1, #161, Toronto, ON, M6J 1H1, Canada
| | - Sean A Kidd
- Complex Mental Illness Program, Toronto Centre for Addiction and Mental Health, 1001 Queen St. W., Unit 2-1, #161, Toronto, ON, M6J 1H1, Canada. .,Department of Psychiatry, Toronto Centre for Addiction and Mental Health, University of Toronto, Toronto, Canada.
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16
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Mohamed WRA, Leach MJ, Reda NA, Abd-Ellatif MM, Mohammed MA, Abd-Elaziz MA. The effectiveness of clinical pathway-directed care on hospitalisation-related outcomes in patients with severe traumatic brain injury: A quasi-experimental study. J Clin Nurs 2018; 27:e820-e832. [PMID: 29193516 DOI: 10.1111/jocn.14194] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2017] [Indexed: 12/14/2022]
Abstract
AIMS AND OBJECTIVES To compare the effectiveness of clinical pathway-directed care to usual care on hospitalisation-related outcomes in patients with severe traumatic brain injury (STBI). BACKGROUND Severe traumatic brain injury is a major cause of disability and mortality in young adults. Clinical pathways endeavour to bring evidence and clinical practice closer together to foster the delivery of best practice and to improve patient outcomes. DESIGN Quasi-experimental study. METHODS The study was conducted in a trauma intensive care unit of a large teaching hospital in Egypt. Patients aged 18-60 years with a diagnosis of STBI, a Glasgow Coma Scale score between 3-8 and a nonpenetrating head injury were consecutively assigned to 15 days of care. The outcomes assessed were complications related to hospitalisation, clinical variances, length of intensive care unit (ICU) stay, ICU readmission rate and patient/family satisfaction. RESULTS Sixty participants completed the study (30 in each arm). Apart from age, there were no significant differences between groups in baseline characteristics. The clinical pathway group demonstrated statistically significantly fewer cases of hospitalisation-related complications on day 15, and a significantly shorter length of ICU stay, lower ICU readmission rate and a high level of patient/family satisfaction when compared with the usual care group. The effect of the intervention on fever, pressure ulceration, hyperglycaemia and readmission to the ICU was no longer statistically significant after controlling for age. CONCLUSIONS The findings of the current study suggest that the implementation of a clinical pathway for patients with severe TBI may be helpful in improving the patient experience as well as some hospitalisation-related outcomes. RELEVANCE TO CLINICAL PRACTICE The provision of clinical pathway-directed care in a trauma ICU may offer benefits to the patient, family and institution beyond that provided by usual care.
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Affiliation(s)
| | - Matthew J Leach
- Department of Rural Health, University of South Australia, Adelaide, SA, Australia
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17
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Abstract
Introduction There has been a growing emphasis on the use of integrated care plans to deliver cancer care. However little is known about how integrated care plans for cancer patients are developed including featured core activities, facilitators for uptake and indicators for assessing impact. Methods Given limited consensus around what constitutes an integrated care plan for cancer patients, a scoping review was conducted to explore the components of integrated care plans and contextual factors that influence design and uptake. Results Five types of integrated care plans based on the stage of cancer care: surgical, systemic, survivorship, palliative and comprehensive (involving a transition between stages) are described in current literature. Breast, esophageal and colorectal cancers were common disease sites. Multi-disciplinary teams, patient needs assessment and transitional planning emerged as key features. Provider buy-in and training alongside informational technology support served as important facilitators for plan uptake. Provider-level measurement was considerably less robust compared to patient and system-level indicators. Conclusions Similarities in design features, components and facilitators across the various types of integrated care plans indicates opportunities to leverage shared features and enable a management lens that spans the trajectory of a patient's journey rather than a phase-specific silo approach to care.
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18
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Hoste P, Vanhaecht K, Ferdinande P, Rogiers X, Eeckloo K, Blot S, Hoste E, Vogelaers D, Vandewoude K. Care pathways for organ donation after brain death: guidance from available literature? J Adv Nurs 2016; 72:2369-80. [PMID: 27328738 DOI: 10.1111/jan.13051] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2016] [Indexed: 01/10/2023]
Abstract
AIMS A discussion of the literature concerning the impact of care pathways in the complex and by definition multidisciplinary process of organ donation following brain death. BACKGROUND Enhancing the quality and safety of organs for transplantation has become a central concern for governmental and professional organizations. At the local hospital level, a donor coordinator can use a range of interventions to improve the donation and procurement process. Care pathways have been proven to represent an effective intervention in several settings for optimizing processes and outcomes. DESIGN A discussion paper. DATA SOURCES A systematic review of the Medline, CINAHL, EMBASE and The Cochrane Library databases was conducted for articles published until June 2015, using the keywords donation after brain death and care pathways. Each paper was reviewed to investigate the effects of existing care pathways for donation after brain death. An additional search for unpublished information was conducted. DISCUSSION Although literature supports care pathways as an effective intervention in several settings, few studies have explored its use and effectiveness for complex care processes such as donation after brain death. IMPLICATIONS FOR NURSING Nurses should be aware of their role in the donation process. Care pathways have the potential to support them, but their effectiveness has been insufficiently explored. CONCLUSION Further research should focus on the development and standardization of the clinical content of a care pathway for donation after brain death and the identification of quality indicators. These should be used in a prospective effectiveness assessment of the proposed pathway.
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Affiliation(s)
- Pieter Hoste
- Department of General Internal Medicine, Ghent University Hospital, Belgium.,Faculty of Medicine and Health Sciences, Ghent University, Belgium.,Department of Intensive Care, General Hospital Sint-Lucas, Ghent, Belgium
| | - Kris Vanhaecht
- Leuven Institute for Healthcare Policy, Department of Public Health and Primary Care, KU Leuven - University of Leuven, Belgium.,Department of Quality Management, University Hospitals Leuven, Belgium.,European Pathway Association, Kapucijnenvoer, Leuven, Belgium
| | | | - Xavier Rogiers
- Faculty of Medicine and Health Sciences, Ghent University, Belgium.,Department of Transplant Surgery, Ghent University Hospital, Belgium
| | - Kristof Eeckloo
- Faculty of Medicine and Health Sciences, Ghent University, Belgium
| | - Stijn Blot
- Faculty of Medicine and Health Sciences, Ghent University, Belgium.,Department of Internal Medicine, Ghent University, Belgium.,Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Queensland, Australia
| | - Eric Hoste
- Department of Intensive Care Medicine, Ghent University Hospital, Belgium.,Research Foundation - Flanders (FWO), Egmontstraat, Brussels, Belgium
| | - Dirk Vogelaers
- Department of General Internal Medicine, Ghent University Hospital, Belgium.,Faculty of Medicine and Health Sciences, Ghent University, Belgium.,Department of Internal Medicine, Ghent University, Belgium
| | - Koenraad Vandewoude
- Faculty of Medicine and Health Sciences, Ghent University, Belgium.,Department of Internal Medicine, Ghent University, Belgium
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19
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Zhang M, Zhou SY, Xing MY, Xu J, Shi XX, Zheng SS. The application of clinical pathways in laparoscopic cholecystectomy. Hepatobiliary Pancreat Dis Int 2014; 13:348-53. [PMID: 25100118 DOI: 10.1016/s1499-3872(14)60279-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Laparoscopic cholecystectomy (LC) is one of the most frequent abdominal surgical procedures. The present meta-analysis aimed to estimate the clinical effects of implementing a clinical pathway for LC compared with standard medical care by evaluating the length of hospital stay, costs, and the outcomes of patients undergoing LC. DATA SOURCES Data were extracted from the following databases: PubMed, EMBASE, the Cochrane Central Register of Controlled Trials, Chinese Medical Citation Index (CMCI), Chinese Medical Current Contents (CMCC), and China BioMedical Literature Database (CBM). We also searched the reference lists of the relevant articles and conference articles. Only randomized controlled trials and controlled clinical trials published from 1980 to 2013 were included. We did not set restrictions on language and country of publications. All of the data were evaluated and analyzed by two reviewers independently with RevMan software (version 5.0). RESULTS A total of 7 trials with 1187 patients were included. The patients who underwent LC with clinical pathway had shorter hospital stay [weighted mean difference=-1.90, 95% CI: -2.65 to -1.16, P<0.00001], lower cost [standard mean difference=-0.69, 95% CI: -0.82 to -0.56, P<0.00001], and better questionnaires based satisfaction with the medical services. CONCLUSIONS The applications of the clinical pathway for LC effectively reduced hospital stay and total costs. However, there was insufficient evidence for proving the differences in postoperative complications. Future research should focus on patient outcomes and identify the mechanisms underlying the effect of the clinical pathway.
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Affiliation(s)
- Min Zhang
- Department of General Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China.
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20
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The QUIRO Study (assurance of quality and innovation in radiooncology): methodology, instruments and practices. Strahlenther Onkol 2014; 190:138-48. [PMID: 24408057 DOI: 10.1007/s00066-013-0555-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 09/11/2013] [Indexed: 10/25/2022]
Abstract
PURPOSE The QUIRO study aimed to establish a secure level of quality and innovation in radiation oncology. Over 6 years, 27 specific surveys were conducted at 24 radiooncological departments. In all, 36 renowned experts from the field of radiation oncology (mostly head physicians and full professors) supported the realization of the study. METHODS A salient feature of the chosen methodological approach is the "process" as a means of systematizing diversified medical-technical procedures according to standardized criteria. On the one hand, "processes" as a tool of translation are adapted for creating and transforming standards into concrete clinical and medical actions; on the other hand, they provide the basis for standardized instruments and methods to determine the required needs of physicians, staff, and equipment. In the foreground of the collection and measurement of resource requirements were the processes of direct service provision which were subdivided into modules for reasons of clarity and comprehensibility. Overhead tasks (i.e., participation in quality management) were excluded from the main study and examined in a separate survey with appropriate methods. RESULTS After the exploration of guidelines, tumor- or indication-specific examination and treatment processes were developed in expert workshops. Moreover, those specific modules were defined which characterize these entities and indications in a special degree. Afterwards, these modules were compiled according to their time and resources required in the "reference institution", i.e., in specialized and as competent recognized departments (mostly from the university area), by various suitable survey methods. CONCLUSION The significance of the QUIRO study and the validity of the results were optimized in a process of constant improvements and comprehensive checks. As a consequence, the QUIRO study yields representative results concerning the resource requirement for specialized, qualitatively and technologically highly sophisticated radiooncologic treatment in Germany.
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21
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Jabbour M, Curran J, Scott SD, Guttman A, Rotter T, Ducharme FM, Lougheed MD, McNaughton-Filion ML, Newton A, Shafir M, Paprica A, Klassen T, Taljaard M, Grimshaw J, Johnson DW. Best strategies to implement clinical pathways in an emergency department setting: study protocol for a cluster randomized controlled trial. Implement Sci 2013; 8:55. [PMID: 23692634 PMCID: PMC3674906 DOI: 10.1186/1748-5908-8-55] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Accepted: 05/15/2013] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The clinical pathway is a tool that operationalizes best evidence recommendations and clinical practice guidelines in an accessible format for 'point of care' management by multidisciplinary health teams in hospital settings. While high-quality, expert-developed clinical pathways have many potential benefits, their impact has been limited by variable implementation strategies and suboptimal research designs. Best strategies for implementing pathways into hospital settings remain unknown. This study will seek to develop and comprehensively evaluate best strategies for effective local implementation of externally developed expert clinical pathways. DESIGN/METHODS We will develop a theory-based and knowledge user-informed intervention strategy to implement two pediatric clinical pathways: asthma and gastroenteritis. Using a balanced incomplete block design, we will randomize 16 community emergency departments to receive the intervention for one clinical pathway and serve as control for the alternate clinical pathway, thus conducting two cluster randomized controlled trials to evaluate this implementation intervention. A minimization procedure will be used to randomize sites. Intervention sites will receive a tailored strategy to support full clinical pathway implementation. We will evaluate implementation strategy effectiveness through measurement of relevant process and clinical outcomes. The primary process outcome will be the presence of an appropriately completed clinical pathway on the chart for relevant patients. Primary clinical outcomes for each clinical pathway include the following: Asthma--the proportion of asthmatic patients treated appropriately with corticosteroids in the emergency department and at discharge; and Gastroenteritis--the proportion of relevant patients appropriately treated with oral rehydration therapy. Data sources include chart audits, administrative databases, environmental scans, and qualitative interviews. We will also conduct an overall process evaluation to assess the implementation strategy and an economic analysis to evaluate implementation costs and benefits. DISCUSSION This study will contribute to the body of evidence supporting effective strategies for clinical pathway implementation, and ultimately reducing the research to practice gaps by operationalizing best evidence care recommendations through effective use of clinical pathways. TRIAL REGISTRATION ClinicalTrials.gov: NCT01815710.
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Affiliation(s)
- Mona Jabbour
- Division of Emergency Medicine, Children’s Hospital of Eastern Ontario, Ottawa, Canada
- Departments of Pediatrics and Emergency Medicine, University of Ottawa, Ottawa, Canada
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Janet Curran
- IWK Health Centre, Halifax, Canada, School of Nursing, Dalhousie University, Halifax, Canada
| | | | - Astrid Guttman
- Institute for Clinical Evaluative Sciences, Toronto, Canada
- Division of Paediatric Medicine, Hospital for Sick Children, Toronto, Canada
- Department of Paediatrics and Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Thomas Rotter
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Canada
| | - Francine M Ducharme
- Departments of Pediatrics and of Social and Preventive Medicine, University of Montreal, Montreal, Canada
- Research Centre, CHU Sainte-Justine, Montreal, Canada
| | - M Diane Lougheed
- Departments of Medicine (Respirology), Biomedical and Molecular Sciences (Physiology) and Community Health and Epidemiology, Queen’s University, Kingston, Canada
- ICES-Queen’s University, Kingston, Canada
| | - M Louise McNaughton-Filion
- University of Ottawa, Ottawa, Canada
- Montfort Hospital, Ottawa, Canada
- Champlain Local Health Integrated Network, Ottawa, Canada
| | - Amanda Newton
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada
| | - Mark Shafir
- Department of Emergency Medicine, Cambridge Memorial Hospital, Cambridge, Canada
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Canada
| | - Alison Paprica
- Ontario Ministry of Health and Long-Term Care, Toronto, Canada
| | - Terry Klassen
- Faculty of Medicine, University of Manitoba, Winnipeg, Canada
- Manitoba Institute of Child Health, Winnipeg, Canada
| | - Monica Taljaard
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Canada
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, Canada
| | - Jeremy Grimshaw
- Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Medicine, University of Ottawa, Ottawa, Canada
| | - David W Johnson
- Division of Emergency Medicine, Alberta Children’s Hospital, Calgary, Canada
- Alberta Children’s Hospital Research Institute, Calgary, Canada
- Department of Pediatrics, Physiology and Pharmacology, University of Calgary, Calgary, Canada
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22
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Baker K, Brierley S, Mitchell G, Roe J. Effecting change using careplans: experience from two fractured neck of femur pathways. AUST HEALTH REV 2012; 36:308-12. [PMID: 22935123 DOI: 10.1071/ah11021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2011] [Accepted: 10/12/2011] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To use a qualitative track of the effects of two fractured neck of femur careplans (1 & 2) implemented at the Ipswich Emergency Department in 2002 and 2003 in order to comment on the reasons for comparative successes and failures as instruments for change in clinical practice. Careplan 1 was initiated by local clinicians in 2002, rescinded in 2003 to make way for the system wide careplan 2, then informally restituted in 2004 after careplan 2 was withdrawn. Careplan 2 did not articulate specific ED management plans. METHOD Biennial retrospective chart audits of two newly introduced evidence-based clinical practices over time was used to track changes from careplan 1. These were the use of regional anaesthesia by medical staff, and the compliance with indwelling urinary catheter insertion by nursing staff. RESULTS Elements of careplan 1 continued despite lack of promotion. There has been significant increase in nerve block (2.8% to 27%) and indwelling catheter insertion (26% to 75%) from 2000 to 2009. Formal use of careplan 1 has declined to 13-20% in 2009. Careplan 2 was withdrawn for review in 2004. CONCLUSIONS Careplans are one way to effect lasting changes in clinical behaviours which may persist beyond their implementation and promotion phases. For acceptance, corporate plans should incorporate local practices. For longevity, local plans should comply with the corporate vision of continuity of care, but local investment in the plan will facilitate uptake.
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Affiliation(s)
- Kylie Baker
- Emergency Department, Ipswich General Hospital, Chelmsford Avenue, Ipswich, QLD 4305, Australia.
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23
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Lodewijckx C, Sermeus W, Panella M, Deneckere S, Leigheb F, Troosters T, Boto PA, Mendes RV, Decramer M, Vanhaecht K. Quality indicators for in-hospital management of exacerbation of chronic obstructive pulmonary disease: results of an international Delphi study. J Adv Nurs 2012; 69:348-62. [PMID: 22716665 DOI: 10.1111/j.1365-2648.2012.06013.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM To report a Delphi study that was conducted to select process and outcome indicators that are relevant to study quality of care and impact of care pathways for patients hospitalized with exacerbation of chronic obstructive pulmonary disease. BACKGROUND Management of patients hospitalized with exacerbation of chronic obstructive pulmonary disease is suboptimal and outcomes are poor. To evaluate the impact of care pathways properly, relevant indicators need to be selected. DESIGN Delphi study. METHODS The study was conducted over 4 months in 2008, with 35 experts out of 15 countries, including 19 medical doctors, 8 nurses and 8 physiotherapists. Participants were asked to rate, for 72 process and 21 outcome indicators, the relevance for follow-up in care pathways for in-hospital management of exacerbation of chronic obstructive pulmonary disease. Consensus (agreement by at least 75% of the participants) that an indicator is relevant for follow-up was sought in two rounds. RESULTS Consensus was reached for 26 of 72 process indicators (36·1%) and 10 of 21 outcome indicators (47·6%). Highest consensus levels were found for the process indicators regarding oxygen therapy (100%), pulmonary rehabilitation (100%) and patient education (94·5-88·6%) and for the outcome indicators concerning understanding of therapy (91·4-85·7%) and self-management (88·6-88·2%). CONCLUSION The selected indicators appear to be sensitive for improvement. Therefore, researchers and clinicians that want to study and improve the care for patients hospitalized with exacerbation of chronic obstructive pulmonary disease should primarily focus on these indicators.
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Verhelst D, Nachtergaele M, Hindryckx C, Vandevyvere K, Seghers S, Smessaert K, Vanderschueren S. Can a care pathway help streamline the care process for patients with chronic fatigue syndrome? ACTA ACUST UNITED AC 2011. [DOI: 10.1258/jicp.2011.011024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
In this paper, the authors show how the implementation of a care pathway can streamline the care for chronic fatigue syndrome (CFS). The methodology of seven phases is used as a guide to develop, implement and evaluate the CFS care pathway. Some patients have already completed the care pathway. With the help of these case studies, a few strengths and weaknesses of the care process can be formulated. The development and implementation of the care pathway result in a structured process. Patients are diagnosed and treated based on an evidence-based method. The care path also leads to an enhancement of the interdisciplinary cooperation. Nevertheless, the criteria for inclusion and exclusion of patients are taken into account insufficiently. Moreover, family doctors should be involved more often. In the future, it is also important to pay more attention to the role of the family members during the treatment. The entire steering group now needs to engage in a discussion about the test pathway and then subsequently put it to use in daily practice. Additional challenges for the steering group include the objective evaluation and the continuous follow-up of the care pathway.
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Care of infants and children with bronchiolitis: a systematic review. J Pediatr Nurs 2011; 26:519-29. [PMID: 22055372 DOI: 10.1016/j.pedn.2010.07.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2010] [Revised: 07/09/2010] [Accepted: 07/19/2010] [Indexed: 11/23/2022]
Abstract
Bronchiolitis is the most frequent cause of hospitalization in the infant population. Management varies widely, and the efficacy of many routinely implemented therapies is not supported by evidence. The purpose of the systematic review was to identify the best evidence available regarding the care of infants and children with bronchiolitis. A two-phase literature search was performed, and 20 publications were appraised. An abundance of evidence regarding management of bronchiolitis was revealed resulting in numerous recommendations. Use of a clinical pathway is proposed as a possible solution for moving this evidence into practice.
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Impact of care pathways for in-hospital management of COPD exacerbation: A systematic review. Int J Nurs Stud 2011; 48:1445-56. [DOI: 10.1016/j.ijnurstu.2011.06.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Revised: 06/20/2011] [Accepted: 06/23/2011] [Indexed: 11/23/2022]
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Vanhaecht K, Ovretveit J, Elliott MJ, Sermeus W, Ellershaw J, Panella M. Have We Drawn the Wrong Conclusions About the Value of Care Pathways? Is a Cochrane Review Appropriate? Eval Health Prof 2011; 35:28-42. [DOI: 10.1177/0163278711408293] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Kris Vanhaecht
- School of Public Health, Faculty of Medicine, Catholic University Leuven, Leuven, Belgium
| | - John Ovretveit
- Medical Management Center, Karolinska Institute, Stockholm, Sweden
| | - Martin J. Elliott
- Department of Cardiothoracic Surgery, Great Ormond Street Hospital for Children, NHS Trust, London, UK
| | - Walter Sermeus
- School of Public Health, Faculty of Medicine, Catholic University Leuven, Leuven, Belgium
| | - John Ellershaw
- Marie Currie Palliative Care Center, University of Liverpool, Liverpool, UK
| | - Massimiliano Panella
- School of Public Health, Faculty of Medicine, University of Eastern Piedmont, Novarra, Italy
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Abstract
Summary Clinical pathways are our most valuable and performant tool in managing health-care processes. Sloppiness and inaccuracy, in both definition and implementation, threaten to erode the concept and, thus, to undermine its power. Back to basics is not a plea for nostalgia, but for continuing consistently to design care according to a patient's needs, to focus on desired clinical outcomes and to anchor the care processes into the daily life of the health-care organization.
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Affiliation(s)
- Arthur Vleugels
- Center for Health Services and Nursing Research, School of Public Health, Katholieke Universiteit Leuven, Leuven, Belgium
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Abstract
AIM Clinical pathways are used worldwide to (re)organize care processes. They are used by multidisciplinary teams in their search towards excellence. The goal of this study is (1) to assess differences in the perception of health professionals in their evaluation of care processes; (2) to assess whether care processes supported by clinical pathways perform better than those not supported by clinical pathways; and (3) to assess the sensitivity and specificity of clinical pathways in predicting well-organized care processes. METHODS A cross-sectional, multi-centre study was performed comprising 309 healthcare workers, 103 care processes and 49 hospitals. The Care Process Self Evaluation Tool (CPSET) was used to score care processes according to their organization. Processes were also scored according to the level of pathway implementation. RESULTS (1) Significant differences between healthcare professionals were found on two of five CPSET subscales. No significant differences were found among the overall CPSET scores. (2) Care processes supported by pathways had the highest CPSET scores. Nonetheless, continuous follow-up is necessary. (3) Clinical pathways have significant impact on the coordination of care (odds ratio: 8.92), follow-up (odds ratio: 6.65) and overall CPSET score (odds ratio: 4.26). Clinical pathways have a positive impact on the organization of care processes. Not all pathways have high CPSET scores, and care processes without pathways can also be well organized. Continuous evaluation is essential. This is the first study to analyse how healthcare teams perceive the organization of care processes with respect to clinical pathways. Our findings are important for other quality improvement methods.
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Affiliation(s)
- Kris Vanhaecht
- Center for Health Services and Nursing Research, Catholic University Leuven, Leuven, Belgium.
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Barbieri A, Vanhaecht K, Van Herck P, Sermeus W, Faggiano F, Marchisio S, Panella M. Effects of clinical pathways in the joint replacement: a meta-analysis. BMC Med 2009; 7:32. [PMID: 19570193 PMCID: PMC2715423 DOI: 10.1186/1741-7015-7-32] [Citation(s) in RCA: 195] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2009] [Accepted: 07/01/2009] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND A meta-analysis was performed to evaluate the use of clinical pathways for hip and knee joint replacements when compared with standard medical care. The impact of clinical pathways was evaluated assessing the major outcomes of in-hospital hip and knee joint replacement processes: postoperative complications, number of patients discharged at home, length of in-hospital stay and direct costs. METHODS Medline, Cinahl, Embase and the Cochrane Central Register of Controlled Trials were searched. The search was performed from 1975 to 2007. Each study was assessed independently by two reviewers. The assessment of methodological quality of the included studies was based on the Jadad methodological approach and on the New Castle Ottawa Scale. Data analysis abided by the guidelines set out by The Cochrane Collaboration regarding statistical methods. Meta-analyses were performed using RevMan software, version 4.2. RESULTS Twenty-two studies met the study inclusion criteria and were included in the meta-analysis for a total sample of 6,316 patients. The aggregate overall results showed significantly fewer patients suffering postoperative complications in the clinical pathways group when compared with the standard care group. A shorter length of stay in the clinical pathway group was also observed and lower costs during hospital stay were associated with the use of the clinical pathways. No significant differences were found in the rates of discharge to home. CONCLUSION The results of this meta-analysis show that clinical pathways can significantly improve the quality of care even if it is not possible to conclude that the implementation of clinical pathways is a cost-effective process, because none of the included studies analysed the cost of the development and implementation of the pathways. Based on the results we assume that pathways have impact on the organisation of care if the care process is structured in a standardised way, teams critically analyse the actual organisation of the process and the multidisciplinary team is highly involved in the re-organisation. Further studies should focus on the evaluation of pathways as complex interventions to help to understand which mechanisms within the clinical pathways can really improve the quality of care. With the need for knee and hip joint replacement on the rise, the use of clinical pathways might contribute to better quality of care and cost-effectiveness.
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Affiliation(s)
- A Barbieri
- Department of Clinical and Experimental Medicine, University of Eastern Piedmont A, Avogadro, Novara, Italy.
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Lemmens L, van Zelm R, Vanhaecht K, Kerkkamp H. Systematic review: indicators to evaluate effectiveness of clinical pathways for gastrointestinal surgery. J Eval Clin Pract 2008; 14:880-7. [PMID: 19018922 DOI: 10.1111/j.1365-2753.2008.01079.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND A systematic review on clinical pathways for gastrointestinal surgery was performed. The aim was to study indicators that are used to evaluate these clinical pathways and to study which effects of clinical pathways are reported. METHODS A search was performed for the period from January 2000 to November 2006 in MEDLINE, EMBASE and CINAHL. The Leuven Clinical Pathway Compass was used to categorize the indicators reported in literature. RESULTS Twenty-three studies were selected, of which 16 were controlled studies. The studies assessed most frequently complication rates, re-admissions, mortality and length of stay. More specific indicators like time to start defecation and time to return to enteral feeding were reported as well. None of the studies reported adverse effects in any of the domains of the Clinical Pathway Compass. CONCLUSION Clinical pathways for gastrointestinal surgery can enhance efficiency of care without adverse effects on outcome. Specific indicators to evaluate these clinical pathways are time to return to enteral feeding and time to defecate. Furthermore, additional to complication rates, number of re-admissions, mortality and length of stay, indicators such as the number of re-operations, pain scores and intensive care unit admission can be assessed to monitor effectiveness and patient safety of the clinical pathways.
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Affiliation(s)
- Lidwien Lemmens
- Department of Perioperative and Emergency Care, University Medical Center Utrecht, Utrecht, The Netherlands.
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McLachlan HL, Forster DA, Yelland J, Rayner J, Lumley J. Is the organisation and structure of hospital postnatal care a barrier to quality care? Findings from a state-wide review in Victoria, Australia. Midwifery 2008; 24:358-70. [PMID: 17275970 DOI: 10.1016/j.midw.2006.10.006] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2006] [Revised: 09/05/2006] [Accepted: 10/19/2006] [Indexed: 11/26/2022]
Abstract
OBJECTIVE to describe the structure and organisation of hospital postnatal care in Victoria, Australia. DESIGN postal survey sent to all public hospitals in Victoria (n=71) and key-informant interviews with midwives and medical practitioners (n=38). SETTING Victoria, Australia. PARTICIPANTS providers of postnatal care in Victorian public hospitals. FINDINGS there is significant diversity across Victoria in the way postnatal units are structured and organised and in the way care is provided. There are differences in numerous practices, including maternal and neonatal observations and the length of time women spend in hospital after giving birth. Although the benefits of continuity of care are recognised by health care providers, continuity is difficult to provide in the postnatal period. Postnatal care is provided in busy, sometimes chaotic environments, with many barriers to providing effective care and few opportunities for women to rest and recover after childbirth. The findings in this study can, in part, be explained by the lack of evidence that has been available to guide early postnatal care. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE current structures such as standard postnatal documentation (clinical pathways) and fixed length of stay, may inhibit rather than support individualised care for women after childbirth. There is a need to move towards greater flexibility in providing of early postnatal care, including alternative models of service delivery; choice and flexibility in the length of stay after birth; a focus on the individual with far less emphasis on care being structured around organisational requirements; and building an evidence base to guide care.
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Affiliation(s)
- Helen L McLachlan
- Clinical School of Midwifery and Neonatal Nursing Studies, La Trobe University, 3086, Australia.
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El Baz N, Middel B, van Dijk JP, Oosterhof A, Boonstra PW, Reijneveld SA. Are the outcomes of clinical pathways evidence-based? A critical appraisal of clinical pathway evaluation research. J Eval Clin Pract 2007; 13:920-9. [PMID: 18070263 DOI: 10.1111/j.1365-2753.2006.00774.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
AIM AND OBJECTIVE To evaluate the validity of study outcomes of published papers that report the effects of clinical pathways (CP). METHOD Systematic review based on two search strategies, including searching Medline, CINAHL, Embase, Psychinfo and Picarta from 1995 till 2005 and ISI Web of Knowledge SM. We included randomized controlled or quasi-experimental studies evaluating the efficacy of clinical pathway application. Assessment of the methodological quality of the studies included randomization, power analysis, selection bias, validity of outcome indicators, appropriateness of statistical tests, direct (matching) and indirect (statistical) control for confounders. Outcomes included length of stay, costs, readmission rate and complications. Two reviewers independently assessed the methodological quality of the selected papers and recorded the findings with an evaluation tool developed from a set of items for quality assessment derived from the Cochrane Library and other publications. RESULTS The study sample comprised of 115 publications. A total of 91.3% of the studies comprised of retrospective studies and 8.7% were randomized controlled studies. Using a quality-scoring assessment tool, 33% of the papers were classified as of good quality, whereas 67% were classified as of low quality. Of the studies, 10.4% controlled for confounding by matching and 59.1% adopted parametric statistical tests without testing variables on normal distribution. Differences in outcomes were not always statistically tested. CONCLUSION Readers should be cautious when interpreting the results of clinical pathway evaluation studies because of the confounding factors and sources of contamination affecting the evidence-based validity of the outcomes.
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Affiliation(s)
- Noha El Baz
- Department of Health Sciences, Subdivision Care Sciences, University Medical Center Groningen, University of Groningen, The Netherlands
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Step by step development of clinical care pathways for older cancer patients: necessary or desirable? Eur J Cancer 2007; 43:2170-8. [PMID: 17870519 DOI: 10.1016/j.ejca.2007.08.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2007] [Revised: 07/31/2007] [Accepted: 08/01/2007] [Indexed: 02/07/2023]
Abstract
Medical and nursing staff in oncology for older cancer patients are confronted with a range of problems including co-morbidity, poly-pharmacy, cognitive impairments, emotional problems, functional limitations, sensory impairment and a lack of social support. Comprehensive geriatric assessment identifies many of the existing problems and can be used to estimate life expectancy and tolerance of treatment. However, health care providers have to interpret and apply the medical and nursing information and must deal with specific problems and care needs throughout the continuum of cancer care. Imperfect interdisciplinary communication, cooperation and patient-provider communication may further complicate the care actually delivered. A clinical care pathway aims to improve continuity, increase multidisciplinary tuning and deliver appropriate patient education, treatment and care for vulnerable older cancer patients. This paper gives an overview of common problems in older cancer patients and addresses communication barriers through the development of clinical care pathways in geriatric oncology.
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Comprehensive geriatric assessment and its clinical impact in oncology. Eur J Cancer 2007; 43:2161-9. [PMID: 17855074 DOI: 10.1016/j.ejca.2007.08.002] [Citation(s) in RCA: 139] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2007] [Revised: 07/31/2007] [Accepted: 08/01/2007] [Indexed: 12/27/2022]
Abstract
Comprehensive geriatric assessment (CGA) is a process that consists of a multidimensional data-search and a process of analyzing and linking patient characteristics creating an individualized intervention-plan, carried out by a multidisciplinary team. In general, the positive health care effects of CGA are established, but in oncology both CGA and the presence of geriatric syndromes still have to be implemented to tailor oncological therapies to the needs of elderly cancer patients. In this paper the conceptualization of geriatric syndromes, their relationship to CGA and results of clinical studies using CGA in oncology are summarized. Geriatric syndromes are associated with increased vulnerability and refer to highly prevalent, mostly single symptom states (falls, incontinence, cognitive impairment, dizziness, immobility or syncope). Multifactorial analysis is common in geriatric syndromes and forms part of the theoretical foundation for using CGA. In oncology patients, we reviewed the value of CGA on the following endpoints: recognition of health problems, tolerance to chemotherapy and survival. Most studies performed CGA to identify prognostic factors and did not include an intervention. The ability of CGA to detect relevant health problems in an elderly population is reported consistently but no randomized studies are available. CGA should explore the pre-treatment presence of (in)dependence in Instrumental Activities of Daily Living (IADL), poor or moderately poor quality of life, depressive symptoms and cognitive decline, and thereby may help to predict survival. However, if scored by the Charlson comorbidity-index, comorbidities are not convincingly related to survival. The few studies that included a CGA-linked intervention show inconsistent results with regard to survival but compared to usual care quality of life is improved in the surviving period. Functional performance scores and dependency at home appeared to be independent predictive factors for toxicity, similar to depressive symptoms and polypharmacy. Overall, CGA implements/collects information additional to chronological age and Performance Score. So far in oncology there are no prognostic validation studies reported using geriatric syndromes or information based on CGA in its decision making strategies.
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Evaluación de una vía clínica para la apendicitis infantil tras dos años de implantación. ACTA ACUST UNITED AC 2007. [DOI: 10.1016/s1134-282x(07)71205-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Abstract
AIM To determine whether clinical/care pathway audit tools can identify the characteristics of well-organized care processes. BACKGROUND Although pathways are used worldwide, confusion exists about the concept and impact. Evaluation Search of OVID-Medline, Cinahl, British Nursing Index; manual search of the Journal of Integrated Care Pathways; contact with Smartgroup on Clinical Pathways and board members of the European Pathway Association and Google search. KEY ISSUES We selected seven of 15 clinical pathway audit tools for this review. Through content analysis, we identified 17 characteristics and grouped them using the realistic evaluation paradigm. The Integrated Care Pathway Appraisal Tool is the most appropriate audit tool to assess clinical pathway documents. CONCLUSIONS It is astonishing that so little research on clinical pathway audit tools has been underwent, given the prevalent use of clinical pathways. Because the concept of clinical pathways remains unclear, a variety of audit tools are needed to help clarify the concept. Further research on the construct and criterion validity of pathway audit tools is necessary to fully understand why and under which circumstances pathways lead to improved care.
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Affiliation(s)
- Kris Vanhaecht
- Centre for Health Services and Nursing Research, School of Public Health, Faculty of Medicine, Catholic University Leuven, Leuven, Belgium.
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Abstract
The aim of this paper is to report on findings identifying some of the difficulties encountered by the multidisciplinary team in the development and implementation of a care pathway for patients diagnosed with schizophrenia. Policy direction has shifted towards greater team working and blurring of professional boundaries. Moreover, there is greater need to deliver care according to set standards and for patients to reach particular outcomes of care. Care pathways are relatively new for psychiatry and will potentially uncover tensions within the team. Data were collected by participant observation and semistructured interviews over a period of 12 months on an acute psychiatric unit. The care team developed the care pathway and the process of development and implementation was observed through action research. Cross-sectional indexing was used to analyse the data, and themes were developed using interview and observational data collection methods. Clinicians argued strongly for clear role boundaries but also defended their perceived control over health care from other professions. The findings indicate that designing a care pathway for people with schizophrenia may produce conflicting perceptions from the team. Conflict may arise through professions being unwilling to accept plurality over roles, which may hinder progress in meeting the needs of patients. The findings also counter the impression that care pathways can be implemented with little impact on the team.
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