Clinical pathway

Clinical pathway
Outline
1- History
2- Introduction
3- Definition of Clinical Pathway
4- Why Clinical Pathways
5- Parts of a Clinical Pathway
6- Selection Criteria
7- Variation
8- Benefits
9- Issues - potential problems and barriers to the introduction of ICPs
10- As active management tools
11- Are Clinical Pathways and Protocols the same thing?
12- Some of the other names used to describe clinical pathways
13- Characterized of clinical pathway
14- Clinical Pathway Development
15- Key indicators for stroke care
16- References

History
1-The clinical pathway conceptappeared for the first time at the New England Medical
Center( Boston,USA )in 1985 inspired by Karen Zander and Kathleen Bower. Clinical
pathways appeared as a result of the adaptation of the documents used in industrial
quality management ,the Standard Operating Procedures(SOPs), whose goals are:
Improve efficiency in the use of resources and Finish work in a set time.
2- In April, 1991 in consultation with the Center for Case Management, South Natick,
developed the Home Health Care Map Tools (now called VNA FIRST Home Care
Steps Protocols.
3- In 2005, the telehealth clinical pathway was introduced to standardize telehealth
visits and telephone calls in homecare.
Introduction
Clinical pathways, also known as care pathways, critical pathways, integrated care
pathways, or care maps ,are one of the main tools used to manage the quality in
healthcare concerning the standardization of care processes.It has been proven that their
implementation reduces the variability in clinical practice and improves outcomes.
Clinical pathways promote organized and efficient patient care based on the evidence
based practice. Clinical pathways optimize outcomes in the acute care and homecare
settings.
Definitions of Clinical Pathway
1- Multidisciplinary management toolbased on evidence-based practice for a specific
group of patients with a predictable clinical course, in which the different tasks
(interventions) by the professionals involved in the patient care are defined, optimized
and sequenced either by hour (ED), day (acute care) or visit (homecare). Outcomes are
tied to specific interventions.
2- A clinical pathway is a tool used in achieving coordinated care and desired outcomes
within an anticipated time frame by utilizing the appropriate resources

available. A clinical pathway is a blueprint that guides the clinician in the provision of
care.
3- Clinical pathways are pre-conceived patient care algorithms, or paths, that are
intended to reduce variability and cost, increase efficiency, and ultimately improve
patient care.
4- Pathways provide patient focused care with benefits to the patient, family and
members of the multi-disciplinary team. They allow for the continuous evaluation and
improvement of clinical practice and help to stimulate research. Their use represents a
new approachto patient care, fulfilling many of the demands of clinical practice”.
Why Clinical Pathways
Due to the ongoing changes in medical technology it has become necessary that
hospitals begun introducing clinical pathways to cut costs and reduce the variation in
care. There are four major reasons for developing clinical pathways):-
1- To improve patient care by improving the quality of patient care through consistent
management by encouraging patient involvement and by identifying and measuring
improvements in patient care and outcomes.
2-To maximize the efficient use of resources by reducing unnecessary documentation
and overlap and reduced length of hospital stay for particular conditions. Patients who
do not make expected progress can be easily identified and the appropriate interventions
made.
3- To help identify and clarify the clinical processes byensuring continuity of patient
care by reducing unnecessary variations. The development and implementation of
clinical pathways increases collaboration between the disciplines, professionals and
agencies. This ensures continuity of patient care by reducing unnecessary variations in
the management of the patient.
4- To supportclinical effectiveness, clinical audit and risk management. Clinical
pathways also provide an appropriate framework to promote and measure the

success ofthe clinical effectiveness cycle, which encompasses:Evidence based practice,
clinical audit, patient involvement, multi-disciplinary, multi-professional working,
outcome measures and Clinical benchmarking.
Parts of a Clinical Pathway
1- Pathway title
2- Inclusion and exclusion criteria
3- Patient’s information
4- Physician’s Notes
S: subjective complaints/symptoms
O: objective physical and laboratory findings
A: assessment/ working diagnosis/ clinical Impression
P: plan of care (diagnostic, therapeutic, rehabilitative, others)
5. Orders
ges)
feedings)
consult/orders)
-limiting, assuring a mother that she can
breastfeed, assuring family that patient’s usual activity may be resumed in 3-7 days)
infection)

-
operative care)
Orders or interventions may be mandatory or optional
atory interventions – marked by bullets (•) and applicable to 100% of the
population
by AP
– marked by tick boxes () and may not apply to 100% of the
population
the patient
ne
6. Pathway activation: by the attending physician or resident-in-charge
7. Pathway acknowledgement: by the nurse-in-charge
8. Variance column
9. Signature column
SelectionCriteria
it resources to
establish and implement a clinical pathway for a particular condition
urse

ion
Variation
A variation is described as being a detour from the patient care activities outlined in the
clinical pathway. In general practice there are three distinct types of variation:-
Three variation
1- Systems variations - these include organizational failures such as the unavailability of
staff or transport.
2- Health and social care professional variations - these include clinical judgments
Regarding the addition or deletion of specified interventions.
3- Patient variations - these include unexpected illness or complications and patient
care.
Benefits
-based medicine and use of clinical guidelines
ement and clinical audit
-ordination of care across different clinical disciplines
and sectors;
t in clinical practice

eline for future initiatives
-defined standards for care.
ations in patient care (by promoting standardization).
documentation.
help ensure quality of care and provide a means of continuous quality
improvement.
Issues - potential problems and barriers to the introduction of ICPs
nexpected changes in a patient's condition
standard conditions better than unusual or unpredictable ones
structure
take time to be accepted in the workplace

As active managementtools them:
- Eliminate prolonged lengths of stay arising from inefficiencies, allowing better use of
- Reduce mistakes, duplication of effort and omissions
- Improve communication with patients as to their expected courseof treatment
- Identify problems at the earliest opportunity and correctthese promptly
- Facilitate quality management and an outcomes focus.
Are Clinical Pathways and Protocols the same thing?
-way to be sure that a
document is a true clinical pathway - it will contain structured variance tracking. It is
not:
Some of the other names used to describe clinical pathways include:
1- Anticipated Recovery Pathways (ARPs)
2- Multidisciplinary Pathways of Care (MPCs)
3- Care Protocols
4- Integrated Care Pathways
5- Pathways of Care

6- Care Packages
7- Collaborative Care Pathways
8- Care Maps
9- Care Profiles
Characterizedof clinical pathway
1- Patient centered - built into packages of care for identified groupings
2- Systematic action for consistent best practice, continuous improvements in patient
care, all with attention to the patient experience
3- Continuous feedback via variance tracking and analysis
4- Multidisciplinary - based on roles competence & responsibility rather than discipline
alone
5- Maps and models clinical and non-clinical care processes
6- Incorporates order and priorities including guidelines and protocols
7- Includes standards and outcomes
The Nurse’s role in using pathways:
-in-charge assists the AP in selecting the appropriate pathway.
rvention that are not cancelled and optional
interventions that are checked
Clinical PathwayDevelopment
The implementation of a clinical pathway is most likely to succeed when the decision to
develop is taken on an organizational basis. Senior management commitment and a
strong medical and nursing lead are essential. Pathway documentation is more likely to
be used if it is simple, clear and user friendly. The process ofpathway development
considers why tasks and interventions are performed, and by whom; since it promotes
greater awareness of the role of each

professional involved in the care cycle.
The development of a clinical pathway to manage patients presenting with chest
pain includes:
1- Patients, or their representatives.
2- General Practitioners.
3- Paramedics.
4- Accident and Emergency staff.
5- ECG Technicians.
6- Pharmacists.
7- Pathologists.
8- Coronary Care staff.
9- Cardiac Rehabilitation nurses.
10- Social Services and Community Staff and members of Primary Health Care Teams.
11- Cardiac Rehabilitation nurses.
12-Social Services and Community Staff and members of Primary Health Care Teams.
Guidelines for the Developmentand Implementation of ClinicalPathways:
The essential steps in the development and implementation of a clinical pathway are
summarized as follows:
1- Educate and obtain supportfrom physicians and nurse, and establish a
multidisciplinary team.
2- Identify potential obstacles to implementation.
3- Use Quality improvement methods and tools.
4- Determine staff interest and select Clinical Pathways to develop.
5- Collect Clinical Pathway data and medical record reviews of practice patterns.
6- Conductliterature review of clinical practice guidelines.
7- Develop variance analysis system and monitor the compliance with documentation
on Clinical Pathways.
9- Use a pilot Clinical Pathway for 3 to 6 months revise as needed.

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