Clinical Pathways

Prepared by: Dr. Alber Paules

Clinical Pathways and CPGs

CPGs and Clinical Pathways are both considered as basic utilization management tools that enable the provider to manage resource utilization and to provide better care within the care setting. Clinical Pathways are constructed or modified based on the relevant clinical practice guidelines (CPGs).

Definition
A (Clinical Pathway) is an optimal sequencing and timing of interventions by physicians, nurses, and other staff for a particular diagnosis or procedure; it is designed to minimize delays and resource utilization.

Definition
It is a multidisciplinary management tool based 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).

Clinical pathways provide a framework for organizing care.

How Developed?
Typically, a multi-disciplinary task force/committee of knowledgeable stakeholders (physicians, nurses, and ancillary staff) is convened to answer the question, What must be done to the patient, and when must it be done? The task force/committee charged with pathway development considers procedural schedules, targeted lengths of stay, expected outcomes, and excepted costs.

Properties of Clinical Pathways

1. Comprehensiveness: clinical pathways cover the whole spectrum of care given to the patient by all members of the care team, taking into consideration the interactions among all those caregivers. They demonstrate a true multidisciplinary plan of care. They are also clinical management tools that guide the interdisciplinary coordination and collaboration. 2. Having Timelines: clinical pathways contain specific timelines for interventions to occur.

Why Developing Clinical Pathways?

A major influence towards the use of clinical pathways was the emergence of teams for taking care of patients, and the communication problems which ensued. The goal of clinical pathways is to ensure that only the indicated steps are taken and that they are taken in the correct sequence.

Why Developing Clinical Pathways?

1) to reduce practice variation (through controlling the resources utilized and the LOS). 2) to educate (care team members, patient, and family), 3) to improve quality of care.

Clinical Pathways Formats

Clinical pathways can be thought as a visualization of the client care process. A variety of formats have been developed for the use of the clinical pathways; the most common is the tabular (time-matrix) format. This format usually shows interventions and patient's outcomes over a specific period of time.

The Tabular format

Specific interventions/outcomes are listed for each category and each time frame. Information on each pathway box directs the staff to perform specific assessments or interventions; in addition, the outcome information alerts staff to unusual occurrences.

Modifying Clinical Pathways

Modifications in already-developed clinical pathways can occur in each of the following conditions:
1) To meet each patient's individual needs (if necessary). 2) When the relevant CPG has been changed.

Types of Clinical Pathways

Inpatient care: most common; initiated at the admission time and end at the time of discharge (e.g.) the myocardial infarction clinical pathway. Complete episode of care: begin at the time the patient presents at the physician's office and end at the termination of posthospitalization follow-up. Life and health management: for the management of chronic conditions.

Variances
If a patient does not achieve an expected outcome, a variance occurs. Clinical pathways help in monitoring of variances in outcomes, thus providing feedback for pathway modification. When variance occurs, the physician-incharge is responsible for calling a meeting of the interdisciplinary team to discuss the variance and re-work the pathway.

Variances
Variances are categorized as patient-, system-, or clinician-caused, depending on the source of the variation. For example, in the case of a post-operative patient who should have been scheduled to receive antibiotics according to the clinical pathway, the variance may be generated from any of the three sources: the patient may not tolerate the medication; the system may not be recommending giving the antibiotic in a timely manner; or the clinician may forget to order a medication.

Variances
It is not only essential to identify when a variance occurs but also to hypothesize why the variance occurred in order to determine corrective/preventive actions that can be implemented. The early identification and immediate corrective actions for variances is crucial for providing the appropriate care for individual patients. The variance analysis process requires that each outcome be evaluated along with the process and the structure that support it.