Evidence Based Practice(EPB)

For
Physical Therapists
Lecture-Topics

 Clinical Pathways
 Framework for Clinical Pathways
 Benefits.
 Pathway Development Teams
 Clinical Practice Guidelines
 Evaluation of the CPGs
 Algorithms
 CPGs and Clinical Pathways Comparison.
Clinical Pathways

 A Care Pathway is a multi-disciplinary

plan of care that blends patient needs,
quality outcomes, and controlled costs,
with predetermined standards of care
using a replicable process.
 Many synonyms exist for the term Clinical
Pathways including: Integrated Care
Pathways, Multidisciplinary pathways of
care, Pathways of Care, Care Maps,
Collaborative Care Pathways.
History & Aims

 Clinical Pathways were introduced in the early 1990s

in the UK and the USA, and are being increasingly
used throughout the developed world.
 Clinical Pathways are structured, multi-displinary
plans of care designed to support the
implementation of clinical guidelines and protocols.
 They are designed to support clinical management,
clinical and non-clinical resource management,
clinical audit and also financial management.
 They provide detailed guidance for each stage in
the management of a patient (treatments,
interventions etc.) with a specific condition over a
given time period, and include progress and
outcomes details.
 Clinical Pathways aim to improve, in particular, the
continuity and co-ordination of care across different
disciplines and sectors.
Framework for Clinical Pathways

Clinical Pathways have four main components (Hill,

1994, Hill 1998):
 A timeline.
 The categories of care or activities and their
interventions.
 Intermediate and long term outcome criteria.
 The variance record (to allow deviations to be
documented and analyzed).
Benefits

Pathways have several benefits to an organization:

 Improve Clinical and Financial Outcomes
 Improve Quality and Coordination of Care
 Support the introduction of evidence-based
medicine and use of clinical guidelines
 Improve multidisciplinary communication, teamwork
and care planning
 Help reduce variations in patient care (by promoting
standardization).
 Reduce Practice Variation, Increase Usage of Best
Practices
 Can support continuity and co-ordination of care
across different clinical disciplines and sectors.
Pathway Development
Teams
 Assemble multidisciplinary teams.
 Define clinical problems and current practice.
 Conduct literature search
 Describe and classify research according to levels
of evidence.
 Formulate guideline recommendations
 Link guidelines to form clinical pathways.
Clinical Practice
Guidelines
 The Institute of Medicine defines CPGs as
“systematically developed statements that assist
practitioner and patient decisions about
appropriate health care for specific clinical
circumstances". Field & Lohr,1992;Candian Medical
Association,1994)
 Guidelines may be based on expert
opinion/Consensus and/or evidence based
practice as identified by research and may be
regional, program based, unit specific, or based on
case types.
Need for CPGs

 CPGs offer recommendations for care

and are prescriptive in nature, helping
the practitioner determine the
appropriateness of selected interventions.
 Official statement or policies for proper
care .
 CPGs could be EBP based or non- EBP
based.
 CPGs may be referred to as practice
parameters, practice policies and
appropriateness criteria.
CPG for Radiography of the
Ankle and Foot. (Ottawa
Ankle Rule )
Ankle X-ray series is required only if there is pain
in the malleolar Zone and any one of the
following:
1. Bone tenderness along the distal 6cm of the
posterior edge of the fibula or tip of the
lateral malleolus.
2. Bone tenderness along the distal 6cm of the
posterior edge of the tibia or tip of the
medial malleolus.
3. Inability to bear weight for four steps, both
immediately and in the emergency
department.
Algorithms

 Algorithms are “Written guidelines to stepwise

evaluation and management strategies that
require observations to be made, decisions to be
considered, and actions to be taken”.
(Hadorn,McCormick,&Diokno,1992)
 Algorithms are simply CPGs arranged in a
decision-tree format.

 A list of well-defined instructions for

completing a task.
Example
This is an algorithm that
tries to figure out why the
lamp doesn't turn on and
tries to fix it using the steps.
Flowcharts are often used
to represent algorithms
graphically.
Algorithms

Algorithm= Logic + control

 CPGs, Algorithms, and Clinical Pathways
Comparison.
CPGs& Algorithms: Clinical pathways

 Focus on identifying best clinical  Focus on operationalizing options.

option.  Setting/institution specific; tailored to fit
 Useful across clinical Settings, local conditions.
apply generally.  Require multi or trans-disciplinary
 May or may not be provider approach based on evidence.
specific.  Produced by a multidisciplinary team.
 Based on evidence, expert opinion
or consensus