2. OUTLINES:
• Introduction
• Definition of clinical pathway
• Synonyms of clinical pathway
• Importance of clinical pathway
• Importance of clinical pathway as Active Management Tools.
• Characteristics of good clinical pathway.
• Component of clinical pathway.
parts of clinical pathway.
3. CONT
• Definition of variance.
• How to analyze pathway variances
• Documenting the variance.
• Keys to pathway success.
• Potential Problems And barriers to the introduction of
clinical pathway.
• Role of nurse manager .
• Role of staff nurse.
4. INTRODUCTION:
Clinical pathways are known by a variety of terms, such as practice
guidelines, clinical protocols, parameters and benchmarks. Clinical
pathways represent a continuum of care that identifies structures
(institutions, facilities, etc.), caregivers (clinical professionals) and
processes (treatment paradigms) that intervene at critical points to
efficiently treat the patient and achieve a defined outcome .This process
is important to ensure patients receive the right care at the right place at
the right time by the right clinician/professional, and to improve the
quality of patient care using the best evidence available.
5. DEFINITION OF CLINICAL PATHWAY:
clinical pathway: A multidisciplinary tool that makes explicit the ustual
client problem and activities that must occur to facilitate the
achievement of expected client outcomes in a defined length of time.
• A Clinical Pathway is thus a road map for a patient as well as for the
treatment team, which supports an Effective In-patient Care.
6. SYNONYMS
• Anticipatory recovery pathways (ARPS)
• Integrated Care Pathways
, • Multidisciplinary pathways of care (MPCS),
• Pathways of Care,
• Care Maps,
7. • Collaborative Care Pathways
• • Critical Pathway
• • Anticipated Recovery Path
• • Managed care plans
• • Care track
• • Care Profiles
8. Importance of clinical pathway ?
1. To improve patient care
2. To maximize the efficient use of resources To help identify and clarify
the clinical processes
3. To support clinical effectiveness, clinical audit and risk management
9. Improtance AS ACTIVE MANAGEMENT TOOLS
* Eliminate prolonged lengths of stay arising from inefficiencies, allowing
better use of resources
* Reduce mistakes, duplication of effort and omissions
* Improve the quality of work for service providers
* Improve communication with patients as to their expected course of
treatment
* Identify problems at the earliest opportunity and correct these promptly
10. CHARACTERISTICS OF A GOOD CLINICAL PATHWAY
INCLUDE:
Validity :Correctly interpreting available evidence, so that when
followed, valid guidelines lead to improvements in health..
Reproducibility: Given the same evidence another guideline group
produces similar recommendations
11. Reliability
Given the same clinical circumstances another health professional
applies them similarly.
Clinical Applicability :
Target population is defined in accordance with scientific evidence.
12. CONT....
Clinical Flexibility
Guidelines identify exceptions and indicate how patient preferences are
to be incorporated in decision making.
Cost effectiveness Guidelines lead to improvements in health at
acceptable costs.
13. CONT…
• Clarity
• Guidelines unambiguous language, and user-friendly formats. Use
precise definitions
Multidisciplinary Process : interests (including patients) contribute to
guideline development. All key disciplines
14. CONT…
• Scheduled Review :Guidelines state when and how they are to be
reviewed
. Documentation assumptions, Guidelines record participants, and
methods; and link recommendations to available evidence
15. FOUR COMPONENTS OF A CLINICAL
PATHWAY:
1. A Timeline.
2. Categories of care or activities and their interventions .
3. Intermediate and long-term outcome criteria.
4. Variance record
16. PARTS OF CLINICAL PATHWAY:
1. Pathway title
2. Inclusion and exclusion criteria
3. Patient’s information
4. Physician’s Notes
5. S: subjective complaints/symptoms
6. O: objective physical and laboratory findings
7. A: assessment/ working diagnosis/ clinical impression
8. P: plan of care (diagnostic, therapeutic, rehabilitative)
18. •Medications/IVS (IV fluids, blood orders, routine medications)
•Nutrition (Enteral and parenteral feedings, diet and fluid
restrictions,
• Activity/Safety (Activity orders and/or limitations (ex.Turn q 2 hours,
PT or OT consult/orders)
• Consults (referrals) - Psychosocial (assurance that illness is self
limiting, assuring family that patient’s usual activity may be resumed
in 3-7 days) - Patient/Family Education (hand hygiene, education,
possible sources of infection)
19. CONT....
• Discharge Planning (assessment of patient outcomes, referrals to
home )
• 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
20. HOW ARE CLINICAL PATHWAYS USED?
General guidelines in using pathways
•The pathway is a permanent part of the patient’s medical record.
•The Pathway may be used in the Care Plan, Orders and Notes Sheet
accomplished by the medical staff.
•The Nurse in Charge and Attending Physician will select the appropriate pathway
on admission OR when the interval of care begins.
•The care delivered and patient outcomes will be managed against the pathway.
21. VARIENCE
• Variance is any mandatory or checked optional intervention that was not done.
• •an abnormal finding
• •An unmet outcome within the time frame
• •Variances may be noted by any care team member.
• •Whenever a variance is noted, the variance code and initials is written in the
variance column.
22. DOCUMENTING VARIANCES
• Whoever noted the variance must make a note to describe the nature and
cause of the variance and any actions taken.
• Variance notes may be written in the resident’s progress notes or nurses’
notes, if nurse-in-charge noted the variance
A variance monitoring form, documenting all variances in the pathway, is filled
out by the nurse supervisor after every pathway patient is discharged
23. HOW TO ANALYZE PATH WAY VARIANCES
1 .Identify critical pathway orders .These are the orders which, if not
carried, will significantly put the patient at risk for harm.
2. Using the variance monitoring form, count the number of variances
that occurred in the critical pathway orders.
3. Determine causes of variances.
4. Pilot test countermeasures.
5. Monitor variance counts and note if they decrease over time..
24. DISCONTINUING THE PATHWAY
The pathway will be discontinued whenever:
The patient’s primary diagnosis changes
The patient’s condition significantly worsens
The patient fails to meet clinical outcomes for 24-48 hours To
discontinue the pathway, a progress note (SOAP) is written by the MD
outlining the patient’s new plan of care and new orders. A new nursing
plan of care is also written . The pathway is then filed in the patient
record.
25. KEYS TO PATHWAY SUCCESS
• Make pathways part of your quality program.
• Ensure strong collaboration between all relevant disciplines, with
a strong medical lead.
•Select appropriate medical conditions in making pathways.
• Base the pathway orders on best available evidence / best
practice.
26. CONT....
• Collect and analyze variances and involve the staff in
interventions to decrease variances.
• Incorporate adherence to pathway policies in performance
appraisal of all staff members.
27. POTENTIAL PROBLEMSAND BARRIERS TO THE
INTRODUCTION OF CLINICAL PATHWAYS
May appear to discourage personalized care Risk increasing
litigation
Don’t respond well to unexpected changes in a patient’s condition
Suit standard conditions better than unusual or unpredictable ones
Require commitment from staff and establishment of an adequate
organizational structure
28. CONT..
• May take time to be accepted in the workplace
• Need to ensure variance and outcomes are properly recorded,
audited and acted upon.
• Problems of introduction of new technology
29. ROLE AS NURSE MANAGER:
1. Assess quality improvement
2. Effective planning
3. Evaluate quality Interdepartmental Communication
4. Educating the staff of other departments about the pathway role and
responsibilities.
5. Provides patient care Follow critical pathway
6. Inform any deviance Collaborate with other professionals
30. WHAT IS YOUR ROLE AS STAFF NURSE
• • Provides patient care Follow critical pathway
• • Inform any deviance
• • Collaborate with other professionals
