A complete guide for critical/clinical pathways

1. CLINICAL PATHWAYS

2. 1. Concept and historical background of the concept
2. Objectives of CP
3. Characteristics of CP
4. Importance of CP in nursing
5. Steps in developing and implementing CP
Learning Outcomes

3. Concept
• The application of computers to generate, validate, secure and integrate
healthcare data to support the decision making activities of clinical and ad
ministrative professional has added an entirely new dimension to the func
tioning of healthcare industry.
• Techniques of Quality Management Science are among the newer appro
aches to managing the delivery of healthcare. One such application of this
science to healthcare is Clinical Pathways.
• Successful case management relies on critical pathway to guide care
• Critical pathway refers to the expected outcomes and care strategies dev
eloped by collaborative practice team.
Collaborative practice is an approach that enables health care pr
oviders to deliver high quality, safe person-centred services to a
chieve the best possible individual health outcomes

4. Skills for collaborative work
• Have a common purpose and goal.
• Trust each other.
• Clarify their roles from the start.
• Communicate openly and effectively
• Appreciate a diversity of ideas.
• Balance the team focus.
• Leverage any heritage relationships.
Case Management: Case management nurses are registered nurses who
coordinate all aspects of the care of individual patients. They ensure proper
utilization of services and resources as well. Case managers provide
assistance within, between, and outside of facilities.
• Share a vision.
• Set expectations early.
• Establish metrics.
• Capitalize on strengths.
• Encourage new ideas.
• Create cross-functional work groups.
• Keep your promises.
• Build team relationships after work.

5. CP: Definition
1. Critical paths are guides that outline the critical or key ev
ents expected to happen each day of patient’s hospitaliza
tion -Cohen & Cesta,2001
2. Critical pathways are one method of planning, assessing, i
mplementing and evaluating the cost- effectiveness of pat
ient care
3. A series of methods and instruments to align member of
the interdisciplinary and interprofessionally team for the c
are of the pre defined patient population in order to reali
ze an efficient, patient centered, coordinated program of
care

6. Synonyms
• Anticipatory recovery pathways (ARPs)
• Integrated Care Pathways,
• Multidisciplinary pathways of care ( MPCs),
• Pathways of Care,
• Care Maps,
• Collaborative Care Pathways
• Critical Pathway
• Anticipated Recovery Path
• Managed care plans
• Care track
• Care Profiles

7. History
The concept of critical pathways is borrowed from the theories of
Continuous Quality Improvement (CQI).
Critical pathways are first developed for the use in industry as a t
ool to identify and manage the rate limiting steps in production pr
ocesses.
In health care, critical pathways were first developed and applied
in 1980s to improve hospital efficiency.
Most of the first critical pathway in the hospital are develop by nu
rses for nursing care alone.
Later on these have been developed by other disciplines covering
all the aspects.

8. FEATURES
• Predetermined course of progress
• Variance analysis
• Fiscal planning
• Directing
• Orientation
• Identifies outcome
• It should be structured multidisciplinary care plan. It supports multidisciplinary ca
re and evidence based clinical practice.
• The goal and key elements of care based on evidence and best practice should be
defined and stated.
• It should guide the management for a well-defined group of patients for a well-defi
ned period of time.
• It sequences the action of multidisciplinary team.
• It facilitates variance managements and allows documenting, monitoring and evalua
ting the variance.
• The essential step in care of patients with specific clinical problem is detailed.
• It should help communication with patient by providing a clearly summary of care.

9. WHAT DOES IT CONTAIN?
• Specific medical diagnosis
• The expected length of stay
• Patient identification data
• Appropriate time frames (in days, hours, minutes or vis
its) for intervention
• Patient outcomes
• Interventions presented in modality groups ( medicatio
ns, nursing activity & so on)
• Nursing diagnosis

10. Why Clinical Pathways?
• To improve patient care
• To maximize the efficient use of resources
• To help identify and clarify the clinical processes
• To support clinical effectiveness, clinical audit and risk management
• Eliminate prolonged lengths of stay arising from inefficiencies, allowi
ng 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 prom
ptly
• Facilitate quality management and an outcomes focus

11. Objectives
• Selecting a best practice when practice style varies unnecessarily.
• Defining the standards for the expected duration of hospital stay an
d for the use of tests and treatment.
• Examining the interrelations among the different steps in the care pr
ocess to find ways to co-ordinate or decrease the time in the ratelimit
ing step.
• Giving all hospital staff a common game plan from which to view an
d understand their various role in the overall care process.
• Providing a framework for the collecting data on the care process so
that providers can learn how often and why patients do not follow an
expected course during their hospitalization.
• Decreasing documentation burden.
• Improving patient satisfaction with care by educating patients and t
heir families about the plan of care.

12. Benefits
• Improve patients care.
• Increase use of recommended medical acre.
• Decrease use of unnecessary tests.
• Decrease increase lengths of stay of patients.
• Reduce costs.
• Increase participation in clinical research protocols.

13. Critical pathway professional
• Physician
• Nurse manager
• Staff nurse
• Social worker
• Dietician
• Occupational therapist
• Pharmacist

14. Clinical Pathway Development
PREREQUISITE:
• Succeed when the decision to develop is taken on an organiza
tional basis.
• Senior management commitment and a strong medical and n
ursing lead are essential
• Pathway documentation is more likely to be used if it is simple
, clear and user friendly
• The process of pathway development considers why tasks and
interventions are performed, and by whom; since it promotes gr
eater awareness of the role of each professional involved in the
care cycle.

15. Basis of Critical Pathway Technique
• Define the processes
• Timing of these processes,
• Note target areas that were critical,
• Measure variation, and make improvements
• Re-measurement.

16. Guidelines for the Development and Implementation
• Educate and obtain support from physicians and nurse, and
establish a multidisciplinary team.
• Identify potential obstacles to implementation.
• Use Quality improvement methods and tools.
• Determine staff interest and select Clinical Pathways to dev
elop.
• Collect Clinical Pathway data and medical record reviews of
practice patterns.
• Conduct literature review of clinical practice guidelines.
• Develop variance analysis system and monitor the complian
ce with documentation on Clinical Pathways.
• Use a pilot Clinical Pathway for 3 to 6 months; revise as ne
eded.

17. Constituents of Clinical Pathways
• Multi-disciplinary, multi-agency, clinical and administrative a
ctivities
• Structured Variance Tracking
• Local and National standards
• Evidence based, locally agreed, best practices
• Tests, charts, diagrams, information leaflets, satisfaction que
stionnaires, etc.
• Scales for measurement of clinical effectiveness
• Outcomes
• Freehand notes
• Scalability to add activities to a standard CP for individualiz
ed care for a particular patient
• Problem, Plan, Goal and Notes or similar structured freehan
d area

18. Limitations of Clinical Pathways
• Implementation of the care pathways has not been t
ested in a scientific or controlled fashion.
• No controlled study has shown a critical pathway to
reduce length of stay, decrease resource use, or impro
ve patient satisfaction.
• Most importantly, no controlled study has shown i
mprovements in patient outcome

19. Barriers to Clinical Pathways
• May appear to discourage personalized care
• Risk increasing litigation
• Don't respond well to unexpected changes in a patient's co
ndition
• Suit standard conditions better than unusual or unpredicta
ble ones
• Require commitment from staff and establishment of an ad
equate organizational structure
• Problems of introduction of new technology
• May take time to be accepted in the workplace
• Need to ensure variance and outcomes are properly record
ed, audited and acted upon.

20. Challenges faced for Implementation
• Difficulties in engaging senior clinicians and persuadi
ng them to participate in the procedure of designing a
nd implementation of the clinical pathways (e.g. engag
ing a cardiologist or neurologist in the process)
• Difficulties in engaging junior medical staff because o
f their high turn-over, limited free time and heavy clini
cal loads
• Problems in finding a common meeting time across
disciplines, and getting the multidisciplinary staff invol
ved in the use of the clinical pathways for the training
for their effective use and learning their importance in
the clinical practice

21. What is your role as staff Nurse
• Provides patient care •
• Follow critical pathway •
• Inform any deviance •
• Collaborate with other professionals

24. Conclusion
A Clinical Pathway is thus a ro
ad map for a patient as well a
s for the treatment team, whic
h supports an Effective In-pati
ent Care.