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Clinical pathways

Clinical Pathways: multidisciplinary plans of best clinical practice.
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 bullet  OpenClinical briefing paper: Care Pathways by Tim Benson. This document discusses care pathways and particularly technologies with the potential to support their development and deployment within the Connecting for Health programme of the NHS in England

Many synonyms exist for the term Clinical Pathways including: Integrated Care Pathways, Multidisciplinary pathways of care, Pathways of Care, Care Maps, Collaborative Care Pathways.

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, multidisplinary 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.

Care Pathways can be viewed as algorithms in as much as they offer a flow chart format of the decisions to be made and the care to be provided for a given patient or patient group for a given condition in a step-wise sequence.

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, and the variance record (to allow deviations to be documented and analysed).

Clinical Pathways differ from practice guidelines, protocols and algorithms as they are utilised by a multidisciplinary team and have a focus on the quality and co-ordination of care.

  • Support the introduction of evidence-based medicine and use of clinical guidelines
  • Support clinical effectiveness, risk management and clinical audit
  • Improve multidisciplinary communication, teamwork and care planning
  • Can support continuity and co-ordination of care across different clinical disciplines and sectors;
  • Provide explicit and well-defined standards for care;
  • Help reduce variations in patient care (by promoting standardisation);
  • Help improve clinical outcomes;
  • Help improve and even reduce patient documentation
  • Support training;
  • Optimise the management of resources;
  • Can help ensure quality of care and provide a means of continuous quality improvement;
  • Support the implementation of continuous clinical audit in clinical practice
  • Support the use of guidelines in clinical practice;
  • Help empower patients;
  • Help manage clinical risk;
  • Help improve communications between different care sectors;
  • Disseminate accepted standards of care;
  • Provide a baseline for future initiatives;
  • Not prescriptive: don't override clinical judgement;
  • Expected to help reduce risk;
  • Expected to help reduce costs by shortening hospital stays
Issues - potential problems and barriers to the introduction of ICPs
  • May appear to discourage personalised 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 establishement of an adequate organisational structure
  • Problems of introduction of new technology
  • May take time to be accepted in the workplace
  • Need to ensure variance and outcomes are properly recorded, audited and acted upon.
Issues for discussion
  • The differences between clinical practice guidelines and care pathways
  • Paper-based ICPs versus electronic ICPs

Campbell H, Hotchkiss R, Bradshaw N, Porteous M. Integrated care pathways. BMJ. 1998 Jan 10;316(7125):133-7.

[PubMed]   [BMJ]

Summary points: "Integrated care pathways are care plans that detail the essential steps in the care of patients with a specific clinical problem and describe the expected progress of the patient; They exist for over 45 conditions or procedures, and national users' groups exist to give advice and support in their use; They aim to facilitate the introduction into clinical practice of clinical guidelines and systematic, continuing audit into clinical practice: they can provide a link between the establishment of clinical guidelines and their use; They help in communication with patients by giving them access to a clearly written summary of their expected care plan and progress over time; Despite the sound principles which underlie integrated care pathways, few evaluations have been done of the cost of developing and implementing them and their effectiveness in changing practice and improving outcomes. "
Adrian Roberts Sue Middleton (Eds). Integrated Care Pathways: A Practical Approach to Implementation Butterworth-Heinemann, 2000

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M. Daniel Sloan and Carole S. Guinane. Analyzing Clinical Care Pathways. McGraw-Hill Professional 1999.

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Schriefer J. et al. Clinical pathways and guidelines for care management. Outcomes Manag Nurs Pract. 2001 Jul-Sep;5(3):95-8.

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[Abstract not available.]

Tim Benson, Care Pathways (OpenClinical briefing paper)

[OC]   []

This document discusses care pathways and particularly technologies with the potential to support their development and deployment within the Connecting for Health programme of the NHS in England

Schriefer J. 1994. The Synergy of Pathways and Algorithms: Two Tools Work Better Than One. Journal of Quality Improvement. Vol. 20(9):485-499.

[PubMed]   []

"Clinical quality improvement efforts at the Medical Center Hospital of Vermont (MCHV) led to the development of critical pathways, which show the ideal plan of care, and algorithms, which help clinicians make one of many complicated decisions within a plan of care. A synergy appears to develop when pathways and algorithms are used together."

Hill M. The development of care management systems to achieve clinical integration. Adv Pract Nurs Q. 1998 Summer;4(1):33-9.

[PubMed]   []

" With development of managed care markets, health care delivery systems face increasing clinical and financial risk. For an integrated delivery system to survive, strategies for clinical integration and care management are essential. CareMap tools, collaborative practice groups, and case management serve as the foundation to accomplish care management over the health continuum. Coordination of care, within an institution and across traditional health settings, to achieve the best clinical and cost outcomes is the goal. The article discusses strategies for clinical integration, categories for measurement of performance, and the need to incorporate automated solutions into the strategic business plan. "

Hill M. CareMap and case management systems; evolving models designed to enhance direct patient care. In: Reengineering Nursing & Health Care: Handbook for Organizational Transformation. ed. Blancett SS, Flarey DL, 1995.

[PubMed]   []

" Reengineering Nursing and Health Care adopts the basic principles of Hammer and Champy's bestselling book, Reengineering the Corporation, as the framework for how reengineering may be implemented in health care settings. The book advances the existing trend away from the compartmentalization of services by department toward full integration to create a seamless organization of health care services. While the primary focus is on nursing, the new imperatives organizational integration and collaboration are emphasized throughout, making this book appropriate for all health care managers, executives and educators. "

Wigfield A, Boon E. Critical care pathway development: the way forward. Br J Nurs. 1996 Jun 27-Jul 10;5(12):732-5.

[PubMed]   []

" In many NHS trusts throughout the UK, critical pathways are being used as a method of managing patient care, enabling trusts to ensure that patients receive appropriate, high quality, cost-effective care. At the same time they can meet some of the requirements of The Patient's Charter, such as involving patients in decision making and keeping them informed during periods of treatment. This article first describes critical pathways and then discusses briefly the reasons why pathways were developed at the Guy's and St Thomas' Trust, and the stages of development before their introduction. "

References: reviews

Kris Vanhaecht, Marcus Bollmann, Kathy Bower et al. Prevalence and use of clinical pathways in 23 countries — an international survey by the European Pathway Association. Journal of Integrated Care Pathways, 2006, 10, 28-34.

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" Objectives. To give an overview on the use and prevalence of clinical pathways. Design. Cross-sectional descriptive study. Study participants. European Pathway Association contact persons in 23 countries. Results. Clinical pathways, also known as critical pathways or integrated-care pathways have been used in health care for 20 years. Although clinical pathways are well established, little information exists on their use and dissemination around the world. The European Pathway Association ( has performed their first international survey on the use and dissemination of clinical pathways in 23 countries. At present, pathways are used with a minority of patients, mainly in acute hospital trusts. Our survey showed that clinical pathways were predominantly viewed as a multidisciplinary tool to improve the quality and efficiency of evidence-based care. Pathways were also used as a communication tool between professionals to manage and standardise outcome-oriented care. Conclusions. There is a future for the use of clinical pathways, but there is need for international benchmarking and knowledge sharing with regards to their development, implementation, and evaluation. "

Dy SM, Garg P, Nyberg D et al. Critical pathway effectiveness: assessing the impact of patient, hospital care, and pathway characteristics using qualitative comparative analysis. Health Serv Res 2005; 40(2):499-516.

[PubMed]   [Health Serv Res]

" OBJECTIVE: To qualitatively describe patient, hospital care, and critical pathway characteristics that may be associated with pathway effectiveness in reducing length of stay. DATA SOURCES/STUDY SETTING: Administrative data and review of pathway documentation and a sample of medical records for each of 26 surgical critical pathways in a tertiary care center's department of surgery, 1988-1998. STUDY DESIGN: Retrospective qualitative study. DATA COLLECTION/ABSTRACTION METHODS: Using information from a literature review and consultation with experts, we developed a list of characteristics that might impact critical pathway effectiveness. We used hypothesis-driven qualitative comparative analysis to describe key primary and secondary characteristics that might differentiate effective from ineffective critical pathways. PRINCIPAL FINDINGS:" All 7 of the 26 pathways associated with a reduced length of stay had at least one of the following characteristics: (1) no preexisting trend toward lower length of stay for the procedure (71 percent), and/or (2) it was the first pathway implemented in its surgical service (71 percent). In addition, pathways effective in reducing length of stay tended to be for procedures with lower patient severity of illness, as indicated by fewer intensive care days and lower mortality. Effective pathways tended to be used more frequently than ineffective pathways (77 versus 59 percent of medical records with pathway documents present), but high rates of documented pathway use were not necessary for pathway effectiveness. CONCLUSIONS: Critical pathway programs may have limited effectiveness, and may be effective only in certain situations. Because pathway utilization was not a strong predictor of pathway effectiveness, the mechanism by which critical pathways may reduce length of stay is unclear. "

Panella M, Marchisio S, Di Stanislao F. Reducing clinical variations with clinical pathways: do pathways work? Int J Qual Health Care. 2003 Dec;15(6):509-21.

[PubMed]   [Int J Qual Health Care]

" OBJECTIVE: To test clinical pathways in a variety of Italian health care organizations in 2000-2002 to measure performance in decreasing process and outcome variations. DESIGN: Creation of indicators, specific for each clinical pathway, to measure variations in the care processes and outcomes. Pre- and post-analysis model to evaluate the possible effect of the clinical pathways on each indicator. SETTING: We tested the clinical pathways in six sites, each with different clinical pathways. RESULTS: Reductions in health care macro-variation phenomena (length of stay, patient pathways, etc.) and in performance micro-variation (variations in diagnostic and therapeutic prescriptions, protocol implementation, etc.) were shown in sites where pathways were implemented successfully. A significant improvement in outcome for patients who were treated according to the clinical pathway for heart failure was also demonstrated. CONCLUSIONS: The overall purpose of clinical pathways is to improve outcome by providing a mechanism to coordinate care and to reduce fragmentation, and ultimately cost. Our results demonstrated that it is possible to achieve this goal. Although controversial elements still exist, we think that clinical pathways can have a positive impact on quality in health care. "

Renholm M, Leino-Kilpi H, Suominen T. Critical pathways:a systematic review. Journal of Nursing Administration 2002; 32(4):196-202.

[PubMed]   []

" Critical pathways are care plans that detail the essential steps in patient care with a view to describing the expected progress of the patient. The authors' review of the literature suggest the use of critical pathways reduces the cost of care and the length of patient stay in hospital. They also have a positive impact on outcomes, such as increased quality of care and patient satisfaction, improved continuity of information, and patient education. "


   What is an integrated care pathway? (on  bullet  About Integrated Care Pathways (from the UK NeLH)  bullet  European Pathway Association    Journal of Integrated Care Pathways from RSM Publishing  bullet  Integrated Care Pathway Users Scotland - ICPUS
Clinical pathways: in practice
   NeLH UK national Care Pathways Database (contains over 2,000 care pathways from over 200 NHS organisations)  bullet  Map of Medicine - demonstration clinical pathways [OC]
Clinical pathways and algorithms on the WWW
 bullet  The BackGuide: "Interactive Educational Web site on the Management of Acute Low Back Pain" (1999) - Institute for Work & Health, Toronto, Canada  USA  Pathways for Medication Safety® (tools developed by the American Hospital Association, the Health Research and Educational Trust and the Institute for Safe Medication Practices with support from The Commonwealth Fund)  UK  Chameleon Information Management Services Ltd (CIMS)
Entry on OpenClinical: 9 September 2003
Last main updates: 18 May 2004; 14 June 2005; (15 March 2006)
Redesigned: 17 May 2004
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