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Integrated Clinical Pathways

Ricardo C. Zotomayor, MD

Life Fellow, PCP

Life Fellow, PCCP

Integrated Clinical Pathways

• Developed in 1990’s in UK and USA

Synonyms

• Integrated Care Pathway

• Multidisciplinary Care Pathways

• Pathways of Care

• Care Maps

• Collaborative Pathways

Campbell H, Hotchkiss R, Bradshaw N, PorteousM. Integrated care pathways. BMJ. 1998 Jan

Integrated Clinical Pathways

• Structured, multidisciplinary plans of care to support implementation of clinical guidelines and protocols

• Supports:

1. Clinical management

2. Clinical/non-clinical resource management

3. Clinical audit

4. Financial management

Integrated Clinical Pathways

• Aim: Improve the continuity of care across disciplines and sectors

• Provide: Detailed guide for each stage of management of patients with specific clinical conditions(Diagnostics/therapeutics)

1. Time period

2. Progress and outcome details

Integrated Clinical Pathways

• Focus: Multidisciplinary team on Quality and Co-ordination of care (vs Practice guidelines/Protocols and Algorithms)

• Components:1. Timeline2. Categories of Care/Activities & Interventions3. Intermediate and Long term outcome criteria4. Variance record – deviations are documented and

analysed

Integrated Clinical Pathways

Campbell H, Hotchkiss R, Bradshaw N, PorteousM. Integrated care pathways. BMJ. 1998 Jan

Integrated Clinical Pathways

Campbell H, Hotchkiss R, Bradshaw N, PorteousM. Integrated care pathways. BMJ. 1998 Jan

Integrated Clinical Pathways

Campbell H, Hotchkiss R, Bradshaw N, PorteousM. Integrated care pathways. BMJ. 1998 Jan

Integrated Clinical Pathways

Campbell H, Hotchkiss R, Bradshaw N, PorteousM. Integrated care pathways. BMJ. 1998 Jan

Integrated Clinical Pathways

Campbell H, Hotchkiss R, Bradshaw N, PorteousM. Integrated care pathways. BMJ. 1998 Jan

Integrated Clinical Pathways

Campbell H, Hotchkiss R, Bradshaw N, PorteousM. Integrated care pathways. BMJ. 1998 Jan

Physical Examination

Initial Lab Tests

Severity-based Treatment Plan

Severity Grading

Response to Treatment

Pharma/Non-pharma Interventions

Clinical response-based Disposition

Ward Management

Labs/Treatment

Ward Management: Pharma/non-Pharma

Response-based Disposition

Intensive Care Pathway

Intensive Care Pathway

Labs/Treatment

Treatment/Other Management

Disposition

Record of Pathway Execution

Variance Record/Analysis/Actions

Appendices

Appendices

Asthma Action Plan

Integrated Clinical Pathways

• "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."

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

Integrated Clinical Pathways

• The European Pathway Association (www.E-P-A.org) has performed their first international survey on the use and dissemination of clinical pathways in 23 countries.

The 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

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.

Integrated Clinical Pathways• " 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. "

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.

Integrated Clinical Pathways• " 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. "

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