pathway management in ambulatory wound care: defining local standards for quality improvement and...

Pathway management inambulatory wound care:defining local standards forquality improvement andinterprofessional carePeter Hensen, Huong-Lan Ma, Thomas A Luger, Norbert Roeder, Martin Steinhoff

Hensen P, Ma H-L, Luger TA, Roeder N, Steinhoff M. Pathway management in ambulatory wound care: defininglocal standards for quality improvement and interprofessional care. Int Wound J 2005;2:104—111.

ABSTRACTGrowing health care costs and changes in health care delivery, such as the adoption of the diagnosis-related groups,have tremendously affected treatment patterns all over the world. Pathway management is suitable to be responsiveto the growing operating requirements and to manage effective and efficient medical care in hospitals. Pathwaysstandardise clinical processes for patients with a similar diagnosis, procedure or symptom thereby optimising thequality of treatment and patient satisfaction. They are utilised by a multidisciplinary team with a primary focus onquality and coordination of care. Considering the key strategies of pathway management, an interprofessional teamcontaining physicians and nurses developed and implemented a clinical pathway for ambulatory treatment of chronicwounds. A precise medical protocol was created to standardise routine procedures, to improve the treatmentoutcome and to provide an integrated documentation that enhances interprofessional collaboration. We designed amodular concept of four different sheets which provide pre-defined standards: (a) medical admission, (b) findings andhistory, (c) topic and systemic treatment and (d) evaluation of outcome criteria. Variances must be merely writtendown in detail. After 1 year in clinical practice, we state that the use of a clinical pathway for chronic woundmanagement is an effective method of improving clinical processes and patient outcomes.

Key words: Clinical pathway . Dermatology . Interprofessional care . Quality improvement . Wound care

INTRODUCTIONThe growing health care costs and the chan-ging health care environment involved areleading to more efficient approaches indelivering medical care. The adoption of

diagnosis-related groups (DRG) in manycountries and their frequent use in reimburse-ment systems was one of the main reasons toimplement pathway treatment in hospitals (1).The clinical pathway originally used in theUnites States of America and Australiaaimed to shorten the hospital stay and reducehealthcare costs, which has become anincreasingly important issue in medicine(2,3). In the meantime, pathways have beenestablished as a strategy to reduce the persis-tent evidence of unexplained variation inmedical practice (4,5). In contrast to manykinds of guidelines, initiated by health profes-sions, state or federal agencies or insurers,pathways describe kinds of institution-based

Authors: P Hensen, MD, Department of Dermatology,University of Muenster, Muenster, Germany and DRG-Research-Group, University of Muenster, Muenster, Germany;H-L Ma, MD, Department of Dermatology, University ofMuenster, Muenster, Germany; TA Luger, MD, Department ofDermatology, University of Muenster, Muenster, Germany;N Roeder, MD, DRG-Research-Group, University of Muenster,Muenster, Germany; M Steinhoff, MD, PhD, Department ofDermatology, University of Muenster, Muenster, GermanyAddress to the Correspondence: P Hensen, MD,Department of Dermatology, University of Muenster, Von-Esmarch-Str. 58, D-48149 Muenster, GermanyE-mail: [email protected]

� Blackwell Publishing Ltd and Medicalhelplines.com Inc 2005 . International Wound Journal . Vol 2 No 2104

Key Points

. the growing healthcare costsand changing healthcare envir-onment are leading to moreefficient approaches in deliver-ing medical cures

. diagnosis related groups arebecoming the norm in manycountries and as part ofnational reimbursement

. pathway treatment beingimplemented in hospitals

& REVIEW

guidelines from the local care perspective.Pathway management that has arisen besidethe implementation of DRG in the UnitedStates and Australia can often be misunder-stood due to confusing nomenclature. In lit-erature, the frequently used term ’criticalpathways’ can also be called ‘care paths’,‘clinical pathways’, ‘care maps’, ‘integratedmaps’ and ‘anticipated recovery pathways’(4,6). Nevertheless, all of these attempt todefine local standards based on the best avail-able evidence and increase efficiency byoptimising the care delivery process. In con-trast to prescribed guidelines, protocols andalgorithms, clinical pathways are utilised bya multidisciplinary team and focus on qualityand coordination of care.In principle, pathway management aims at

both implementation of institutional guide-lines and recommendations developed bysocieties or authorities into clinical practice,and to harmonise interprofessional care to alocal agreed clinical approach in daily routineof medical care.Because clinical pathways have been estab-

lished as an appropriate tool to standardisemedical care in an inpatient setting, it shouldbe also suitable for application in an ambula-tory and day clinic setting, where the patientsrecur continually. In many places, the clinicalmanagement of chronic wounds is merelysubject to individual experiences and thelocal approaches established in the course oftime. Furthermore, the chronic nature ofcomplex wounds, the variability in causesand clinical outcomes and the lack of researchin wound care interventions make it difficultto prescribe and to evaluate (7,8). Consideringthese concerns, in the dermatology’s ambula-tory wound care centre, an interprofessionalteam containing physicians and nurses devel-oped and implemented a clinical pathway forthe ambulatory treatment of chronic wounds.The key strategies of the pathway conceptwere primarily to apply a strategy and geta viable tool for quality management andassurance and secondly, to improve the inter-professional collaboration (9,10).

PATHWAY IMPLEMENTATIONThe methodological approach and the aims ofimplementation pathway management areshown in principle in Figure 1. As a firststep, an interprofessional team of senior and

junior residents and nurses experienced inwound treatment were recruited. Duringinterval meetings, a modular concept whichcontains divided care-sections was created.Authorised guidelines developed by theGerman Dermatologic Society (www.derma.de) concerning chronic venous insuffi-ciency, leg ulcer, compression dressing andquality assurance in phlebology were takeninto account as well as existing nursing stan-dards concerning wound therapy. The entirecare delivery process, beginning with theadmission because of the primary symptom‘leg ulcer’ and ending with the discharge orintended surgery intervention, was defined byusing a flowchart. The sequential and chron-ological order was stipulated thereby on amutual basis. This flowchart illustrates a deci-sion tree that discloses the status of the treat-ment process and suggests the next followingstep.One of the purposes of the created pathway

is to provide a single document which informsall members involved in the clinical workflow,to document all medical and paramedicalprocedures. Therefore, as a second step, aprecise medical protocol was created tostandardise routine procedures. This protocolconsists of four different sections (sheets),each containing modular steps for which theparticular competency and responsibilitywere defined. The construction of integrateddocuments should enhance teamwork in thedaily routine. The different care-sectionsencompass (a) the medical admission, (b)medical findings and history, (c) topic andsystemic wound treatment and (d) evaluationof pre-defined outcome criteria.After creating a suitable framework for the

ambulatory wound pathway, a pilot phase of3 months was initiated to verify clinicalappropriateness and to determine interprofes-sional manageability. Piloting a pathway in adefinite time period helps to identify areas inwhich the pathway may need to be changedand builds trust among hospital staff (11).During this phase, the modular pathway con-struction was partially rearranged due toemerging misunderstandings in the course ofaction and some apparent illogical catenationswhich solely came to the fore when the path-way was applied in practice. After expirationof the initial pilot phase, the optimised path-way was transformed into daily routine.

Pathway management in ambulatory wound care

� Blackwell Publishing Ltd and Medicalhelplines.com Inc 2005 . International Wound Journal . Vol 2 No 2 105

Key Points

. many different terms appear inthe literature regarding diagno-sis related groups

. in principle, pathway manage-ment aims at both implementa-tion of institutional guidelinesand recommendations fromrecognised bodies

. pathways developed for inpatient settings are also suita-ble for ambulatory patients

. a pathway for implementation ispresented

. the pathway presents a standard-ised protocol of care

. a pilot study was carried outover 3 months to verify clinicalappropriateness

PATHWAY CONTENTSFinally, four prescribed documents and twoflowcharts elucidating the order of sectionswere established throughout the care process.Comprehensive education of hospital staffwho should be involved was performed. Asshown in Figure 1, protocol sheets werecreated to present the contents of the particu-lar current or following procedure. The pre-defined process steps could be ticked offeasily. Furthermore, it was necessary to writedown when and from whom the section stepwas fulfilled. Variances and deviations fromthe pre-defined pathway which have beenrequired must be written down in detail.This proceeding is absolutely recommendedto consider the patients’ individualities. Theorder and the contents of the main sections areshown in Table 1. The sections admission andmedical findings and history encompassall essential information for the attendingphysicians and nurses (Figure 2). The sectiontreatment contains some crucial steps tomanage (Figure 3):

. Debridement

. Exudation

. Granulation

. Epithelisation

. Wound dressings

. Compression therapy

. Systemic therapy

This section has to be recurrently processedat every consultation. Finally, the section evalu-ation will be filled out at the end of thetreatment process to evaluate some pre-defined outcome criteria.

PATHWAY IN USEThe introduced pathway in ambulatorywound care is a dynamic but ‘ready to use’instrument for daily routine. Quality improve-ment of the entire care process is based onperiodical revision meetings to reflect thedefined standards, analysis of variances onthe care being delivered at regular intervalsand the evaluation of pre-defined quality indi-cators such as time to make the definite

Clinical experiences/local resources

Authorised guidelines /evidence-based medicine

Pathway management

Protocol

Procedure Who? When? Done? Comment

Done

Done

Done

Done

Done

[Variance record]

#

1

2

3

4

5

Entry

Section

Decision

Proc.1 Proc.2

Result

Flowchart

Figure 1. Methodological approach of pathway management.



Key Points

. the output of the study wasfrom prescribed documentsand two flow charts

. continuous education was animportant component ofadoption

. the adoption is a dynamic pro-cess with regular review andrevision

diagnosis or achieved reduction of para-meters like pain or itch. Regular inspectionsof variance records helped to identify com-mon reasons why the pathway had not beenfollowed. This led to the discussion withinthe team and regular updating of the path-way when appropriate. The introducedwound pathway was revised several timeswith the active participation of the involvedstaff members. The available variance recordswere taken into account. During the courseof time, the local therapy line was adapted tocurrent standards when necessary. During acontinuous evaluation process, a componentfor systemic therapy was added. After 1 yearof experience, we state that the use of aclinical pathway for chronic wound manage-ment is an effective method of improvingclinical procedures, which benefits patientoutcomes.

BENEFICIAL ASPECTSThe effectiveness of guidelines predominantlydeveloped by national authorities or medicalsocieties is discussed controversial concerningthe introduction into clinical practice. On theone hand, the lack of transparency regardingthe development of guidelines is a majorobstacle in their appraisal (12). Moreover,guidelines in general are not a very welcomeattendant to clinicians because of the assump-tion that the physician’s autonomy isrestricted (13). Although these are valid con-cerns, within a quality improvement context,however, guidelines are a crucial form of pro-cess specification and optimisation (14).Hence, pathway management provides anew way to overcome some obstacles whichare associated with guideline implementation.In contrast to imposed guidelines, the mainbenefit of pathway treatment is the conceptual

Table 1 Order of essential pathway sections and contents

Section Content

Admission

Scheduling Remind previous findings/applied drugs

Avoid MRSA-admission

Admission – nurse Check enclosed documents

Prepare laboratory tests

Admission – physician Clinical examination and history

Coordinate outstanding tests

Preliminary diagnosis

Set individual quality target

Medical history and findings

History Evaluate medical status

Evaluate previous procedures

Evaluate cofactors

Findings Evaluate vessel-related and allergic findings

Evaluate internal medicine findings

Evaluate consultant findings

Definite diagnosis

Treatment

Documentation Course of disease

Electronic photo documentation

Procedures Definite local therapy

Definite systemic therapy

Advices for home caring

Reporting and scheduling

Evaluation

Main objective Achievement of objectives

Time required

Secondary objectives Reduction of pain

Reduction of itch

Individual Patient satisfaction

Physician’s appraisal

MRSA, methicillin resistant staphylococcus aureus.



Key Points

. after one year of use, the clin-ical pathway for chronic woundmanagement has proven aneffective method benefittingclinical outcomes

. the pros and cons of adoptionof standardised pathways arediscussed

. pathways are more for guidancerather than specific guidelines

integration of external knowledge and inter-nal experiences. Unfortunately, there is cur-rently little evidence that supports theeffectiveness of pathway management, atleast at present. But several investigationsconcerning standardised approaches to thedelivery of care may advice to assume thatpathway management is beneficial for processdelivery and medical outcomes (15,16). Theamount of improvement, however, may varyconsiderably.

In order for a hospital to become account-able for delivering high quality care, it mustbe able to deliver three sets of information:evidence of continuous quality improve-ment, outcome management and clinicalpractice standards and guidelines (1).Pathway management provides a modelwhich combines these three aspects to oneinstrument of quality management. This willbe achieved by considering the followingcriteria:

Intendedadmission

Scheduling/Infectioncontrol

Admission(nurse/

physician)

History

Patch-testing

Contactdermatitis?

Arterialpressure

Angiography Angiology?

Completestatus?

Skin biopsy?

Consultation?Medical

consultations

Medicalfindings

TumourMixedulcers

Diagnosis

Treatment

Macro-angiopathic

ulcer

Micro-angiopathic

ulcer

Vasculo-pathy Vasculitis Trauma

Ulcuscruris

venosum

Biopsy

Phlebologicstatus

Figure 2. Flowchart showing essential elements of the sections admission and findings and history.



Key Points

. little evidence supports the effec-tiveness of pathway management

. in order for a healthcare facilityto deliver high quality of care,they must have a process ofoutcome management and clin-ical practice standards andguidelines

. pathway management providessuch a model

Treatment

Digital photoand

electronicdocumentation

Surgery?

NO

Eschar?

Exudation?

Encouragegranulation?

Encourageepithelisation?

Xerosis?Inflammation?

Art. anklepressure

>80 mmHG

Systemicdisorder?

Yes

Treatment

Report tooutpatientspecialist

Physic.

Surgery? NO

NO

NO

Yes SchedulingReadmission?

Discharge

Report? NurseReport toambulant

care

Yes

OP NOWound

conditioning?

IDebridement

IIExudation-

management

IIIEncouragegranulation

IVEncourage

epithelisation

VPerilesional

therapy

VICompression

therapy

Sheet IIsystemictreatment

Figure 3. Flowchart showing essential elements of treatment.



. Available internal knowledge andresources are presented in combinationwith authorised guidelines

. Responsibilities and roles in the pathwayprocess are clearly constituted

. Provided quality levels will be disclosedby defined wound care standards

. Outcome criteria may be defined indivi-dually considering patient’s require-ments and wound conditions

. Standardisation of the care process is ableto reduce variances in treatment patternsand is opposite to intuitive and experience-guided treatment

. Quality improvement is ensured by per-iodical reviews within the team

. Workflow construction on a mutual basiscontribute to interprofessional collabora-tion and better acceptance among eachother

. Outcome measurement focus on both theindividual quality objective and the qual-ity of health care providing

PERSPECTIVEPathway management is an integrative tool tooptimise interprofessional care and qualitymanagement in hospitals (Figure 4). It hasbeen shown as a suitable tool to provide stan-dardisation and quality improvement in dailyambulatory wound care. Some beneficialaspects were pointed out, but there is cur-rently no valid and effective method to evalu-ate entirely the efficiency (17). Particularinstitutional side-effects and the impacts on

the human resources development are notprecisely evaluable, although they serve asadditional purposes of the entire concept. Itis presumed that combining quality of individ-ual and organisational care objectives with thebusiness objectives would lead to a wideradoption by the medical and paramedicalstaff involved (18,19). Further research will beneeded to measure and evaluate effectivenessand efficiency of the wound pathway shownhere and pathway concepts at all. Equally,cost-effectiveness studies of wound manage-ment is further essential but require the defini-tion of what is an acceptable and consistentoutcome for the treatment program (20). Theintroduced concept of pathway managementwill make a contribution to determine outcomecriteria which consider both the operating effi-ciency and the individuality of wound care.

Key Points

. pathway management has been estab-lished as a suitable tool to face the grow-ing operating requirements in health careunits

. pathway primary focus on standardisa-tion in patient treatment, but they areapplicable also in an ambulatory setting

. chronic wound management is difficultto standardise in principle

. a modular concept was developed by aninterprofessional team

. external guidelines and internal know-ledge and resources were concatenated

. four sections were defined to cover theentire care delivery process

— medical admission— medical findings and history— topic and systemic wound treatment— evaluation of pre-defined outcomecriteria

. a pilot phase of 3 months was initiated totest and verify

. pathway management is performed byusing concise protocols and supportiveflowcharts which illustrate the careprocess

. deviations from the pre-defined pathwayare added by way of explanation

. the pathway defines a corridor, however,individual treatment will be ensured

. the treatment steps will be processedrecurrently at every consultation

Inte

rpro

fess

iona

l

colla

bora

tion

Continuesevaluation

Quality

improvement

Figure 4. Interlocking benefits of pathway management.



Key Points

. pathway management is anintegrative tool to optimizeinterprofessional care and qual-ity management in hospitals

. there are no current methodsavailable to fully evaluate effi-ciency of the approach

. further work is required to fullyvalidate this approach

. positive indicators show appropri-ateness of a pathway approach tocare

. finally, pre-defined outcome criteria willbe evaluated

. the pathway concept overcomes theobstacles associated with authorisedguidelines

. periodical assessment and review ensurequality improvement

. quality improvement focuses on individ-ual and organisational quality standards

. pathway management is an integrativeinstrument to advance interprofessionalcare and to manage quality in hospitals

REFERENCES1 Cheah TS. Clinical pathways — The new paradigm

in healthcare? Med J Malaysia 1998;53:87—96.2 Pearson SD, Kleefield SF, Soukop JR, Cook EF, Lee TH.

Critical pathways intervention to reduce length ofhospital stay. Am J Med 2001;110:175—80.

3 Dy SM, Garg PP, Nyberg D, Dawson PB, Pronovost PJ,Morlock L, Rubin HR, Diener-West M, Wu AW.Are critical pathways effective for reducing post-operative length of stay? Med Care2003;41:637—48.

4 Pearson SD, Goulart-Fisher D, Lee TH. Critical path-ways as a strategy for improving care: problemsand potential. Ann Intern Med 1995;123:941—8.

5 Welch WP, Miller ME, Welch HG, Fisher ES,Wennberg JE. Geographic variation in expendi-tures for physicians’ services in the UnitedStates. N Engl J Med 1993;328:621—7.

6 Campbell H, Hotchkiss R, Bradshaw N, Porteous M.Integrated care pathways. BMJ 1998;316:133—7.

7 Barr JE, Cuzzell J. Wound care clinical pathway:a conceptual model. Ostomy Wound Manage1996;42:18—26.

8 Tallon R. Critical paths for wound care. Adv WoundCare 1995;8:26—34.

9 Kitchiner DJ, Bundred PE. Clinical pathways. Med JAust 1999;170:54—5.

10 Atwal A, Caldwell K. Do multidisciplinary integ-rated care pathways improve interprofessionalcollaboration? Scand J Caring Sci 2002;16:360—7.

11 Yandell B. Critical paths at Alliant Health System.Qual Manag Health Care 1995;3:55—64.

12 Miller M, Kearney N. Guidelines for clinical prac-tice: development, dissemination and implemen-tation. Int J Nurs Stud 2004;41:813—21.

13 Brook RH. Practice guidelines and practicingmedicine. Are they compatible? JAMA 1989;262:3027—30.

14 Berwick DM. The clinical process and the qualityprocess. Qual Manag Health Care 1992;1:1—8.

15 De Luc K. Care pathways: an evaluation of theireffectiveness. J Adv Nurs 2000;32:485—96.

16 Walldal E, Anund I, Furaker C. Quality of care anddevelopment of critical pathway. J Nurs Manag2002;10:115—22.

17 Darer J, Pronovost P, Bass EB. Use and evaluation ofcritical pathways in hospitals. Eff Clin Pract2002;5:114—9.

18 CabanaMD, RandCS, PoweNR,WuAW,Wilson MH,Abboud PA, Rubin HR. Why don’t physiciansfollow clinical practice guidelines? A frameworkfor improvement. JAMA 1999;282:1458—65.

19 Huttin C. The use of clinical guidelines to improvemedical practice: main issues in the United States.Int J Qual Health Care 1997;9:207—14.

20 Tallon R. Cost-effective wound care: new prioritiesdriven by outcomes. Adv Wound Care 1995;8:48.



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