Editorial Clinical pathways A practical tool for specifying, evaluating and improving the quality of clinical practice MJA 1999; 170: 54-55
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The article by Dowsey et al1 in this issue of the Journal
is significant. This is the first report in the
Australian medical literature that documents the impact of clinical
pathways in a tertiary care setting, and is also one of the first
randomised trials to show that the use of pathways can improve
clinical outcomes.
A clinical pathway is a tool that sets locally agreed clinical standards, based on the best available evidence, for managing specific groups of patients. The pathway forms part or all of the patient's record and allows the care given by members of the multidisciplinary team, together with the progress and outcome, to be documented. Variations from the pathway are recorded, and analysis allows a continuous evaluation of the effectiveness of clinical practice.2,3 Information thus obtained is used to revise the pathway to improve the quality of patient care. Pathways were introduced into the United Kingdom in the early 1990s and are used for treating patients with a wide variety of clinical conditions in primary, secondary and tertiary care. They may be diagnosis-based (as in the management of myocardial infarction), or symptom-based (as for the investigation and treatment of patients presenting with chest pain). They may also include a specific procedure, such as renal biopsy, or encourage the use of therapeutic guidelines, such as postoperative analgesia. Standardisation of care has been shown to improve outcomes4 and poor quality healthcare is often associated with unjustifiable variation in clinical practice.5 Dowsey and colleagues1 have shown that when they introduced pathways for hip and knee joint arthroplasty better patient outcomes were achieved. The use of clinical practice guidelines based on the best available evidence has generally been welcomed,6 but implementation requires specific action at a local level.7,8 Pathways facilitate the use of guidelines by the multidisciplinary team, as they are locally agreed and are available in the patient's record when decisions are being made. Analysis of the causes of variation further encourages adherence to the guidelines when they are clinically appropriate. Some clinicians believe that guidelines and pathways over-emphasise the clinical condition at the expense of individual patient care. In our experience, pathways provide patient-focused care, as they constantly monitor quality, and any deviation from the pathway identifies complications early. The plan of care is clearly defined and shared with the patient; in some instances patients are involved in the development of this plan. Pathways also facilitate discharge planning as the median length of stay is defined. As Dowsey et al and others have shown,1,9 pathways reduce the length of hospital stay without an increase in complications or unscheduled reattendance. In our clinical experience, pathways have been used successfully to coordinate care across the primary-secondary care interface. Chronic conditions such as asthma, obstructive pulmonary disease, diabetes and palliative care have been managed in this way.10 Some hospitals and general practices coordinate care using pathways for investigating and managing patients who present with conditions such as a breast lump or acute rectal bleeding. While few papers have been published, the National Pathways Association in the UK has information on the successful use of pathways in many clinical settings (a website is currently being developed, but is not yet available; Australian readers can contact D J K by emailing Denise.KitchinerATRLCH-TR.NWEST.NHS.UK). Pathways also have a part to play in clinical risk management. When the pathway is developed, current practice is reviewed and the most recent evidence incorporated into the pathway. Potential risks can be identified and procedures established to minimise them. By including these in the pathway, changes in practice can rapidly be communicated to all members of the multidisciplinary team. Analysis of variation from the pathway can be used to monitor areas of potential risk. Poor documentation can fail to indicate whether a guideline has been followed, and this can readily be addressed by the introduction of the pathway. Another aspect of risk management is preventing the recurrence of untoward events. Pathways can include guidelines that ensure all health professionals are aware of potential risks and take appropriate action to prevent them from recurring. The National Pathways Association in the United Kingdom is undertaking research into the factors that contribute to the successful implementation of pathways. Most clinicians involved in this process agree that making changes that lead to improved outcomes requires active involvement from senior medical staff. There must also be a commitment from management to provide resources to establish and run the program, as time is needed to develop pathways and educate staff. Analysis of variation from, and regular revision of, the pathways is also essential to maintain the improvements in clinical practice. The concept of pathways is based on sound principles, but evaluation of their use is essential, and the article by Dowsey and colleagues contributes towards that evaluation. There is a need for further research into the use of pathways, the outcomes that they achieve and the costs involved. Recently, the National Health Service in the UK introduced the concept of Clinical Governance.11 This involves a process of continuous quality improvement for which senior clinicians and managers are directly responsible. It has moved the emphasis from cost containment, as demonstrated in the North American model of managed care, to a process of managing clinical care to improve quality within the resources available. Pathways have been recognised as one option for facilitating this process,12 allowing changes to be driven by clinicians rather than managers.
Denise J Kitchiner Peter E Bundred
©MJA 1998 | ||
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