Integrated Clinical Pathways

Integrated Clinical Pathways (ICPs) are care team management plans that display goals for patients and provide the sequence and timing of actions necessary to achieve these goals with optimal efficiency.1 The purposes of an ICP are to decrease variation in care, to increase adherence to clinical guidelines, to improve efficiency, and, most importantly, to improve patient outcomes.

ICPs have four specific features2:

  1. An explicit statement of the goals and key elements of care based on evidence, best practice, and patient expectations;
  2. The facilitation of the communication, coordination of roles, and sequencing the activities of the multidisciplinary care team, patients and their families;
  3. The documentation, monitoring, and evaluation of variances and outcomes; and
  4. The identification of the appropriate resources.

In this section, we describe a process for developing and implementing ICPs for any patient population. For Project TICKER, our ICPs focused on pediatric congenital heart surgery patients undergoing repairs for ventricular septal defect (VSD) and tetralogy of Fallot (TOF). We intend for you to follow the processes outlined here for tool development and implementation in order to customize the ICPs as much as needed for your patient population.

Tool Development

In order to customize existing ICPs or to develop new ones, we recommend the following steps:

  1. Identify unit-based, multidisciplinary expert panels within your institution. Involving frontline clinicians, who make decisions for these patients on a daily basis, will increase buy-in for the implementation process. These are the tasks for the expert panels:
  • Complete chart reviews, using several agreed upon categories (such as inotropes, monitoring, pain/sedation, timing of echocardiograms, etc.), to learn how care was provided and with what degree of consistency.
  • Review evidence and clinical pathways from other institutions (see bibliography).
  • Discuss and decide on standard practices. Areas of high inconsistency found in the chart reviews will be your top priorities to address in terms of standardizing care.
  • Use the TICKER ICP for either VSD or TOF as a template to draft the ICP for your patient population, starting with standards of care immediately following surgery and continuing with each post-operative day until expected discharge. Following are some strategies we developed as we drafted and tested our ICPs:
    • Use the Integrated Clinical Pathways Checklist to ensure that all components are addressed.
    • Establish eligibility criteria, as well as a list of circumstances when a patient should come off the pathway.
    • Create a cover page for each packet, including the inclusion/exclusion criteria as well as instructions for preparing the packets and identifying pathway patients on census sheets.
    • Family advisors suggested these strategies:
      • Leave some space on the sheet for each day devoted to summarizing the daily goals in simpler, less clinical terms to aid parents in understanding the goals for the day and to help their child make progress.
      • Post photos of the physician team for the week in each PICU/CICU room to help parents put faces to names.
  • Test and refine your draft ICP using the rapid improvement method of PDSA (Plan-Do-Study-Act) cycles, a simple quality improvement tool based on the scientific method.
    • Complete a PDSA cycle for each patient you are testing on the ICP.
    • Evaluate the ICP with various methods, including debriefs in person with the front line staff who used the template, feedback surveys delivered electronically, and simple auditing of the completed forms.
    • For example, some of our PDSA cycles revolved around where to keep the ICP packets that were in progress in the ICU. We started with a plan to keep the packet in the patient’s door to be filled out on morning and evening rounds by the fellow physician. (This process was already in place for standardized PICU daily goals sheets, which have been used on our ICU for several years.) The “do” step involved the unit coordinator’s making a copy of the packet and placing it in the patient’s door. We studied by observation that the packet did not stay in the patient’s door but was often carried back to the physician work stations by the resident physicians to enter orders and then did not return to the door pocket. The “act” step was to add a note to each page of the packet that it should stay in the patient’s door when not being filled out.
    • Plan on completing approximately 10 cycles or cases before moving on to the full implementation phase.

    Implementation Process

    There are several components necessary for successful implementation: training, education, process measurement, communication, ownership, and governance structure. In this section, we describe important points for each component.

    • Training: Once PDSA cycles are successful in finalizing the ICP format and best use design, the next step is training service line personnel through various formats, such as staff meetings, faculty and physician conferences, real-time in the units, as well as multidisciplinary meetings related to the project. The ICPs are designed with a “how to use” section on the cover page in order to reinforce the process learned in training.
    • Education: Assess the need in each unit for clinical education and make a plan for who will lead the educational sessions and how. The education required will take more or less effort depending on how significant the changes in practice are. An essential aspect for everyone to understand is that the ICP provides a general guideline and should not be seen as rigid. Be sure to include a note such as the one below on all pages of the ICP. This pathway is a general guideline and does not represent a professional care standard governing providers’ obligations to patients. Care is revised to meet the individual patient needs.
    • Process measurement: Your core team should collect the completed ICPs and review them for compliance, which is defined as documented utilization in all inpatient units, including pathway variation, when applicable (see Measurement). Feedback related to compliance and clinical pathway variations can be reviewed at the peer review quality improvement conference (see Getting Started).
    • Communication: Develop various methods of communication and prompting to remind clinicians to use the ICP and keep the documentation near the patient. Possible options are email prompts to physician providers and unit directors with upcoming patients scheduled for one of the ICP procedures, patient/census lists with patients highlighted, identification of patients at weekly cardiac surgery conferences, and a prompt added to nurse handoff sheet.
    • Ownership: Identify an owner for the ICP who will be responsible for monitoring the process measurement and intervening when a problem arises. At the start of the project, the owner will likely be the physician leader but could transition later in the project to another provider who treats these patients.
    • Governance structure: Find out whether your institution has a governance group for clinical pathways, and, if so, investigate the process in the early planning phase of your project. The governance group can help determine an electronic (Web-based) home for all ICPs and standardized guidelines for management of surgical complications. They will also keep track of review dates for each ICP. Since our institution did not have an established governance structure, we created our own Web site to make the tools available.

     

     

    ICP Recommendations

     

    Tools & Resources for Integrated Clinical Pathways

    Bibliography for Integrated Clinical Pathways
    Integrated Clinical Pathway Checklist

    AHRQ Innovations Exchange: PDSA Cycle

    Pediatric OR Antibiotics guide
    VSD/ASD Integrated Clinical Pathway Packet

    VSD/ASD Packet Cover Sheet (MS Word)
    VSD/ASD Post-operative Day 0 (MS Word)
    VSD/ASD Post-operative Day 1 (MS Word)
    VSD/ASD Post-operative Day 2 (MS Word)
    Cardiac Discharge Goals Sheet (MS Word)

    TOF Integrated Clinical Pathway Packet

    TOF Packet Cover Sheet (MS Word)
    TOF Post-operative Day 0 (MS Word)
    TOF Post-operative Day 1 (MS Word)
    TOF Post-operative Day 2 (MS Word)
    Cardiac Discharge Goals Sheet (MS Word)

    Cardiac OR to ICU Handoff Packet

    Cardiac OR to ICU Handoff Process (MS Word)

    NICU to ICU Handoff Packet

    Nurse Communication Form (MS Word)
    Transfer Process (MS Word)

    Complications

    Guidelines for DVT/VTE
    Chylothorax
    JET Guidelines

     

    References

    1 Every N, Hochman J, Becker R, et al. Critical pathways : A review. Committee on Acute Cardiac Care, Council on Clinical Cardiology, American Heart Association. Circulation. 2000; 101(4): 461-5.

    2 Davies R, Gray C. Care pathways and designing the health-care built environment: An explanatory framework. J Integr Care Pathw. 2009 April 1; 13(1): 7-16.