UNDERSTANDING CLINICAL PATHWAYS AND THE NURSE’S ROLE IN PATIENT

CARE.

1. Introduction
Clinical pathways are multidisciplinary plans (or a best possible plan of clinical care) for
specified groups of patients with a particular diagnosis. It’s a documented sequence of
clinical interventions that are coordinated to produce high quality care [7].

They serve as management, clinical and audit tools and are specific to the institution
using them. They not only begin with admission and end with discharge from the
hospital, but focus on the interdisciplinary effort required (e.g. they merge medical and
nursing plans with those of say physical therapy, nutrition, or mental health) to benefit a
patient. This improves collaborative practice and team approaches and maximizes
availability of expertise from multiple disciplines.

Clinical pathways have four main components:

 A timeline, (activities grouped as immediate, intermediate or long term). The
focus is on the quality and co-ordination of care. They do not replace normal
treatment plans, standards of care, physician orders. Rather, they stabilize the
process of patient care, the management of clinical and financial outcomes. 2.
Background
 Focusing on the patient rather than the system, using efficient processes and
methods; therefore they are a quality tool. They are implementable across all
healthcare settings (acute, community, primary, mental health, private,
independent, M.O.H). Note however that they may not work in emergency
situations.
 Definitions: A clinical pathway is a tool for coordinated care to achieve desired
outcomes within an anticipated time frame by utilizing the appropriate resources
available. It is a pre-conceived patient care algorithm, or path, intended to
minimize variability and cost, increase efficiency, leading to improved patient
care. Clinical Pathways benefits patients, family and members of the multi-
disciplinary team. They enable continuous evaluation and improvement of
clinical practice and help to stimulate research.
 Justification: medical technology is changing; it is necessary that health
facilities introduce clinical pathways to cut costs and reduce the variation in care.

Quality is improved by consistent management through patient involvement and by

identifying and measuring the improvements in outcomes (mortality, morbidity).

Efficient use of resources is maximized by reducing unnecessary documentation and

reduced length of hospital stay for particular conditions. Patients failing to make
expected progress are easily identified and the appropriate interventions made.

Identifying and clarifying clinical methods and processes ensure continuity of patient
care and reduce unnecessary variations. Collaboration between disciplines, professions
and agencies also increase. This ensures continuity of patient care by reducing
unnecessary variations in the management of the patient.
Resulting effectiveness supports subsequent clinical audit, risk management and
evidence based practice.
In a hospital setting, patients with similar illnesses having surgery might be handled
differently though the clinical outcomes are the same. Economic outcomes however will
defer because of say, length of hospital stay and patient conditions (i.e., co-morbidity).

A variation is changed patient care activities not previously outlined in the clinical
pathway. There are three distinct types of variation:
Systems variations - these include organizational failures such as the unavailability of
staff transport.
Health and social care professional variations - these include clinical judgments
Regarding the addition or deletion of specified interventions; and
Patient variations - these include unexpected illness or complications and patient
care. As active management tools they:

Unnecessary variation is not good because:

 It erodes quality of care, and
 makes it more difficult to assess interventions
Unnecessary variations in care of patients with the same diagnosis can be reduced
through:
 Eliminate prolonged lengths of stay caused by inefficiencies (this allows better
use of resources).
 Reduce mistakes, duplication of effort and omissions
 Improve the quality of work for service providers
 Improve communication with patients as to their expected course of treatment
 Identify problems at the earliest opportunity and correct these promptly
 Facilitate quality management and focus on outcomes to reduce financial risk
caused by provider variability.

Figure 1: Physicians give medical care based upon tradition, their own training and
personal experience. This means patients with a common condition are treated
differently by different physicians resulting in differing outcomes. Quality improvement
here depends on Peer review and quality assurance.

Figure 2: by using a clinical pathway, patients of a common type (e.g., knee

replacement surgery) are treated using a single process defined by the clinical pathway,
potentially eliminating waste and duplication of effort.

Clinical risk management: After developing a pathway, current practice is reviewed

and the newest evidence incorporated. Identify potential risks and establish procedures
to minimize them. New changes in practice are then rapidly communicated to all
members of the multidisciplinary team. Secondly, guidelines will ensure that all health
professionals are aware of potential risks and take appropriate action to prevent them
from recurring.

A true clinical pathway tool must have a mechanism to record

variations/deviations from planned patient care activities ( it contains structured
variance tracking). It differs from protocols and guidelines, a process map, flow chart,
guideline or decision tree.

Other names to describe a clinical pathway are: Anticipated Recovery Pathways

(ARPs), Multidisciplinary Pathways of Care (MPCs), Care Protocols, Integrated Care
Pathways, Pathways of Care, Care Packages, Collaborative Care Pathways, Care
Maps.

Clinical Pathway Development: implementing it will likely succeed if it’s developed by

all key stakeholders: committed senior managers, medical and nursing leaders. The
document should be simple, clear and user friendly.
Example: the development of a clinical pathway to manage patients presenting with
chest pain includes: Patients, or their representatives; General Practitioners;
Paramedics; Accident and Emergency staff; ECG Technicians; Pharmacists;
Pathologists; Coronary Care staff.

Case management and Case Managers: There are three major elements to the
coordination role of the case manager:
1
1) Managerial responsibilities regarding the patient pathway during an episode of care.

2) The coordination of the multidisciplinary team.

3) The clinical responsibilities involved in implementing a plan of intervention.

The case becomes a catalyst to mobilize the team for common purpose through
meetings or phone calls and other forms of effective communications. Her role is to
oversee the evaluation and satisfaction of client needs as well as the achievement of
anticipated clinical outcomes from pre-hospitalization to post-hospitalization (along the
clinical pathway plan within the allotted time frame).

To do the above well, there need to increase professional visibility of nurses away from
the traditional image a provider who faithfully executes the doctor’s orders, which limits
the nurse to the conservative role of physical care, in medication delivery and in
patient monitoring.
Modern Nursing training encourages updating of their skills to become confident and
assume more prestigious duties. Changing societal values and increasing technology
demand that the organization of patient care delivery also changes. The role of the
nurse has now changed to be a case manager with qualities of leadership, coordination
and managerial competence.
Role of the Case Manager At the administrative level:
To coordinate the care delivered to a group of patients;
To facilitate communications between care providers and hierarchies;
To oversee the follow-up of consultations and that they are linked to other services;
To eliminate task duplications, plan for care delivery and implement the plans of care
and to ensure their follow-up.
Aspects of Case Management:
Requires a complete and integrated services network.
Takes the client in charge in his overall case without fragmenting care.
Is focused on the person and his family.
Is guided by specific objectives shared by all team members.
Is managed using structured, systematic and multidisciplinary clinical path way plans.