Critical Path Network: Clinical pathway for colorectal procedures

Clinical pathways development in Singapore

By Soh Mun Chin, RN
Senior Case Manager
Tan Tock Seng Hospital

Singapore is a small country in Southeast Asia with a land area of 682 square km and a population of 4.4 million. Singapore is a multiracial society. The ethnic groups include 77% Chinese, 14% Malay, 8% Indian, and 1.5% other.

The health care financing in Singapore is a dual system:

  • private;
  • subsidized.

For the private system, patients pay out of pocket for their medical expenses. Patients in the subsidized system get 65% to 80% subsidy from the Ministry of Health, depending on the class status they choose: Paying A, B1, B2, or C class beds.

The health care mission in Singapore is:

  • to promote good health and reduce illness;
  • to ensure that Singaporeans have access to good and affordable health care that is appropriate to their needs;
  • to pursue medical excellence.

Clinical pathways in Singapore

Clinical pathways were first developed and implemented in Tan Tock Seng Hospital (TTSH) in May 1996. TTSH is the second largest acute-care hospital in Singapore. It has 1,200 beds.

The first clinical pathways implemented are the following:

  1. hip fracture [length of stay (LOS) 11 days/10th postoperative day (POD)];
  2. ischemic stroke (LOS 5 days);
  3. hemorrhagic stroke (LOS 10 days).

The goals of the clinical pathways initiative were to accomplish the following:

  • streamline variations on care;
  • standardize care and ensure that minimal standard of care are provided to the patient;
  • ensure patients are seen timely;
  • ensure that interventions are carried out timely, with no delays;
  • provide quality and cost-effective care to patients;
  • ensure clinical outcomes and goals are met.

Currently, TTSH has 11 clinical pathways, which are actively running and used by the health care team. The pathways include:

  1. asthma (LOS 3 days);
  2. acute chronic obstructive pulmonary disease exacerbation (LOS 5 days);
  3. acute myocardial infarction, uncomplicated (LOS 7 days);
  4. congestive heart failure (LOS 5 days);
  5. diabetic ketoacidosis in the emergency department (ED);
  6. transurethral resection of prostate (LOS 4 days);
  7. colorectal procedures (LOS 10 days/8th POD);
  8. total knee replacement (LOS 10 days/8th POD);
  9. acute lumbar spinal injury with paralysis (LOS 18 days);
  10. diabetic/ischemic foot with or without minor procedures (LOS 8-10 days);
  11. diabetic/ischemic foot with major procedure (LOS 10th POD).

The implementation of clinical pathways at TTSH certainly has had an impact on the ways that care is being delivered and has been a great pathway and difficult journey for health care providers to have a complete paradigm shift. It was not an easy journey for all of us who were involved with the design, development, and implementation.

In TTSH, clinical pathways are developed by the collaborative effort of the multidisciplinary team to provide the best sequence and timely interventions for selected homogenous groups of patients and to ensure clinical quality outcomes are met.

Developing the colorectal pathway

Here, I would like to share our experience of the development of the colorectal pathway. The colorectal surgeon, Denis Cheong, MD, first initiated this pathway. Its goals are to:

  • standardize care for patients with colorectal surgeries;
  • provide timely pre- and postoperative education to patients and families;
  • prevent/reduce postoperative complications;
  • improve patient, family, and staff satisfaction.

The project team was formed in October 1998. The team members include:

  • colorectal surgeon — chairperson/"champion" for the team;
  • stoma nurse clinician;
  • case manager;
  • registered nurse representative;
  • medical social worker;
  • dietitian;
  • physiotherapist.

The case managers collated the pathway content from the team members and formatted them onto the TTSH clinical pathway template. Cheong, the project leader, was not happy with the hospital format and wanted his own format, which the clinical pathway steering committee did not approve.

The pathway was put on hold because the surgeon refused to get it implemented. The final version of the pathway was put in "cold storage" for about a year.

In early 1999, with the changing health care policy and implementation of case-mix funding and diagnosis-related groups (DRGs), many hospital administrators had to review their care delivery system. Then came the initiative by the Ministry of Health to divide the health care system into two clusters: National Healthcare Group (NHG) and SingHealth Group.

The CEOs for both the clusters are given the autonomy to run the care delivery services. They are monitored by their performance in managing the resources and care delivery services.

TTSH is under the umbrella of NHG. The CEOs of NHG and TTSH strongly support clinical pathway development and implementation as a tool to use for delivering a minimal standard of care to the patients. Because of that support, the colorectal pathway surfaced again for implementation. The pathway was piloted in October 1999 and was reviewed and remodified in February 2000.

The latest revision was done in August 2002. It has greatly improved features, and the latest version was tailored for standardization across the cluster hospitals in NHG.

The purpose of standardizing the clinical pathway format was to provide a standard way of using the clinical pathways by nurses, physicians, and other allied health care providers across the cluster hospitals.

The latest format was approved by the clinical pathway steering committee and NHG clinical management committee.

Benefits/impact of clinical pathways

Some of the benefits and effects of the pathways include:

  • There is standardization of care.
  • Minimal standard of care is provided to patients.
  • There is improved quality of care.
  • There are reduced length of stays.
  • There are reduced post-op complications.
  • There is improved patient/family satisfaction with care.
  • There is improved staff satisfaction.
  • There is improved communication with patient/family and health care professionals.
  • Patient/family are well informed of the plan of care.
  • Clinical outcomes are met.
  • Patient/family receive education and caregiver training on time.
  • Discharge planning initiated on admission and patients are discharged timely.
  • Clinical pathway data collected serve as a tool for clinical service improvement and future research projects and paper presentations in conferences.
  • Colorectal surgeons review the clinical pathway data report and benchmark against themselves and against the other clusters in terms of their care management.
  • Clinical pathways serve as an education/orientation tool for new nurses, house officers, and medical officers.
  • Nurses like to use the pathways because they don’t have to write care plans for patients, as the pathway is the plan of care.
  • Junior physicians like the pathway because it serves as a guide for them in ordering treatment and tests for the patient.

Format design features

The format of the clinical pathway for colorectal procedures consists of the following features:

  • The cover page lists the DRG codes, principal diagnosis, comorbid conditions, principal procedures, and complications during the patient’s stay. (To see sample, click here.)
  • Guidelines for health care professionals on the use of the pathway are printed on the back of the front cover page.
  • Pre-op day to discharge days are listed next.
  • Physician’s orders are on the left-hand corner of the pathway.
  • Nursing and other allied health care team interventions are on the right-hand corner.
  • Multidisciplinary team notes and documentation are on the back of the daily pathway.
  • The health care team members tick on the interventions that have been done and do charting by exception. They only need to chart on the outcomes of the interventions or anything that is unusual and variances from the standard.
  • The variance form is placed at the end of the pathway and removed and submitted to the case manager upon patient discharge.
  • The pathway is a legal document and is kept in the patient’s medical record.

{For more information on Singapore’s clinical pathways, contact:

  • Soh Mun Chin, RN, Senior Case Manager, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433. E-mail: Telephone: (65) 3578526. Fax: (65) 3578530.]