Pharmacists' role in critical pathway development

Pharmacists using new technology, new knowledge, and evidence-based medicine approaches can and should play a critical role in answering questions about the value of critical pathways, according to members of the 2005 American College of Clinical Pharmacy (ACCP) Task Force on Critical Pathways.

Writing in an ACCP White Paper published in Pharmacotherapy, task force members said that as pharmacists continue to play a leading role in managed care, opportunities will be available for them in the critical pathway process that will be essential to ensure future success of critical pathways.

The White Paper says critical pathways represent comprehensive management plans that aim to optimize and streamline patient care. Some specific critical pathway goals include providing continuous quality improvement, decreasing service fragmentation through managed care, optimizing health care delivery cost-effectiveness, guiding a patient and family through expected treatment and progress, and increasing satisfaction of patients, families, staff, physicians, and third-party payers.

Critical pathways create targeted patient outcomes and quality endpoints that form a foundation for common expectations, shared responsibility, regular communication, and early problem detection and intervention among all members of the health care team, the White Paper says. Also, they identify specific time frames and desired outcomes associated with each care step, with the goals of minimizing delays and maximizing resource utilization.

Not treatment guidelines

Critical pathways are differentiated from clinical treatment guidelines. Clinical treatment guidelines may be intended to define appropriate care for a specific indication. The White Paper says the main difference between critical pathways and disease-specific guidelines is that critical pathways focus on targets of care for the clinical management of patient groups instead of addressing decisions on individual patient management.

Because pharmacotherapy is a central component of many critical pathways, pharmacists should take leadership roles in developing, implementing, and assessing critical pathways, the authors said. Critical pathways have been used to establish and document the valuable, accountable roles of pharmacists as essential members of the health care team. Official statements regarding practice guidelines and pharmacists' involvement in patient management, particularly drug therapy and outcomes, have been published by the ACCP and the American Society of Health-System Pharmacists.

"With the advances of clinical pharmacy and medicine, particularly new health care knowledge and technology, pharmacists have been extensively involved in various aspects of the critical pathway," the authors said. "Therefore, a more comprehensive and updated document is warranted to incorporate those changes." The intent of the White Paper was to review the steps in critical pathway development, to discuss the pharmacist's role in critical pathways, and to describe use of critical pathways to maximize delivery of health care while ensuring efficient and effective resource use.

The task force said the process of developing and implementing a critical pathway follows these steps to:

1) identify target patient population, procedure, or disease category;

2) educate staff about critical pathways;

3) convene a multidisciplinary group of care providers;

4) identify key outcomes and corresponding timelines for accomplishing key outcomes;

5) gather information, which may include chart audits;

6) develop critical pathways based on ideal, realistic, or current practice;

7) educate the staff about the critical pathway and its implementation plan;

8) implement the critical pathway;

9) evaluate the critical pathway periodically;

10) insert new alternatives, interventions, and plans into the critical pathway to improve performance;

11) reevaluate the critical pathway after each adjustment.

The report said the process also includes evaluating a health care facility's current process of care and review of medical evidence and external practices. Once a critical pathway is implemented, a follow-up assessment of its impact, using predefined outcomes and baseline observations, should be considered, according to the task force.

Seek support

Before undertaking development and implementation of a critical pathway, planners must take steps to ensure the support of the medical staff and the health system's administration. The authors said an interdisciplinary team must be formed to discuss and determine the goals of management of the selected disease state being addressed by the critical pathway. Team members should be aware of the current standard of care for whatever pathway is being pursued. Experts in the particular specialty, as well as those who will use the pathway, should be consulted and included. Rational cost-effective therapy intended to achieve definite outcomes that improve a patient's quality of life is the goal from the pharmacist's standpoint, the White Paper said. Also, mechanisms to ensure efficacy and patient safety should be incorporated into a pathway.

Another element in developing a critical pathway is defining the desired clinical outcomes that can be achieved for most patients in the selected population. Thus, a desired clinical outcome might be curing a disease with no adverse effects, within a given time frame and for a given cost. "Critical pathway development offers an ideal opportunity to examine current practice habits for the selected patient population," the researchers said. "Before constructing the critical pathway, the best practice for the target population should be defined by using literature review and benchmarking."

This step, the report said, affords the pharmacist an opportunity to build rational and cost-effective drug therapy into the standard of practice for the selected patient population. At meetings of team members discussing best practices, pharmacists should be prepared to support their recommendations for drug therapy with scientific data, if available, and with benchmarking information and cost analyses. The researchers said impediments to pathway development include lack of data on current practices and outcomes with specific disease states, difficulty in gaining consensus from multiple practice groups, and time-intensive personnel requirements.

Because successful implementation of a critical pathway depends on health care provider education and understanding of the purpose and need for the pathway, a six-month pilot test of pathways is recommended by the researchers so providers can become familiar with using the pathway and the team can modify it as potential improvements are identified.

Because measuring a pathway's impact can be time-consuming, this is a good time to start thinking about how technology can assist the pathway process. The researchers said that automation will help ensure that policies and protocols already in place are followed. A key factor in designing critical pathways is to determine variables that will be measured before implementation. With outcome variables in mind, an institution may be able to create reports that would be beneficial to many areas of the health care system. Patient and financial outcomes need to be considered when measuring a critical pathway's impact, and outcome measures should consider approaches that allow easy retrieval of results or benchmarks from an electronic database.

Again, the report said, pharmacists play a key role in these processes. They should ensure that any software programs that are written are not prone to creating errors. They also should ensure that needed elements and links to other databases (such as allergy and reaction information, drug interaction information, dose range information, laboratory results, and problem lists or diagnoses) are built into the critical pathway to streamline the order entry process and promote practitioner ease of use and compliance.

Review, revise practices and protocol

As part of critical pathway development and implementation, pharmacists must review or revise current pharmacy practices and protocols and implement them to ensure practice consistency. The researchers said a pharmacist can "play an important role on a team evaluating a critical pathway that requires appropriate drug utilization, including those in which drugs are ancillary, such as diagnostic or surgical procedures.

Pharmacy services, including but not limited to pharmacotherapy consults and discharge drug counseling, should be integrated into the critical pathway, and documentation of such services should be incorporated into the overall care plan.

After a critical pathway is developed, those who will be using it need to be educated, and pharmacists can provide education to medical and nursing staff on protocols and drug therapies to be used or incorporated into the pathway. The groups should also be told of performance standards and goals pharmacy is measuring.

"The three Cs — communication, continuity, and consistency — cannot be overemphasized," the researchers said. "As pharmacists use a critical pathway, they can model and educate other clinicians about the pathway. Pharmacists should prospectively design drug use evaluations in such a way that areas of the critical pathway involving safety, adherence, variation, and efficacy, including specifically designated outcomes, can be assessed. Analysis of the results, with suggested alterations, should be shared with the groups who developed and use the pathway and appropriate clinical and/or administrative committees."

During the past decade, the researchers said, critical pathways have evolved and become common tools in providing health care. The onus is on health care professionals to intensify the validation and justification for using critical pathways in clinical practice, and pharmacists have an important role to play in that process.

Download the ACCP White Paper from