Old hat or cutting edge? The state of the art of clinical pathways

Interdisciplinary approach important for modern pathways

Every year, Hospital Case Management’s reader survey asks case managers what they like most and least about the newsletter. And every year, readers variously compliment and criticize us for the extent to which we cover clinical pathways.

The diversity of responses and the strength of case managers’ feelings about pathways aren’t necessarily surprising. Even though clinical pathways first were developed more than a decade ago, some hospitals only now are implementing them, while other facilities have been using them for years and are moving on to a new generation of automated case management tools. So what is the state of the art? Are clinical pathways old hat or cutting edge? And if you aren’t using pathways, what are you using?

Karen Zander, RN, MS, CMAC, FAAN, who pioneered clinical pathways at New England Medical Center in Boston in the 1980s, says the same forces that initially created interest in pathways are in play today. They include:

  • changes in economics in health care;
  • initiatives and regulations for quality improvement and best practice from an expanding body of evidence;
  • the desire for automation of the health care record;
  • the search for better ways to involve patients, families, and partners.

She adds that clinical pathways are one of the few tools that can combine content and action. "A guideline is a content tool. It doesn’t record action; it just tells you the content," says Zander, now principal and co-owner of the Center for Case Management in South Natick, MA. "An algorithm is a content tool. A clinical path, in some organizations, is a content tool when it’s used as a reference. If it then crosses over into being part of the medical record and replaces things like progress notes and treatment sheets, then it becomes an action tool."

How pathways are used at different facilities depends, in part, on the facility’s level of commitment to moving beyond content tools, she adds. "It’s a huge decision, a high-maintenance decision. As soon as you start to try to structure content into action tools, you are tying yourself to a high-maintenance strategy where you have to keep refreshing the content and reworking the format of the action tools; and then ultimately, you’re going to be driven to having to get a computer. It’s an interesting quandary: Are we just going to consider content; or are we going to make a tool where we really have to do something with that content and have roles, expectations, policies, and procedures upon the use of that content with patients?"

Toni Cesta, PhD, RN, director of case management at Saint Vincents Hospital and Medical Center in New York City, says it’s important to take an interdisciplinary approach to pathways, in part, because of the expectations of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in Oakbrook Terrace, IL. "The Joint Commission is looking for interdisciplinary care plans, but also interdisciplinary patient problems and expected outcomes," she says.

Some early tools focused on tasks without including associated outcomes or interdisciplinary patient problems, Cesta explains. They tended to be brief and idiosyncratic to the particular organization at which they were developed. Then a second generation emerged, emphasizing outcomes and interdisciplinary plans. "But now what we’re really looking for are interdisciplinary patient problems and outcomes together," she says. "Also, people are starting to think more about incorporating documentation into the tools themselves with the outcomes."

Newer tools are attempting to incorporate medical interventions with other disciplines’ interventions and expected outcomes, "sort of melding all of that together into one set of problems and outcomes," Cesta adds. "That’s the challenge of what everyone’s struggling to do right now. It’s the third generation, in a way."

Another important development for clinical pathways has been the incorporation of "evidence-based medicine," in the form of best-practice indicators, Zander says. "Doctors like best-practice indicators," she says. "They will talk to you about indicators. They won’t talk to you about paths. But if they sign off on the indicators, you can start building paths from them. You can build order sets."

Physicians’ positive response to evidence-based indicators could represent an opportunity to revive a moribund pathway program, Zander adds.

"It’s a really good chance to revisit them, but don’t go in with a blank piece of paper," she says. "Go in with a set of researched indicators." (For more information on clinical indicators, see the Center for Case Management’s web site at cfmc.com.)

Alamance Regional Medical Center in Burling-ton, NC, has been using clinical pathways since 1994 and recently implemented an automated component. Brenda S. Holland, MSN, RN, CareWays coordinator at Alamance, says the facility’s successful group of pathways has evolved steadily over the years, based on a number of factors, including clinical research, length of stay, and cost factors.

"We’re looking now at JCAHO indicators, and of course, those are integrated into the CareWays," Holland says. "So we try to link those with our cost-analysis system here and look at other hospitals as to how well they’re doing."

Holland is satisfied with the outcomes Alamance has achieved using pathways, most notably its overall length of stay. She adds that pathways can represent "a very good learning experience, and they are very useful when the nurses look at the care plans. One nurse can go from one unit to another unit, just pick it up, and see what needs to be done for the patient. I think they will be even more user-friendly once we get them automated and can get some more concrete data that we can look at other hospitals with."

Alamance may be ahead of the curve in terms of adding automation to its pathway program. In her consulting work, Cesta says she still doesn’t see much computerization of pathways or other case management tools. "Obviously, the Internet is helping us in terms of getting clinical information to put into the tools themselves," she says. "But as far as them being available on-line and in hospitals to use and document against, I have not seen a lot of that. There aren’t that many case management departments I have visited that even have any kind of automated system at all."

Whether your pathways are automated or not, it’s important to have a policy that outlines how frequently you review them, Cesta says. "Usually, it should be annually or biannually that they are reassessed for currency. The literature should be re-reviewed at that time, and the content should be brought up to date if it’s not representing the state of the art at that point in time. People shouldn’t just sit back after they’ve developed these kinds of tools. It really should be an ongoing process — almost a part of your CQI [continuous quality improvement] process."

Such continual updating is important because the clinical literature changes. "The state of the art changes. The medications recommended for particular diagnoses change over time," Cesta says. "So it’s really important that [pathways] are kept up to date because they do represent the organization’s standard of care for the management of that diagnosis or surgical procedure. If they’re not as current as possible, you’re putting yourself in a liability situation should there be a problem. How do you defend a tool that’s out of date?"

How Practice Improves

[At the 2003 Hospital Case Management Conference, to be held April 27-29 in Atlanta, Cesta will present a pre-conference one hour session for case managers: "Integrating Prospective Payment and Managed Care Reimbursement Systems with Case Management" (1 hour), and "The Case Manager in the Hospital Setting: Role Functions and Model Design" (1 hour). Cesta also will present a post-conference session. For more information or to register, call (800) 688-2421.]