Outlining integrated care pathways

ICP demonstrates a sound mechanism for quality improvement, and if developed, can be an operational asset to the organisation, writes Sheenu Jhawar

Integrated care pathways are the latest advancement within the purview of quality improvement initiatives in the western, and some parts of the eastern world. By definition, an Integrated Care Pathway (ICP) is a multi-disciplinary outline of anticipated care, placed in an appropriate time-frame, to help a patient with specific condition or set of symptoms move progressively through a clinical experience to positive outcomes.

Translated simply, an ‘integrated care pathway’ is just what the title suggests- it is a document that charts the pathway of care for a patient afflicted with a particular disease or set of diseases, thereby integrating the care to be received from all members of the clinical and non-clinical team.

In a way, it replaces the conventional medical record. It is not only a novel form of documentation, but also serves as a tool to assist the quality of clinical processes, by promoting evidence based medicine and auditing its effectiveness in a constantly changing clinical environment.

As suggested, ICPs essentially plot out the optimal anticipated sequence and timing of interventions, by physicians, nurses, and other professionals for a particular diagnosis or procedure. This anticipated sequence derives from ‘evidence based practice’ or ‘clinical guidelines’ which can be described as the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.

A guideline can also be defined as ‘an indicator of a course of action that should be followed’. A pathway is also defined as ‘the route to be taken’. As is apparent, both sound like, they mean the same thing. So, how are they different and what relationship exists between them?

To delve deeper, clinical guidelines are systematically developed statements, which assist professionals to make decisions about appropriate healthcare for specific clinical circumstances. They are normally produced as national documents with wide ranging implementation, and can therefore overlook local issues.

Pathways are derived from these guidelines, but are customised to the organisation in which they will be used. They act as prompts for the care which will be provided. They are multi-disciplinary in nature, combining both the clinical and non-clinical teams in service delivery. Moreover, they are timely sequences, and thus they not only outline what should be done but also what will follow in the continuation of care and who will deliver what, starting from the admission process until discharge arrangements.

Pathways also derive inputs locally from multi-disciplinary teams in outlining the course of care. This involves varied issues like the local socio-economic culture, patient expectations, payment methods et cetera. Having discussed the concept of ICPs, let us look at what happens next.

Against this anticipated sequence, the team documents the actual care provided to the patient. The documentation is process based, ‘tasks to be done’, and outcome based that is ‘outcomes to be achieved’. While the ICP acts as the template of care to be provided, it is not intended to compromise clinical judgement. The members of the clinical team can deviate from the pathway if there is a valid reason for doing so.

The pathway asks each clinician to determine whether each defined intervention is appropriate for a given patient, thereby promoting clinical freedom based on the needs of the individual. Thus there might be several variations from the anticipated sequence of care. A subsequent analysis of these variations provides invaluable input, not only for the prospective patient treatment, thus minimising clinical risks, but also if the pathway itself needs to be modified to incorporate the changes in the long run.

ICPs are dynamic documents and change is to be expected as new evidence, clinical guidelines and treatment patterns emerge. Even though, steps to manage ’common variations’ are incorporated within the main ICP document, yet this list cannot be exhaustive. Sometimes it might be pertinent to deviate from one pathway of care and go to another in case of too many variations owing to the patient suffering from a set of complications.

For example in the case of a patient suffering form fracture neck of femur, as well as a history of chronic heart problem, there may be a need to consult the two different pathways for both conditions. In this case, simple variance documentation is inapt. Instead, by combining the different pathways, and multi-disciplinary teams, ’integrated care’ pathway is achieved.

Developing ICPs is a very complex and time consuming phenomenon. It can be very difficult, considered, that given any particular set of symptoms, no patient is clinically identical, nor responds in the same way to a treatment. Besides the guidelines also have to be modified and adapted locally to suit the local choices (given that the adaptations are evidence based).

All the clinicians, and other members have to be taken on board with the pathway, which in itself is a daunting process. A question that may arise is, if that is so, why undertake this task at all.

The benefits of ICPs overshadow the difficulties. There are reports of a number of benefits associated with the introduction of integrated care pathways into clinical practice. These include reduction in the length of stay in hospital, reduction of costs in patient care, improved patient outcome, improved quality of life, reduced complications, increased patient satisfaction with the service, improved communication between staff, and reduction in time spent by health staff in carrying out paperwork.

Furthermore, Integrated care pathways

• Facilitate the amalgamation of local protocols with universal clinical guidelines in a easy to follow format
• Facilitate shared practice with minimal variations
• Minimise delays, maximise quality of care
• Provide co-ordinated and consistent care
• By providing explicit standards, help reduce unnecessary variations in patient care, eg delimiting the diagnostic tools required
• Provide a visual representation of the care plan
• Improve communication between the clinical team, as the holistic care given is documented on a single record
• Care pathway can be costed to achieve the most cost effective way of treatment- in conjunction with the best practice norms
• Clinical audit of the variances can be undertaken to determine their impact on the outcomes of care, and thus improvise the existent pathways

ICPs can also be invaluable in minimising clinical risk and thereby litigation since they incorporate complete documentation. As this is done against the current best practice norms, and ’accounted for’ variations, the hospital and its staff base are well protected too. Integrated care pathways demonstrate a sound mechanism for quality improvement, and if developed, can be an operational asset to the organisation.

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