Integrated Care Pathways: a tool for implementing change and extending roles in clinical practice

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Integrated Care Pathways a tool for
implementing change and extending roles in
clinical practice
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Central Middlesex Pathways

• Began 1991
• 100 AE, 85 surgery, 40 medicine, 35
  acute outreach
• assessment and management protocols for
  emergency and elective care
• multidisciplinary notes hospital wide
• moving into outpatients

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Integrated Care Pathway Definition

• Determines locally agreed MDT practice
• Based on guidelines and evidence
• For a specific client group
• Forms all or part of the record of care
• Facilitates the evaluation of care given
• Supports continuous quality improvement
• National Pathways Association

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Principles of ICP development

• focus care around the patient
• simplify process
• incorporate evidence
• streamline documentation
• highlight key variances
• delivered by staff with extended skills

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Process of Protocol Development

• Involve all stakeholders
• Strong facilitation
• Start simple
• Particular to generic
• Review and modify
• Ownership

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Key Questions

• What - is the most appropriate care?
• When - is the most appropriate time?
• Who - is the most appropriate person?
• Where - is the most appropriate location?

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Embed Audit in Every Day Practice

• Clear milestones identified
• evidence based standards
• critical steps in the process
• areas of great variation
• priorities for the organisation

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Variance from Milestones

• charted on the patient record stating the reason
  for variance
• provides a method of individualisation
• allows the protocol to be dynamic not static
• alerts a need for action
• evaluation becomes an integral part of care

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Asthma Milestones
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Pathway manager

• Nurse or physio
• encourages use
• collates variance
• stimulates maintenance

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How to start

• top level support
• process redesign expertise
• expert facilitation
• group willing to change
• stimulus or wish for change
• local ownership

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Pathways promote change in practice
Anti-D in Rhesus -ve Women

• Received Anti-D 1996 1998
• 28 Weeks 65 96
• 36 Weeks 77 100
• Post natal 69 100
• RCOG Review No 97/02 - 10 failure rate to
  administer

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Pathways promote guideline implementation and
effective interventions

• 
  Myocardial Infarctions discharged on
  treatment when not contraindicated .
  Aspirin 1994 89
• 1998 100
• Beta blockers 1994 78
• 1998 96

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Operated Within 24 Hours of Presentation with
Miscarriage
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Variation In CareAsthma 1998
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Variation In CareAsthma 1999
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ICPs support extensions of roles

• Discontinuing IVIs and removing venflons
• Catheter removal
• anaesthetic preassessment
• discharge from hospital

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ICPs support role extension for physiotherapists
and nurses

• measuring and interpreting blood gases
• instituting nasal ventilation
• therapeutic bronchoscopy

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A E minors nurse practitioners

• see and discharge 40 of attenders
• order and read x-rays
• prescribe analgesics, antibiotics
• refer direct to specialist clinics
• now developing majors practitioner role

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ICPs support generic acute outreach team

• Multidisciplinary team
• acute care at home
• continuation of acute and elective pathways
• prevention of admission
• low readmission rate
• high patient satisfaction
• 2 wards work for 1 wards funding

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Key Success Factors

• top down commitment
• bottom up development
• facilitating support department
• nursing and medical leadership
• case manager role in maintenance
• training modules

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Benefits

• predictable, pt focused, high quality care
• team building / communication
• educational tool
• concurrent clinical audit data
• reductions in length of stay and waste
• accountability
• tool for clinical governance

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Conclusion

• Pathways are a powerful mechanism for
• supporting change in the process of care
• embedding evidence and audit
• supporting extension in clinical roles
• delivering clinical governance

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E-mail address

• john.riordan_at_nwlh.nhs.uk