[Clinical pathways. A useful steering instrument or a limitation for medical treatment?]

Effect of a computerized decision support system on the treatment approach of stage III or IV pressure injury in patients with spinal cord injury: a feasibility study

BACKGROUND

Stage III and IV pressure injuries (PIs) in patients with spinal cord injury (SCI) require complex interdisciplinary and interprofessional treatment approaches that are difficult to implement. Practical aspects, such as information exchange and coordination, remain challenging. We investigated whether a computerized decision support system (CDSS) could increase treatment adherence and improve clinical outcomes and interprofessional collaboration.

METHOD

In this feasibility study, a core team developed the initial treatment process and adapted it based on several discussions with clinical experts and information technologists. The CDSS followed the Basel Decubitus Approach and was used in a clinic specializing in SCI. Thirty patients with SCI admitted for stage III/IV PI between July 2016 and May 2017 were randomly allocated to standard or CDSS-supported care. Between-group differences in treatment adherence, complication rates, length of stay, and costs were analyzed using descriptive statistics. The use of the CDSS and potential barriers and facilitators were evaluated through interprofessional focus groups, transcribed verbatim, and thematically analyzed (30 participants).

RESULTS

No differences in SCI characteristics, comorbidities, or PI characteristics (localization: ischium [number (n) = 19 PI, 63%], sacrum [n = 10 PI, 33%], recurrent PI [n = 21, 70%]) were found between the two groups. Furthermore, no statistically significant differences were observed in treatment adherence, frequency of major (20% vs. 13% between CDSS and control group) and minor (33% vs 27%) complications, and length of stay (98 [±28] vs 81 [±23] days). Healthcare professionals found the CDSS to be helpful for visualizing the treatment process. However, the high workload and difficulties in the information technology processes, such as missing reminders, slow computer performance and data processing, and poor accessibility, hindered the effective implementation of the CDSS.

CONCLUSION

The implementation of the CDSS to support the treatment of stage III/IV PI in patients with SCI was feasible and included definitions of milestones, interventions, and outcomes. However, to assess the impact of the CDSS, a longer observation period is required. Further, the technical difficulties must be addressed, and solid integration of the CDSS into the clinical information system is necessary.

TRIAL REGISTRATION

This quality improvement project received a declaration of no objection from the Ethics Committee of Northwest and Central Switzerland (EKNZ UBE-16/003), and ethical approval was received for the focus groups (EKNZ Req-2017-00860).

[Clinical pathway for total knee arthroplasty. I: Pathway conception and effect on functional quality of results]

PURPOSE

The aim of the current study was to evaluate patient-centred and economic outcomes after introduction of a clinical pathway for total knee arthroplasty.

METHODS

In a prospective trial two sequential cohorts of patients undergoing total knee arthroplasty were recruited. Baseline treatment was surveyed in cohort I and the clinical pathway was developed and evaluated in cohort II. Data from WOMAC, EQ-5D as well as partial cost data were collected. The study design was ratified by the local Independent Ethics Committee.

RESULTS

There was an increase in WOMAC score of 39% for cohort I and 35% for cohort II in 3 months follow-up. Similar results were found for ED-5D with an increase of 30% for cohort I and 25% for cohort II. Partial cost rates could be lowered from 4303 EUR to 419 EUR. Despite this significant cost saving we were not able to improve the ratio of improvement in quality of life to costs.

CONCLUSION

With the aid of a clinical pathway the process for implementation of a total knee arthroplasty was improved and treatment quality assured.

[Clinical pathway "total knee arthroplasty"]

Total knee arthroplasty is a standardized intervention in orthopedic departments. Due to the standard character of the procedure it is predestinated to be performed in a clinical pathway. We developed a clinical pathway for total knee arthroplasty and aim to show the details of it and discuss it together with the current literature. Total knee arthroplasty is a standardized procedure and is therefore predestinated to be included in a clinical pathway. The team consists of different groups which are combined in this path to work together in a very structured and standardized manner. We describe and discuss our clinical pathway for total knee arthroplasty and the initial experiences which are very promising.

[Clinical pathway - conservative back pain treatment]

Back pain is a very common clinical picture. The causes are often not only somatic, which generally has led to a biopsychosocial understanding of this disease. Therefore, it is necessary to employ a multimodal treatment approach to achieve effective and longer-lasting relief. Such a concept requires the cooperation of multiple disciplines in a sophisticated and strongly organized manner. In our clinic we have developed a clinical pathway for conservative back pain treatment that avoids the use of too much time by careful coordination of the therapy elements. It has proven to be a successful tool for the efficient treatment of patients with primarily somatically caused back pain. The following article describes this clinical pathway.