A Strategy for the Renovation of a Clinical Pathways Program

Clinical Pathways Programs in Children's Hospitals

BACKGROUND AND OBJECTIVE

Clinical pathways translate best evidence into the local context of a care setting through structured, multidisciplinary care plans. Little is known about clinical pathway programs in pediatric settings. The purpose of this study was to determine the prevalence of clinical pathway programs and describe similarities and differences.

METHODS

We performed a cross-sectional web survey to assess the existence of a clinical pathway program, number, type, and creation or revision of clinical pathways, and its characteristics in the 111 hospitals of the Pediatric Research in Inpatient Settings network.

RESULTS

Eighty-one hospitals responded to the survey (73% response rate). Most hospitals had a clinical pathway program (63%, n = 50 of 80) that was hospital-wide (70%, n = 35 of 50). Freestanding children's (48%, n = 39 of 81), academic (60%, n = 43 of 72), teaching hospitals (96%, n = 78 of 81) made up the largest proportion of survey respondents. There was no funding for nearly half of the programs (n = 21 of 46, 46%). Over a quarter of survey respondents reported no data collected to assess pathway utilization and/or care outcomes (n = 19 of 71, 27%).

CONCLUSIONS

Greater than half of respondents confirmed existence of a program. Freestanding, academic teaching hospitals accounted for the most responses. However, nearly half of surveyed programs were unfunded, and many are unable to measure their pathway outcomes or demonstrate improvement in care. Survey respondents were enthusiastic about participating in a national collaborative on pediatric clinical pathways.

Clinical Pathway Adherence and Missed Diagnostic Opportunities Among Children with Musculoskeletal Infections

INTRODUCTION

Clinical care pathways (CPs) integrate best evidence into the local care delivery context to promote efficiency and patient safety. However, the impact of CPs on diagnostic performance remains poorly understood. The objectives of this study were to evaluate adherence to a musculoskeletal infection (MSKI) diagnostic CP and identify recurrent failure points leading to missed diagnostic opportunities (MDOs).

METHODS

Retrospective chart review was performed from January 2018 to February 2022 for children 6 months to 18 years of age who had an unplanned admission for MSKI after being evaluated and discharged from the pediatric emergency department (PED) for related complaints within the previous 10 days. MDOs were identified using the Revised Safer Dx. Demographic and clinical characteristics of children with and without MDOs were compared using bivariate descriptive statistics. An improvement team reviewed the diagnostic trajectories of MDOs for deviations from the MSKI CP and developed a fishbone diagram to describe contributing factors to CP deviations.

RESULTS

The study identified 21 children with and 13 children without MSKI-associated MDOs. Children with MDOs were more likely to have an initial C-reactive protein value > 2 mg/dL (90.0% vs. 0%, p = 0.01) and returned to care earlier than children without MDOs (median 2.8 days vs. 6.7 days, p = 0.004). Factors contributing to MDOs included failure to obtain screening laboratory tests, misinterpretation of laboratory values, failure to obtain orthopedic consultation, and failure to obtain definitive imaging.

CONCLUSION

Several recurrent deviations from an MSKI diagnostic CP were found to be associated with MDOs. Future quality improvement efforts to improve adherence to this MSKI CP may prevent MDOs.

Use of Google Analytics to Explore Dissemination Activities for an Online CKD Clinical Pathway: A Retrospective Study

Background:

Data on dissemination strategies that generate awareness of clinical pathways for kidney care are limited.

Objective:

This study reports the application of Google Analytics to describe the reach and use of the Chronic Kidney Disease Pathway (CKD-P) using a multi-faceted dissemination strategy.

Design:

The design of this study is a retrospective descriptive study.

Setting:

This study was conducted in Alberta, Canada.

Patients:

Individuals who accessed the CKD-P Web site between November 5, 2014, and May 31, 2019.

Measurements:

Dissemination activities included print, electronic, in-person meetings, and a laboratory prompt. We used Google Analytics over a 5-year period to evaluate the following CKD-P Web site user metrics: number of sessions, pageviews, visit duration, user path, and bounce rate (when an individual visits a single page of the Web site and leaves the Web site without interacting with additional pages).

Methods:

We plotted dissemination activities alongside Web site metrics using control charts and described the data using means and percentages. We performed chi-square test for trends to evaluate year-over-year usage.

Results:

There were 83 294 users, 90 805 sessions, and 231 684 pageviews. The overall bounce rate was 45.7%. Each user had an average of 1.5 sessions and a session duration of 2 minutes and 8 seconds. There was a significant positive trend for total annual users (P = .008), new users (P = .009), number of sessions (P = .006), and pageviews per day (P = .016).

Limitations:

We were unable to confirm if users were primary care providers and if word-of-mouth dissemination among providers/researchers drove people to use the CKD-P.

Conclusions:

Google Analytics was a useful and accessible tool for evaluating CKD-P reach and use trends. It was challenging to identify how individual dissemination activities contributed to CKD-P reach; however, repeated dissemination appeared to play a role in increasing CKD-P use.

Trial registration:

Not applicable—observational study design.

Assessment of Healthcare Professional’s Knowledge, Skills, Motivation, and Commitment to Clinical Pathways Implementation

BACKGROUND: Healthcare providers are facing challenges to deliver qualified and efficient health services in response to the current health system. Clinical pathways (CPs) are a tool to achieve the best clinical outcomes at the lowest cost. The implementation should be supported by healthcare professional’s capacity involved in the process. AIM: The aim of the study was to assess healthcare professionals’ knowledge, skills, motivation, and commitment to clinical pathways (CPs) implementation in Universitas Sumatera Utara (USU) Hospital. METHODS: This cross-sectional study was conducted at USU Hospital with 65 healthcare professionals as participants who consist of 10 specialist doctors, 50 nurses, and 5 pharmacists. These participants were selected using quota sampling and interviewed using a developed and structured questionnaire. This questionnaire was tested for its validity and reliability with r > 0.5 and Cronbach’s Alpha > 0.6. Pearson correlation test with p < 0.05 was used for analyzing the relationship among variables on CPs implementation. RESULTS: The healthcare professionals in USU Hospital had high knowledge, motivation, and commitment, but moderate skills in CPs implementation. There were positive correlations between knowledge and skill (p = 0.039), motivation and skill (p = 0.001), commitment and skill (p = 0.001), and motivation and commitment (p = 0.001) on CPs implementation. CONCLUSION: USU Hospital healthcare professional’s knowledge, motivation, and commitment to CPs implementation were adequate, but their skills were moderate. The motivation is substantially related to the healthcare professional’s commitment to CPs implementation. This study recommended the hospital explore and grow skills in communication, coordination, and affective commitment among individuals, teamwork, and leaders for the sake of willingness to achieve the values or goals of the CP implementation in their organization.

Impact of Education-based HEART Score Pathway on Coronary Computed Tomography Angiography Utilization and Yield in the Emergency Department

OBJECTIVE

There is a growing consensus to reduce unnecessary testing among low-risk chest pain patients. The objective of this study was to evaluate the impact of implementing an education-based HEART score pathway in the emergency department on coronary computed tomography angiography (CCTA) utilization and yield.

METHODS

A retrospective before and after intervention study was conducted at a single site. Adult emergency department patients undergoing CCTA for suspected acute coronary syndrome were included. Primary outcomes were CCTA utilization and yield. Utilization was defined as the percentage of patients evaluated with CCTA and yield was calculated as the percentage of patients with a diagnosis of obstructive coronary artery disease, defined as ≥50% stenosis in any one coronary artery due to atherosclerosis.

RESULTS

1540 patients undergoing CCTAs were included. CCTA utilization before and after were 2.2% [95% confidence interval (CI) 2.0-2.3] and 2.0% (95% CI 1.9-2.2), respectively; mean difference 0.1% (95% CI -0.1 to 0.3; P = 0.21). The mean age was 53 years (SD = 11) and females were 52%. Of 1477 patients included in CCTA yield analysis, patients diagnosed with obstructive coronary artery disease before and after were 15.0% (95% CI 12.6-17.7) and 16.2% (95% CI 13.6-19.1), respectively; mean difference 1.2% (95% CI -2.6 to 5.1; P = 0.53).

CONCLUSIONS

There was no significant change in the CCTA utilization or yield after the implementation of an education-based HEART pathway in a large academic center. Our findings suggest adopting a more comprehensive approach for deploying such evidence-based protocols to increase institutional compliance.

Qualitative Study to Understand Pediatric Hospitalists and Emergency Medicine Physicians' Perspectives of Clinical Pathways

Introduction:

Healthcare costs are rising, and clinical pathways (CPW) are one means to promote high-value care by standardizing care and improving outcomes without compromising cost or quality. However, providers do not always follow CPW, and our understanding of their perceptions is limited. Our objective was to examine pediatric hospital medicine (PHM) and pediatric emergency medicine (PEM) physician perspectives of CPW.

Methods:

We conducted semistructured, in-depth, one-on-one qualitative interviews with PHM and PEM physicians between February 2017 and August 2017. Interviews were audio-recorded, professionally transcribed, and accuracy verified. Using an inductive analytic strategy, we systematically coded the data to identify themes.

Results:

We interviewed 15 PHM and 15 PEM physicians. These providers identified many benefits and limitations of CPW, which positively or negatively impact resource utilization, communication, education of personnel, patients, and families, as well as practice behaviors and attitudes. Perceived benefits included (1) reduction of unnecessary utilization, (2) standardization of care, (3) improved communication, (4) education of oneself and others, and (5) confidence and validation when actions align with CPW. Limitations of CPW were (1) resource utilization for revisions, updates, and dissemination; (2) “tunnel vision” and cognitive biases; (3) loss of autonomy; (4) prescriptive medicine; (5) information overload; (6) pressure to adhere; and (7) guilt if actions do not align with CPW.

Conclusions:

CPW are tools with advantages and disadvantages that are used and viewed differently by providers. Such insight into how physicians perceive CPW may help to optimize hospital improvement work and enhance high-value care.