Clinical pathway

A clinical care pathway (English: clinical pathway ) is a descriptive model as a pattern for a flow chart for performing a medical treatment. The mode for the order may be temporal, causal or simply final. This schedule can be designed as a decision tree as well as a simple daily schedule.

Clinical pathways are - if possible - developed in consideration of existing clinical practice guidelines as a pattern. They usually contain quality indicators, with their metric repeated use in clinical practice can be examined as an instance in an individual case.

• 3.1 The planning instrument as type
• 3.2 The clinical pathways as a tool of medical methodology
• 3.3 The clinical pathways as a tool for cost planning

• 4.1 Standard procedures

• 7.1 Target Description
• 7.2 lanes
• 7.3 linearity

Historical

The path concept was first used in 1957 by the American Dupont company to improve product quality in a development process.

One of the first reactions in the medical practice in 1985 in the United States at the Boston New England Medical Center Hospital.

Common use is the Pfadkonzeopt rather in the care of the case in the general social economy.

Clinical treatment pathways in clinical routine

The clinical pathways as a tool for quality assurance

The treatment path is designed occupational groups - across departments and partially - cross, with the aim of a minimum outcome and quality of care, defined using the necessary and available resources and with defining the tasks and the implementation and outcome responsibilities. The treatment path provides the setting used in the treatment process, while supporting the treatment and related documentation and allows the annotation. Deviations from the norm are noted for the purpose of continued evaluation and improvement ( charting by exception ).

The clinical pathways as a tool of workflow control

For the control in routine clinical practice, a clinical treatment path is created as a pattern in the rule, and then instantiated for the treatment in individual cases for each patient as an individual schedule. With the beginning of the process each action plan in advance deadlines and resources are allocated, resulting from the standardized minimum run times for the individual actions (eg in the DRG system ). Which of the alternative actions contained in the schedule actually take place, the attending physician will decide the further course.

The control instrument with time constraint

If the clinical treatment path instantiated as a schedule for the individual case, it may be tied to time for settlement provided the start and expected duration. Only then the controller can link the clinical care pathway with event messages from the clinical sequence, which are determined by monitoring or by recognition in context.

Clinical pathways as a planning tool in clinical routine

The planning tool as type

Without instantiation for a patient, the clinical treatment path is a type or pattern. This type is used to abstract planning a treatment, not as an instrument to control follower.

For the control of the individual treatment of a patient or case (English case) must this guy be instantiated resources (personnel, equipment, space ) and the identity of the patient (case ID) are concatenated with the identifiers of the participants.

The clinical pathways as a tool of medical methodology

The clinical treatment paths can map the structure of a medical guideline and thereby integrate individual methods of diagnostic assessment, diagnosis, invasive procedures or minimally invasive procedures, medication and other therapies. Because of the structure a clinical care pathway can be used as an instrument of work planning for a team. This plan is developed with the progress of treatment. For this, the model of a daily routine plan has been established. This a clear workflow control for the participating teams is possible.

The clinical pathways as a tool for cost planning

The clinical treatment paths can provide the framework of a cost accounting or contribution margin accounting in the hospital. Due to the structured documentation of planned treatments, surgeries, medications, gifts, visits, etc., a clinical care pathway can be further developed as an instrument of standard costing. For this, the model of a daily routine plan has been established. This a clear cost analysis for defined cases groups is possible.

Clinical benefit paths

The benefits of clinical pathways has been shown in several systematic reviews. A systematic review of outcome measure of efficacy was consistently show positive effects of clinical pathways on the outcome criteria quality of care, safety and resource consumption. A Cochrane review from 2010 showed that fewer complications, shorter hospital stays and lower costs are achieved through the use of paths. A recent study from Germany came to the conclusion that the implementation of paths a positive effect on process quality, but it is questionable whether benefits and costs in a favorable ratio. See Critical voices in treatment pathways " fads " which can be understood in the context of increasing commodification and " industrialization " of medicine.

Standard procedures

Standardized Procedures ( SOP, Eng. Standard operating procedures ) are usually closer version of a clinical care pathway in which with a specific objective, each branch was despite medical grounds eliminated. In this case, there is no relation to any international standard or to any industrial standard for the content of the action. The recommended, for example as part of the authorization procedure. There the identical repetition of a procedure is in a cohort is a prerequisite for the systematic separation of effects in the subsequent evaluation of the results. For the medical value of an action, such a restriction is not oriented without case-specific decisions on the outcome for the patient, but on the validity of the study results. Another application is the procedure for a triage under the restriction of the availability of resources.

Examples of application

Clinical pathways are created in a variety of objectives. No two paths several authors resemble each other, as the reception of the authors will result in the available methodology, based on evidence or consensus based on various characteristics. In addition, the objective of the application of clinical pathways is determinative. There are

• Clinical pathways for preliminary costing
• Clinical pathways for the workflow in the organization of work
• Clinical pathways for medical documentation
• Clinical pathways for the support of the power detection

In general, the well-known hospital information systems support the respective objectives only weak. A mobile solution that the employee follows in -patient treatment for patients is not yet known. Solutions for ambulatory care, however, are already well spread.

In a meta-analysis of 1,094 English-language studies of clinical pathways were evaluated. Recognizable lacks both the meta-study as many of the cited studies, a clear structure of goal orientation and characteristics of the solution. Amazing classifying is " only 15 studies " randomized controlled trial designs as " high needs " fulfilling. In fact, studies are obvious for randomization with medical issues, while for deterministic aspects of improved labor organization randomization is not scientifically justified.

Applications to control the clinical routine in the division of labor

A well-known example in ambulatory care is the solution factis from the checkpoint suite of Lohmann & Birkner, Berlin or the workflow tasks from the GKV suite of Atacama GmbH, Bremen.

Another example are the emergency medStandards standards for the entire spectrum of internal medicine and surgery in German-speaking and English-speaking emergency department. Also there is the CheckMe! Hospital standards which path templates for gynecology to include local adaptation.

An application with similar support in a hospital information system was introduced in the Surgical Clinic I of Ingolstadt Hospital for cholecystectomy.

Criticism

The clinical path alone does not a reflection of a treatment plan. He serialized priority chores during treatment. A concept for such contact following to update embedding can not be seen in the literature.

Target Description

The pure flow orientation can be a beginning and sections defined status and objective description missing for

• Symptoms and findings
• Expected diagnostic
• Therapy target
• Outcome

There is a need of a surrounding frame that determines the selection of the path and its composition. Without this framework, the objective for the treatment in the clinical path remains undetermined.

Swimming lanes

Parallelizing various branches, such as histology, serology, and relocating in other functional areas is only transparent when the clinical path according to the concept of " lanes " ( swim lanes ) is structured in several branches.

Linearity

Most clinical pathways are modeled strictly linear. which avoids Mehrdeutigkeitten, but does not show the re- entry into a loop in the iterative procedure.