Critical pathway

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In health care, critical pathways are "schedules of medical and nursing procedures, including diagnostic tests, medications, and consultations designed to effect an efficient, coordinated program of treatment."[1] They have been used as the core logic of clinical decision support systems, [2] and to structure quality improvement reviews. [3]

At a detailed level, there is a similarity between recognition of medical critical procedures, and the life-critical procedures, standardized by checklists, of human factors engineering and specific domains such as aviation safety. These disciplines recognize the problems of information overload and situational awareness. Emergency medicine relies significantly on standardized protocols, often by checklist, for situations requiring quick response under pressure, such as cardiac arrest and coma. Basic support of cardiac or respiratory arrest is quite standardized, and, as diagnostic information such as electrocardiograms become available, increasingly specific pathways are selected. For example, once it is known that a patient is in ventricular fibrillation, the pathway will be markedly different than that for asystole.

Measuring adherence is difficult.[4]

Effectiveness

"Clinical pathways are associated with reduced in-hospital complications and improved documentation without negatively impacting on length of stay and hospital costs." according to a meta-analysis by the Cochrane Collaboration.[5]

As examples, a critical pathway may improve the outcomes of pneumonia[6][7], chest pain[8][9], and maybe stroke[10].

References

  1. Anonymous (2015), Critical pathway (English). Medical Subject Headings. U.S. National Library of Medicine.
  2. Morris AH (2000). "Developing and implementing computerized protocols for standardization of clinical decisions.". Ann Intern Med 132 (5): 373-83. PMID 10691588.
  3. Pearson SD, Goulart-Fisher D, Lee TH (1995). "Critical pathways as a strategy for improving care: problems and potential.". Ann Intern Med 123 (12): 941-8. PMID 7486490.
  4. van de Klundert J, Gorissen P, Zeemering S (2010). "Measuring clinical pathway adherence.". J Biomed Inform 43 (6): 861-72. DOI:10.1016/j.jbi.2010.08.002. PMID 20696277. Research Blogging.
  5. Rotter T, Kinsman L, James E, Machotta A, Gothe H, Willis J et al. (2010). "Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs.". Cochrane Database Syst Rev (3): CD006632. DOI:10.1002/14651858.CD006632.pub2. PMID 20238347. Research Blogging. Review in: Ann Intern Med. 2010 Aug 17;153(4):JC2-12
  6. Carratalà J, Garcia-Vidal C, Ortega L, Fernández-Sabé N, Clemente M, Albero G et al. (2012). "Effect of a 3-Step Critical Pathway to Reduce Duration of Intravenous Antibiotic Therapy and Length of Stay in Community-Acquired Pneumonia: A Randomized Controlled TrialA 3-Step Critical Pathway for CAP.". Arch Intern Med 172 (12): 922-8. DOI:10.1001/archinternmed.2012.1690. PMID 22732747. Research Blogging.
  7. Marrie TJ, Lau CY, Wheeler SL, Wong CJ, Vandervoort MK, Feagan BG (2000). "A controlled trial of a critical pathway for treatment of community-acquired pneumonia. CAPITAL Study Investigators. Community-Acquired Pneumonia Intervention Trial Assessing Levofloxacin". JAMA 283 (6): 749-55. PMID 10683053[e]
  8. Reilly BM, Evans AT, Schaider JJ, Das K, Calvin JE, Moran LA et al. (2002). "Impact of a clinical decision rule on hospital triage of patients with suspected acute cardiac ischemia in the emergency department.". JAMA 288 (3): 342-50. PMID 12117399.
  9. Nichol G, Walls R, Goldman L, Pearson S, Hartley LH, Antman E et al. (1997). "A critical pathway for management of patients with acute chest pain who are at low risk for myocardial ischemia: recommendations and potential impact.". Ann Intern Med 127 (11): 996-1005. PMID 9412306.
  10. Kwan J, Sandercock P (2004). "In-hospital care pathways for stroke.". Cochrane Database Syst Rev (4): CD002924. DOI:10.1002/14651858.CD002924.pub2. PMID 15495038. Research Blogging.