Despite advances in pharmaceuticals and technology, heart failure (HF) continues to be a large health-related economic burden. Numerous programs and systems have been implemented over the years in an attempt to decrease the cost and length of hospital stay involved in the care of patients with HF. Disease-based guidelines have helped to incorporate evidence-based practices into the care of HF patients. An instrument that has been put into practice to improve efficiency in using those guidelines is clinical-based pathways that define and organize the processes involved in patient care management.1–5

CLINICAL MANAGEMENT PATHWAYS

development in a timely manner.6 The medical field began using clinical management pathways in the 1980s when nurses developed them to structure patient care processes within a designated timeframe.7 This was in response to the government’s prospective payment system of diagnostic related grouping (DRG), which was implemented in 1983. With DRGs, payment for hospitalization is limited to a predetermined length of stay (LOS) based on the patient’s diagnosis. This has led to an increased emphasis on containing costs in health care without sacrificing the quality of patient care.8 HF disease management programs, multidisciplinary clinics, case management, observation units, patient telemanagement, and clinical pathways are multiple strategies that have been developed in attempts to reduce HF costs.9

Practice guidelines originated in the 1950s and Clinical management pathways, also known as were used by the industry to coordinate project critical pathways, caremaps, and integrated care pathways, are designed to be used in conjunction with the present standard of care as a tool to decrease variation in outcomes and maintain care within a specified LOS. They facilitate clinical interventions by guiding the patient’s hospitalization through a sequence of steps toward a desired outcome. Clinical pathways are generally applied to high-volume diagnoses or procedures and those with longer LOS and mortality, such as HF, myocardial infarction, coronary artery bypass grafting, hip surgery, or vascular surgery. These procedures tend to have a predictable course of events during the hospitalization and marked variation in care.10 Pathways are designed to be integrated management plans that improve clinical outcomes, resource usage, coordination and quality of care, and discharge process. With the use of clinical pathways, clinical performance variation is decreased and hospital LOS and related costs are reduced.8,11,12 The content of clinical pathways designates the major interventions and patient outcomes, and is based on expert guidelines, current standards, and published clinical trials.13

CLINICAL PATHWAY DEVELOPMENT

Clinical pathway development has historically been initiated by nursing, but in many institutions this led to lack of physician commitment.10 Incorporating a multidisciplinary team to evaluate current practice and collect clinical data for development of the clinical pathway is the best way to begin the process and encourage involvement from nonnursing disciplines (Fig. 19-1).14 Traditionally, a physician leader or “champion” heads the committee, contributing leadership and clinical expertise. The team may consist of physicians (cardiologists, emergency room physicians, internists), nurses, nurse practitioners, administrators, quality improvement (QI) committee members, case managers, and members from social services, nutrition, cardiac rehabilitation, respiratory therapy, and pharmacy.

A retrospective chart review of financial data, LOS, readmission data, mortality, and direct costs for HF admissions will more than likely illuminate the need for a clinical pathway to guide inpatient HF management within a designated timeframe. A literature review of current data on HF pathways and standards of care for HF provides the groundwork for developing a template. Clinical goals must be defined before developing the clinical pathway. The committee should set objectives and goals to include clinical outcomes measurement, Joint Commission on Accreditation of Healthcare Organizations (JCAHO) compliance, patient satisfaction, and clinical pathway monitoring.11 The goals must be translated into elements of care in a sequence of events and expected patient progress over a designated timeframe.12 To accomplish this, frequent team meetings are required. The format for a clinical pathway may range from a simple checklist to detailed steps for the process of care. Standardized admission and discharge orders may coincide with the pathway and provide a solid foundation to support the interventions on the pathway (App. 19-A).

Prior to implementation of the pathway, educational in-services on content of the pathway and QI concepts are provided to those involved with the care of HF patients. The physician leader presents the pathway to appropriate physicians at medical grand rounds and/or through memos. An HF nurse or advanced practice nurse in-services the inpatient staff, and patients receive a copy of their own pathway. The nursing staff provides education on the pathway to the patient and their family. Pathways should identify an accountable person to ensure that clinical outcomes are met in a timely fashion.15

Multidisciplinary roles within the pathway must be clearly defined as to those responsible for documenting information, analyzing data, and educating the patient and family. Variances are the patient outcomes or staff actions that do not meet the expectation of the pathway or do not occur within the designated timeframe. These variances should be tracked throughout the process of using and developing the pathway, in order to define areas that need improvement. Piloting of the pathway is necessary for analysis, by the HF nurses. Printed educational materials a quarterly basis.13 A chart audit may also be are given to the patient and their family, and other used as part of the QI process to ensure that HF audiovisual learning tools may be used, such as patient care adheres to the clinical pathway.16 videotapes, heart models, or computer web-Identification of variances and evaluation of based programs. A longer, more detailed educa-clinical indicators can lead to improvement in tion session for the patient and family may take the process of managing patient care (Table 19-1). place in the outpatient setting. Consults along the The pathway content is updated by yearly evalpathway are specific to the patient’s needs, but uation of patient variances and LOS, as well as may include cardiac rehabilitation, nutrition, and reviewing current clinical practice for the spesmoking cessation. Diagnostic tests are specified cific diagnosis or procedure. as to when they should be performed during the hospitalization. HF medications may be listed on the pathway as outlined in national guidelines for BARRIERS TO CLINICAL HF care. Dietary guidelines and activity level PATHWAYS advance as appropriate along the pathway.

Comprehensive hospital-specific perfor-Some health-care professionals feel that clinical mance and benchmarking reports about pathways are time-consuming and “cookbook processes and outcomes of care are gathered by medicine,” applicable to only the “ideal,” not the the QI committee and presented to the team on complex patient. One large barrier to using a clinical pathway is a lack of voluntary participation among key individuals. The additional paperwork involved in tracking outcomes and data regarding use of the pathway is seen as a burden to some health-care workers, but these documents may be used as a QI tool, and may serve to fulfill regulatory requirements. The paper format may affect the ability to effectively evaluate variances, link clinical processes with patient outcomes, and see real-time benefits.17 Absence of documentation can lead to pathway discontinuity and inaccurate data. Continued education, frequent communication, and sharing of outcome data encourage participation with the pathway. Cost savings should be evaluated, and the information shared with the multidisciplinary team and hospital administrators. Automated pathways may be created to coincide with electronic medical record charting and to query outcome data in a more timely fashion.

BENEFITS OF A HEART FAILURE CLINICAL PATHWAY

Pathways have been shown to decrease LOS and resource consumption.8 They may help to define the patient care roles and responsibilities of health-care professionals, improve integration and communication in the health-care system, develop learning processes within an organization, reduce inpatient mortality, and improve patient clinical outcomes. They support risk management, utilization management, and the evaluation that is necessary for growth and improvement in any setting. Pathways can assist with documentation and validation of the desired outcomes.12

Clinical pathways address the complex needs of HF patients and are designed to increase the use of appropriate medications, consults, and education. Consumers may find clinical management pathways attractive due to better service, improved communication from providers, and superior outcomes. This information can be used as a marketing tool by health-care institutions. Increased patient satisfaction is related to a decrease in medical lawsuits, and in most cases, a patient’s decision to sue results from weak attitudes or inferior communication skills by providers.18

Goals to be achieved by using a clinical pathway include decreasing, LOS, readmissions, and emergency rooms visits; documenting left ventricular dysfunction; prescribing appropriate medications; initiating nutrition consults; and scheduling a follow-up appointment with the HF team or the patient’s health-care provider 1–2 weeks following discharge. Periodic review of pathways allows an opportunity to incorporate new advances in medical care and may provide a source of continuous medical education for providers.7

OUTCOMES RELATED TO CLINICAL PATHWAYS

Preventing medical errors contributes to cost savings in health care and enhances patient outcomes. It is estimated that between 44,000 and 98,000 patients die annually due to medical errors in the United States.19 Reducing variations in care practices by standardizing the patient’s clinical path may be an effective tool to reduce the probability of medical errors.
The high cost of health care has necessitated the adoption of cost-effective approaches in patient management. As an interdisciplinary instrument, clinical pathways move the patient care process through a sequence of clinical interventions toward desired outcomes (Table 19-2). These outcomes may include cost-efficient care and reduced variations in patient management.