Clinical treatment path

A clinical pathway ( engl .: clinical pathway ) is a description model as a pattern for a schedule for carrying out a medical treatment . The mode for the order can be temporal , causal or simply final . This schedule can be designed as a decision tree but also as a simple daily schedule.

Clinical treatment pathways are developed - if possible - taking into account existing medical guidelines as templates. They usually contain quality indicators with the metrics of which repeated application in clinical practice as an instance can be checked in individual cases.

Historical

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

One of the first implementations in medical practice occurred in 1985 in the USA at the Boston New England Medical Center Hospital.

The path concept is more generally used in the care of individual cases in the general social economy.

Clinical treatment pathways in routine clinical practice

The clinical treatment pathways as an instrument of quality assurance

The treatment path is designed across professional groups and sometimes across departments with the aim of achieving a minimum outcome and adequate treatment quality , defined use of the necessary and available resources, as well as defining the tasks and responsibilities for implementation and results. The treatment path provides the specification for controlling the treatment process based on the division of labor, at the same time supports the documentation accompanying the treatment and allows comments. Deviations from the norm are noted for the purpose of continued evaluation and improvement ( charting by exception ).

The clinical treatment pathways as an instrument of workflow control

For the control in the clinical routine, a clinical treatment path is usually created as a pattern and then instantiated as an individual flow plan for the treatment in each individual case for the respective patient. At the beginning of the process, planned dates and resources are assigned to the individual campaigns in advance, which result from the standardized minimum duration for the individual campaigns (e.g. in the DRG system). The attending physician decides in the further course of the process which of the alternative actions contained in the schedule actually take place.

The control instrument with time constraints

Once the clinical treatment path has been instantiated as a schedule for the individual case, it can be tied to time settings for the intended beginning and expected duration. Only then can the control link the clinical treatment pathway with event reports from the clinical process that are determined by monitoring or by recording in context.

Clinical treatment pathways as a planning tool in clinical routine

The planning instrument as a type

Without instantiation to a patient, the clinical pathway is a type or pattern. This type is used for the abstract planning of a treatment, not as an instance for concurrent control.

For the control of the individual treatment of a patient or case, this type must be instantiated with the identifiers of the participants, the physical resources (staff, device, room) and the identity of the patient (case ID).

The clinical treatment pathways as an instrument of medical methodology

The clinical treatment paths can the framework of a medical guideline mapped while individual methods of diagnostic assessment , the diagnosis , the invasive procedures or minimally invasive surgery , the medication and other therapies involve. The structured design a clinical care pathway can be used as an instrument of work planning are used for a team. This plan will evolve as treatment progresses. The model of a daily schedule has been established for this. This enables clear workflow control for the teams involved.

The clinical treatment pathways as an instrument of cost planning

The clinical treatment pathways can provide the framework for cost unit accounting or contribution margin accounting in the hospital . With the structured documentation of planned treatments, operations, medication, stays, etc., a clinical treatment path can be further developed as an instrument for budgeting . The model of a daily schedule has been established for this. This enables a clear cost analysis for defined case groups.

Leverage clinical pathways

The utility of clinical pathways has been demonstrated in several systematic reviews. A systematic review to measure efficacy results showed consistently positive effects of clinical pathways on the outcome criteria of care quality, safety and resource consumption. A Cochrane review from 2010 showed that fewer complications, shorter lay times and lower costs can be achieved through the use of pathways. A current study from Germany comes to the result that the implementation of paths has a positive effect on the process quality, but it is questionable whether the cost and benefit are in a favorable ratio. Critical voices see “fads” in treatment pathways, which can be understood in the context of increasing economization and “industrialization” of medicine.

Standard procedures

Standardized procedures (SOP, English Standard Operating Procedures ) are usually a narrower version of a clinical treatment path in which, with a specific objective, every branch has been eliminated regardless of medical justification. There is no reference to any international or industrial standard for the content of the procedure. This is recommended, for example, in the context of approval procedures. There, the identical repetition of a procedure in a cohort is a prerequisite for the systematic separation of effects in the subsequent evaluation of the results. For the medical value of a procedure, such a restriction is not based on the outcome for the patient, without case-specific decisions , but on the validity of the study results. Another use case is the procedure for triage while restricting the availability of resources .

Examples of application

Clinical pathways are created with a variety of objectives. No two paths of several authors are alike, since the authors' reception of the available methodology on the basis of evidence or consensus will lead to different manifestations. In addition, the objective of the application of the clinical pathways is decisive. So there is

• Clinical Pathways for Estimation
• Clinical paths for the workflows in the work organization
• Clinical Paths for Medical Documentation
• Clinical Pathways to Support Service Recording

As a rule, the known hospital information systems support the respective objectives only weakly. A mobile solution that follows the employee to the patient in inpatient treatment is not yet known. Solutions for outpatient care, on the other hand, are already well established.

In a meta-study, 1,094 English-language studies on clinical pathways were evaluated. It can be seen that both the meta-study and many of the studies cited lack a clear structure of goal orientation and characteristics of the solution. The classification of “only 15 studies” of randomized controlled study designs as fulfilling “high requirements” is astonishing. In fact, studies with a medical topic make sense for randomization, while randomization cannot be scientifically justified for deterministic aspects of improved work organization.

Applications to control clinical routine in division of labor

A well-known example in outpatient care is the solution component factis from the Checkpoint Suite from Lohmann & Birkner, Berlin or the task workflow from the GKV Suite from Atacama GmbH, Bremen.

Another example is the emergency standards medStandards for the entire spectrum of internal medicine and surgery in German-speaking and English-speaking emergency wards. There is also the CheckMe! Clinical standards, which contain path templates for gynecology for local adaptation.

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

criticism

The clinical path alone does not represent a treatment plan. It primarily serializes activities during treatment. A concept for such embedding, which is to be continuously updated, cannot be identified in the literature.

Goal description

The pure process orientation lacks an initially and sectionally defined status and target description for

• Symptoms and findings
• expected diagnosis
• Therapy goal
• Outcome

A surrounding framework is required, which determines the choice of the path and its composition. Without this framework, the objective for treatment in the clinical path remains indeterminate.

Customization

In the type model of a clinical pathway, there is no individual cut for the individual case. This must be done in a case-specific instantiation step, which means that the clinical path has to be adjusted again for each individual case. No implementations are known for this, for example in a workflow engine of an established clinic information system.

Division of labor

The commissioning of medical or nursing services according to a clinical path must organize the allocation of the tasks to the various roles or qualifications. In publications on the model approach, the division of a work-sharing process into serially or cooperatively working roles is not addressed.

Swimming lanes

The parallelization of different branches, such as histology, serology, and the relocation to other functional areas only becomes transparent when the clinical path is structured in several parallel branches according to the concept of " swim lanes " .

Linearity

Most clinical paths are modeled strictly linear. This avoids ambiguity, but does not show the re-entry into a loop with an iterative approach.

literature

• PC Dykes: Design and Implementation of Interdisciplinary Care Pathways - An Overview. In: PC Dykes, K. Wheeler (Ed.): Critical Pathways - Interdisciplinary Care Paths . Bern 2002.
• Eversmeyer / Hörtemöller: [1] The treatment path in the G-DRG system. Effects of the introduction of a treatment pathway as part of cross-sector patient management on patients and employees, illustrated using the example of benign prostatic hyperplasia , dissertation University of Osnabrück 2018
• M. Greiling, M. Hessel, K. Berger: Path management in the hospital . Stuttgart 2004.
• M. Greiling, J. Mormann, R. Westerfeld: Controlling clinical pathways . Kulmbach 2003.
• Patrick Heinrich: Development and evaluation of IT-supported clinical treatment pathways . Dissertation, University of Erlangen 2009.
• HA Kahla-Witzsch, T. Geisinger: Clinical Pathways in Hospital Practice . Stuttgart 2004.
• C. Weßel: Treatment Pathways as Quality Management Instruments. Dissertation, University of Basel 1999.

Individual evidence

1. ^ Definition according to Greiling. ( Memento of September 29, 2007 in the Internet Archive ) Medical controlling of the University Hospital Münster
2. ↑ T Geradi: A regional hospital association's approach to clinical pathway development . In: J Healthc Qual , 1994, 16, pp. 10-14.
3. ↑ M. Noll-Hussong: [Development of an Internet-based clinical pathway exemplified by the fibromyalgia syndrome]. In: pain . 2012 Apr, 26 (2), pp. 123-130.
4. ↑ Systematic review to measure effectiveness results . (PDF; 511 kB) Final report. HTA project report, 16th Ludwig Boltzmann Society, Vienna 2008.
5. ↑ Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs . Cochrane Database of Systematic Reviews 2010
6. ↑ Perioperative quality of care is modulated by process management with clinical pathways . PMID 21706138
7. ↑ E Mouhsine, M Wettstein, G Echenmoser et al .: [Clinical pathway in traumatology, a fashion or need?] In Rev Med Suisse , 6, 2010, pp 2438-2442.
8. ↑ P Hartzband, J Groopman: The new language of medicine . In: N Engl J Med , 365, 2011, pp. 1372-1373.
9. ↑ C Koitka et al .: Outcome measurement of clinical treatment pathways in international studies: a systematic literature review .
10. ↑ Checkpoint Suite ( Memento of the original dated December 10, 2014 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. (PDF) 
11. ↑ Task workflow from the GKV Suite ( Memento of the original from March 4, 2016 in the Internet Archive ) Info: The archive link was automatically inserted and not yet checked. Please check the original and archive link according to the instructions and then remove this notice. Atacama GmbH 
12. ↑ medStandards emergency standards
13. ↑ CheckMe! Clinic standards