| Abstract|| |
Proper implementation of guidelines is clearly associated with better medical outcomes. Success of guidelines' implementation depends on the tools used to accomplish it. Clinical pathways, also known as Integrated Care Pathways, represent one such tool that clearly promotes the implementation of guidelines and research evidence into clinical practice. They also encourage multidisciplinary teamwork, help in staff education, and aid in clinical research and audit. Additionally, they help in cutting hospital care costs. Important steps for a successful pathway development and implementation include getting leadership support, involving relevant people, selecting the right area of practice, using multiple implementation strategies and regularly assessing and monitoring pathway implementation.
|How to cite this article:|
Hassan IS. Knowledge translation through clinical pathways: Principles for practical development and successful use. Saudi J Kidney Dis Transpl 2013;24:351-63
|How to cite this URL:|
Hassan IS. Knowledge translation through clinical pathways: Principles for practical development and successful use. Saudi J Kidney Dis Transpl [serial online] 2013 [cited 2020 Jan 20];24:351-63. Available from: http://www.sjkdt.org/text.asp?2013/24/2/351/109603
| Introduction|| |
The huge gap between evidence and practice for clinical and preventive health services calls for a deeper understanding and better use of effective quality improvement tools. , Clinical pathways (CPs), also called Integrated Care Pathways, are proven tools for evidence-based guideline implementation and knowledge translation. ,,, This was highlighted in a recent Cochrane's systematic review of the subject.  Over the years, CPs have become an integral part of quality improvement in all health-care disciplines and services. ,,,,,, CPs are structured, multidisciplinary care plans that detail the essential steps in the care of patients with a specific clinical problem. ,, They organize, sequence, and time the major interventions, both medical and non-medical, by clinicians and nursing and other health-care providers that the patient should receive. , CPs are believed to be a tool as well as a concept that assists in applying guidelines, locally agreed upon protocols, and evidence-based practice into a daily, patient-specific management and care plan. In a review on the subject,  the use of CPs resulted in a multitude of other beneficial effects including reduction in the length of stay in hospital, encouraging teamwork and staff communication, and enhancing junior and new staff education and training. They also facilitated data collection for research and audit while reducing medical and nursing staff paperwork. CPs also promoted patients' right of information and increased patient's satisfaction with the service. They led to a reduction in the cost of patient care and improved patient outcomes. All together, CPs improve the quality of patient care.
In this manuscript, the author describes his experience in developing and disseminating CPs for use in the Department of Medicine at the King Abdulaziz Medical City in Riyadh, Saudi Arabia, and the acceptability of a particular pathway implementation format that the department employed. The author starts by first highlighting and emphasizing the essential competencies and skills that a pathway development and implementation team should acquire before embarking on such an endeavor.
| Principle Pre-Requisites for Pathways' Development and Successful Use|| |
Like other quality improvement tools, CPs must be evidence based and implemented using proven process-change activities and system redesign principles. Furthermore, staff must be competent and well trained in their use. Organizational and individual (professional) barriers to successful implementation must be dealt with at the outset.
The development team must have an in-depth knowledge of evidence-based practice, namely: asking answerable questions, acquiring evidence using the right search strategies, and critically appraising the evidence. Ability to search in the cyberspace and specifically in the medical literature, e.g. in Pubmed, medical specialties societies', and guidelines web-pages and quality improvement sites for published pathways is mandatory.
Pathways are tools for bringing up change in practice. As such, an in-depth understanding of management of change (process change skills) is imperative. A simple Plan-Do-Study-Act cycle might not be adequate for guaranteeing a successful change. [Table 1] portrays the steps that should be taken for affecting a successful change. , Additionally, and allied to the process change exercise, a redesigning of the system in its structure, e.g. expanding staff roles and responsibilities and changes in staff's job description, are almost always necessary. ,
|Table 1: Steps for developing and successfully implementing a clinical pathway.|
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Clinicians as well as allied health professionals who share in implementation of CPs need to be fully competent in its use. Regular training in use of CPs must be a part and parcel of staffs' daily educational activities, e.g. in the morning meetings, ward rounds, academic talks and half-day meetings, and in the induction courses for the new employees.
Organizational barriers such as lack of leadership support, lack of necessary supporting structures, e.g. educational department, monitoring staff, and individual barriers such as lack of knowledge or skills and poor attitude to change, hinder any attempt for the use of quality improvement tools in general and CPs in particular. These need to be addressed. [Table 2] depicts some of these barriers and the interventions that may be employed to deal with them. ,
| The Setting|| |
The King Abdulaziz Medical City is a tertiary-care center serving the National Guard recruits, their dependents, and members of the public requiring highly specialized care. The Medical City, with over 1200 beds, includes the King Fahad National Guard Hospital, The Cardiovascular and Liver Transplantation Unit, The Ambulatory Care Center, King Abdulaziz Dental Center, Primary Health Centers, Um Al Hammam Outpatient Specialized Health Care Facility, and the Emergency Care Center. The department of medicine is one of the largest in the Kingdom with 12 divisions, namely dermatology, endocrinology, gastroenterology, hematology/oncology, infectious diseases, internal medicine, nephrology, neurology, physiatry (rehabilitation), psychiatry, pulmonology, and rheumatology. The number of senior medical staff (consultants, associates, and assistants) exceeds 70, all of whom are highly qualified and experienced physicians. In addition, the department runs a high-caliber and renowned residency-training program with up to 60 trainees enrolled.
| The First Steps|| |
Striving for further improvements in the quality of care medical patients receive, a Clinical Practice Guidelines Committee (currently called the Knowledge Translation Committee) was formed by the chairman of the Department of Medicine. Its tasks were clearly stated as follows: (a) developing evidence-based practice guidelines for the common medical problems related to the practice of general internal medicine, (b) disseminating this information and ensuring the implementation of these practice guidelines, (c) periodically reviewing the effectiveness of these guidelines and updating their content as new evidence emerges, while continuing to ensure patient safety, and (d) monitoring the adherence to these guidelines and making further relevant recommendations. Committee members were selected from different divisions, some of whom have already had experience in developing CPs. In its first introductory meeting, the committee agreed on several principles. These principles included expanding the committee membership to involve other relevant staff (e.g., pharmacy and nursing), mechanisms for selecting and prioritizing the medical conditions that need consideration, employing multiple implementation strategies, and devising means for monitoring and assessing the impact of the intervention on patient care.
| Selecting an Important Area of Practice|| |
A priority survey with a list of common or acute in-patient medical problems was sent to all staff members who were involved in acute patient care. Physicians were requested to score each condition as follows: a score of three is given if the participant felt that there was an urgent need to develop a guideline for that particular medical condition, a score of two if the matter is thought to be semi-urgent, and a score of one if the need was not urgent. The total score was then calculated. The medical condition that scored highest, indicating that it needed the most urgent attention, was diabetic ketoacidosis (score = 46). This was followed by bronchial asthma (score = 44), pulmonary thromboembolism (score = 43), chronic obstructive airways disease (score = 42), hyperosmolar hyperglycemia (score = 41), in-patient warfarin therapy (score = 41), acute meningitis (score = 40), community-acquired pneumonia (score = 39), need for oxygen therapy (score = 39), stroke (score = 37), congestive heart failure (score = 36), intravenous to oral antibiotic switch (score = 34), epilepsy (score = 32), and administration of intravenous fluids (score = 31).
| Selecting the Implementation Strategies|| |
From the outset, the committee agreed that multiple implementation strategies should be employed. This was based on the experience and recommendations of experts that clearly advise against relying on single strategies for guidelines implementation. , All the relevant staff participated in both the guideline development phase as well as in incorporating them in a mutually approved implementation process. This was of utmost importance, otherwise the committee's recommendations will neither be adopted nor will they change the clinical practice.
Relevant medical divisions were requested to prepare two formats for the medical condition under consideration. The first is a written format containing the essential theoretical (guideline-based) information covered in short paragraphs with specific headings as outlined by the committee [Table 3]. The division is given the liberty of adding any other vital information as appropriate. The second is an implementation format. The committee specifically devised this format with the following goals in mind: (a) it should, as a rule, contain practical information that has an impact on treatment outcome, length of stay, cost of care, and readmission rates, (b) it should be user friendly and should not increase the physician's work-load, (c) it should be built into daily patient-care and assist in a real-time disease and patient management decisions, and (d) it should contain clear indicators on when a patient is ready for discharge and when and which specialty is to follow this patient. To achieve all these goals, the committee pre-printed the format on the regular sheet that residents use for admitting patients. Important practical advise was highlighted in a sidebar that followed the pertinent sections of history, examination, investigation, treatment, discharge, follow-up, etc. Admission and discharge order sheets were also included to assist in guideline implementation.
|Table 3: Headings to be covered in the written pathway format (based on evidence-based published guidelines).|
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An example of such a format for diabetic ketoacidosis is depicted in [Table 4].
|Table 4: Management of diabetic ketoacidosis: Clinical pathway that is being used at the Department of Medicine at King Abdulaziz Medical City in Riyadh, Saudi Arabia|
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| Launching, Monitoring, and Encouraging Implementation|| |
Once the formats were produced, they were sent to all physicians in the department who are involved in the care of such patients. They were also sent to all medical and non-medical staff that may be involved as per the pathway recommendations such as diabetes and pulmonary educators or physiotherapists as well as relevant departments such as intensive care and emergency departments, which may potentially be involved. The feedback and recommendations of these different entities were then incorporated in the final version of the pathway.
Once a pathway was finalized, the committee organized workshops with the active participation of the relevant divisions. These work-shops were run before the official launch of the pathway. All staff, medical and non-medical, were invited to attend these workshops.
To monitor the implementation of the pathways, the committee involved the hospital Clinical Pathways Committee and the department of quality management. A system redesign step was later undertaken with the employment of a knowledge translation monitor. The latter was an allied health professional who was specifically trained to become a pathway monitor. Pathway-specific Key Implementation Indicators were developed by the committee. Interested staff, called Pathway Champions, were invited to become members of the monitoring teams. These teams were requested to audit their findings and had the privilege of publishing their results in medical journals. Weekly spot-checks by committee members, admitting consultant verification, clinical teaching units league table on guideline implementation, and regular workshops on the different pathways were other interventions the committee adopted to improve pathway implementation. To further encourage compliance with the pathway recommendations, residents who were consistent in pathway implementation were offered a certificate of a "Guideline Implementer" by the department. Additionally, and in agreement with the director of the residency training program, pathway implementation has become part of the residents' evaluation.
| Acceptability of the Implementation Format by Medical staff|| |
A survey form was sent to all consultant and resident staff affiliated to the Department of Medicine. The questionnaire addressed the ease of using the pathway, its impact on workload, and its educational and practical value. It also covered the flexibility of the pathway in dealing with unusual patient cases and views on its future use. In addition, participants were requested to propose changes and/or enter any other comments on the pathway format. The results of the survey are shown in [Table 5] and [Table 6]. It was clear that the selected format for guidelines implementation has gained wide acceptability by most participants in the survey. Posting the pathway on the Intranet was one major request by several residents, a request that the committee has complied with.
| Hindsight Issues: Obstacles, Difficulties, and Lessons|| |
Several practical and organizational issues have hindered the proper and complete fulfillment of the guidelines committee's duties. Not all medical staff members were committed or keen to change their practice. For some senior staff, the use of clinical pathways was undesirable. Several physicians voiced their concern that these pathways may not apply to all patients and that there will be a serious lack of individualized care. The non-availability of a dedicated "Clinical Pathway Team" resulted in serious difficulties with the dissemination, continual staff education and training, and close monitoring of pathways implementation and impact.
The first year of the committee has been a partial success only but was extremely rich and enlightening. To achieve all its goals, the committee has recognized the following specific issues: (1) it is vital that the chosen CPs be acceptable and welcome by staff; (a) the right area of practice must be selected, (b) all relevant staff must be involved in their preparation, (c) it should be based on recognized guidelines and medical evidence, (d) should not increase workload, and (e) should be readily available and accessible at the point of patient care; (2) multiple implementation strategies are employed, e.g. educational materials and reminders, regular workshops, patientmediated interventions, financial and personal incentives, etc.; and (3) full leadership and organizational support (both financial and manpower) for the development, dissemination, implementation, and monitoring of these pathways. In that regard, governmentled adoptions of integrated care pathways in all health facilities and hospitals in the Kingdom may further enhance their utilization and monitoring and further improve the quality of care patients receive.
| Final Remarks|| |
The use of the selected pathway format gained wide acceptance and became part of the residents' daily patient care and culture. The request to continue in developing more pathways was explicit and unambiguous by most staff, both junior and senior. The momentum is further sustained by the dedication and support of the department chairman and senior physicians and by the enthusiasm of the guidelines committee members. Currently, seven pathways are in use (diabetic ketoacidosis, community-acquired pneumonia, bronchial asthma, chronic obstructive pulmonary disease, acute sickle cell crisis, elevated INR, and acute bacterial meningitis).
| Acknowledgment|| |
The author wishes to acknowledge the valuable input of the Clinical Practice Guidelines Committee members, namely Dr. Mohamed Al Moamary, Dr. Yousef Saleh, Dr. Khalid Al Khathlan, Dr. Sadoon Al Sadoon, Dr. Hind Al Ghadeer, Dr. Maha Al Ammari, Ms. Rehana Alothman, Dr. Muhammad Al Daker, Dr. Afaf Al Shammary, and Dr. Sami Bashi. Special thanks is rendered to Professor Mohammed Harakati, previous chairman for the Department of Medicine, who ordered the formation of the committee and the current Chairman, Dr. Salih Bin Salih, for his continuous support to the committee and its activities.
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Imad S Hassan
Chairman, Knowledge Translation Committee, Department of Medicine 1443, King Abdulaziz Medical City, King Fahad National Guard Hospital, PO Box 22490, Riyadh 11426
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]