Critical Pathways as a Strategy for Improving Care: Problems and Potential

In recent years, intense pressures to reduce the costs of health care have led many health care organizations to seek strategies that reduce resource utilization while maintaining the quality of care [1-5]. Among the most popular of the methods intended to meet this challenge are critical pathways. Critical pathways are management plans that display goals for patients and provide the corresponding ideal sequence and timing of staff actions to achieve those goals with optimal efficiency [6-8]. Interest in critical pathways has increased tremendously during the past several years as early anecdotal reports of their cost-saving potential have been disseminated, usually outside the peer-reviewed medical literature [7, 9, 10]. The rapid push for critical pathway implementation comes from intense competitive pressures and the persistent evidence of unexplained variation in medical practice [11, 12]. Many managed care organizations have added their weight to this process by mandating certain critical pathways or seeking partner hospitals that are willing to develop their own [7]. However, no controlled study has shown a critical pathway to reduce the duration of hospital stay or to decrease resource use, nor has any study shown critical pathways to improve patient satisfaction or outcomes [13]. Nevertheless, like other promising medical technologies, critical pathways are being disseminated before controlled trials have been done to evaluate their effectiveness. Despite the lack of data, an increasing number of physicians will be asked to participate in critical pathway development. Even more will find that their hospitalized patients are already on pathways that they may or may not have endorsed. To enhance the effectiveness of critical pathwaysand minimize the disruption to the patientphysician relationshipphysicians and other caregivers must understand the origin, potential benefits, and potential pitfalls of this new method. Critical Pathways: A New Form of Clinical Guideline Critical pathways have varying formats and are known by many names, including critical paths, clinical pathways, and care paths. Interpreted formally, a critical pathway is the sequence of events in a process that takes the greatest length of time. Like the techniques of continuous quality improvement, critical pathway techniques were first developed for use in industry as a tool to identify and manage the rate-limiting steps in production processes [14-17]. First developed in the 1950s, the Critical Path Method was frequently linked with a similar approach, the Program Evaluation and Review Technique, to coordinate multiple contractors or persons in a project by identifying the key sequence of events, or critical path, the requirements of which would drive the timeline of the overall project [18, 19]. Critical pathway techniques have subsequently been applied to projects as diverse as construction, civil engineering, town planning, marketing, ship building, product design, and equipment installation [6]. Critical pathways were first developed and applied to health care in the 1980s, when prospective payment systems focused greater interest on potential methods to improve hospital efficiency [6]. Most of the first critical pathways in hospitals were developed by nurses for nursing care alone [20, 21], but multidisciplinary teams soon began developing pathways to encompass all aspects of care for hospitalized patients [22-24]. In general, efforts to develop critical pathways in health care have not incorporated the formal techniques used by industrial predecessors to identify the true critical pathway in any care process [18, 25]. Instead, when critical pathways are used to plan medical care, the specific goals usually include the following: 1. Selecting a best practice when practice styles vary unnecessarily. 2. Defining standards for the expected duration of hospital stay and for the use of tests and treatments. 3. Examining the interrelations among the different steps in the care process to find ways to coordinate or decrease the time spent in the rate-limiting steps. 4. Giving all hospital staff a common game plan from which to view and understand their various roles in the overall care process. 5. Providing a framework for collecting data on the care process so that providers can learn how often and why patients do not follow an expected course during their hospitalization. 6. Decreasing nursing and physician documentation burdens. 7. Improving patient satisfaction with care by educating patients and their families about the plan of care and involving them more fully in its implementation. The general format of critical pathway guidelines is the Gantt chart, which outlines the suggested patient care process based on a time-task matrix, listing the components of care in one column and cross-aligning these entries with columns pertaining to time [8]. Figure 1 is an example of such a chart for a critical pathway for patients who have had coronary artery bypass graft surgery. Categories of multidisciplinary staff actions are listed in the first column of the pathway, with specific actions for each day of hospitalization. As indicated in Figure 1, a patient's diet is expected to progress successfully from ice chips to clear liquids on the first day after surgery. For all other categories of patient care, critical pathways likewise explicitly mark the transition points of patient progress and lay out a coordinated map of staff activities to achieve those transitions in the most efficient way possible. Figure 1. The first 2 days of a simplified critical pathway for patients who have had cardiac surgery. Critical pathways differ from most clinical guidelines, protocols, and algorithms in several key respects. First, clinical guidelines often address the appropriateness of care by delineating the indications for tests or treatments. Critical pathways, on the other hand, have almost always focused on the quality and efficiency of care after decisions have already been made to admit the patient or perform the procedure. Another way in which critical pathways differ from most clinical guidelines is that they are multidisciplinary in their development and in the scope of their implementation. Critical pathways are also designed along specific timelines, sometimes even in hour-by-hour detail, for indicated actions, and pathways not only spell out these specific actions but also enumerate expected intermediate patient outcomes that serve as checkpoints for the performance of both the patient and the pathway. Yet another distinguishing feature of critical pathways is that their comprehensive design allows them to be used as a part of the patient record, often replacing other documentation entirely [6, 24]. All staff interventions and intermediate clinical outcomes that occur as expected can be simply initialed on the critical pathway document. If staff actions or intermediate patient outcomes do not occur as expected, however, a variance from the pathway is said to have occurred [26]. Variances, too, can be noted on the document, along with an explanation of their cause or causes, and, if needed, a plan can be described to return the patient to the expected course of treatment and outcomes. Critical Pathway Development Topic Selection Critical pathways are typically developed for the hospital care associated with high-volume, high-cost diagnoses and procedures, particularly those for which inefficient variation in the process of care is thought to exist [6]. Surgical procedures, such as coronary artery bypass graft surgery and total hip replacement, lend themselves particularly well to critical pathways because the care process differs relatively little from patient to patient. For this same reason, obstetric procedures such as normal vaginal delivery and cesarean section have also been subjects of pathways in many institutions [24]. For most medical diagnoses, however, patient care has proved more difficult to translate successfully into critical pathways because of the greater heterogeneity among patients and problems [6, 27]. Some institutions have reported that pathways fail when used for medical patients who have either multiple problems and therefore multiple relevant pathways or a problem that does not fit neatly within any single standardized pathway [27-29]. Despite these concerns, however, pathways have been designed and implemented at many institutions for medical diagnoses such as myocardial infarction, stroke, and deep venous thrombosis [23]. Team Composition The group that is organized to develop a critical pathway should be multidisciplinary in order to bring to the table the knowledge and perspectives that are necessary to view the care process in its entirety. Although many institutions have appointed nurses as the leaders of critical pathway teams [6], we have found that having a physician-expert lead each team lends credibility to the pathways and builds a foundation of support among all clinicians. Each pathway team should also have a group facilitator from the hospital administration, a housestaff physician, a member of the quality management department who has expertise in critical pathway methods, and a community-based primary care physician, whose perspective on inpatient care is likely to differ from that of hospital-based physicians. The lack of active involvement by physician-experts is cited as a key reason for the failure of pathway programs; critical pathways that are developed without physician input have ended up sequestered in a part of the medical record where physicians do not often look [27, 30]. Simply gathering physicians, nurses, and other staff around the same table, however, may not be enough to generate the level of teamwork and communication necessary for success. It is an important challenge, especially for physicians trained in an individualistic ethic, to learn how to participate in and lead these teams eff