Care PathwaysRCN, BMIA, eHNN joint event

12th February 2004

Ross ScrivenerInformation ManagerQuality Improvement

ProgrammeRCNI

Overview

• Quality Improvement Programme

• QIP and care pathways– Survey of staff views 2000

– RCN care pathway survey 2000/1

– NeLH Protocols and Care pathways

• Future directions

Quality Improvement Programme

• Evidence-based resources

• Implementing quality improvement

• Information support

• Educational opportunities

Care Pathways - clinical governance

• getting evidence into practice

• tackling variations in practice

• improving patient information

• enhancing multi-professional collaboration

• structured approach to care planning

RCN Survey 1998/1999

Aims

• how clinical staff understand, experience and use care pathways

• explore staff perception of relationship between care pathways and evidence-based practice

RCN Survey 1998/1999

Methods

• first phase - national survey 1998

• All NHS Trusts sent questionnaire

• RR = 70%

• second phase - experience and views

• 22 trusts invited, 16 took part

• 63 taped interviews were analysed

RCN Survey 1998/1999

• characteristics and types of pathway

• strategic benefits

• clinical and patient benefits

• success factors/challenges

• pathways and evidence

• variance recording and analysis

Comments on pathway characteristics

“…they were brought in to address a lot of the process problems, because a lot of the time I don’t think we are aware of how to track our patients,…and (care pathways) could manage some of the care issues, care interventions, such as doing the right thing at the right time…” Senior sister/Site C

Comments on pathway characteristics

“…(working in different ways) drives you to say, what do we want from a patient and then if this is the outcome that we expect, then this is the input we need, so it’s changing things ...in terms of saying what do we want to achieve, what do we have to do to achieve that, rather than the traditional approach of what are we going to do today... Executive nurse/Site K

Comments on strategic benefits

“…the risk management of complaints and litigation is helped a great deal by improved (pathway) documentation …A pathway tells you where a patient should be, so you’re alerted quickly if something is not right.”

Pathway co-ordinator/Site P

Comments on clinical benefits

“I can quote our work for stroke, it has improved outcomes. The stroke ICP (has)…reduced hospital-acquired pressure sores by a third...hospital acquired UTI by two thirds, we’ve reduced aspiration pneumonia by about 4% or 5%,we’ve reduced length of stay by about two weeks...

Executive nurse/Site K

Comments on clinical benefits

“…pathways are...making people stop and ...understand each other’s roles and responsibilities…what we’re seeing here is the power of them for multi-professional education…the breast cancer pathway has developed occupational standards…a project on the stroke pathway (is) using GPs, speech and language therapists and nurses…”

Pathway co-ordinator/site L

Comments on patient benefits

“…I think having them accessible to the patients enables better communication between staff and patients…some of the patients were really quite encouraged to see that their care was planned, that it wasn’t all going to be chaos…”

Pathway co-ordinator/Site P

Success factors

“The starting point is having Trust backing at a very senior level…”

Paediatric cardiologist/Site I

“(the consultant) is very well respected by his colleagues in the hospital…”

ICP co-ordinator/Site N

“(the pathway co-ordinator is)…a sounding board…a mediator…a great support…” Sister CCU/Site C

Challenges “I’m just frightened that we lose some of

our professional autonomy…you feel like a bit of a robot…” Charge nurse/Site C

“it is cook book medicine , but it is needed…” Consultant, A&E/Site H

“There’s a proportion of people...looking at research and evidence as a base for their practice, but for a lot of people that’s still very threatening”

Pathway co-ordinator/Site C

Challenges

“We had set up multi-disciplinary records but we still had a doctor tearing up (the pathway) on a ward round…We had another doctor who sent his junior in at night to separate all the multidisciplinary notes out again…”

Head of Quality/Site A

Challenges

Pathways and evidence

“That is the whole thrust of it…evidence needs to be available at the point of delivery of care, and pathways are the only way to do that.. It’s one way of bringing evidence into day-to-day practice…I think it’s the only way to actually do it consistently…”

Consultant, A&E/Site A

RCN Survey 2001

Response

• 405/1069 responses (RR 37.8%)

• 79% reported care pathway activity

• 89% from acute sector

• 2879 care pathways identified

RCN Survey 2001

Results - clinical topics

1. stroke (n=111)

2. fractured neck of femur (n=95)

3. diabetes related (n=80)

4. total hip replacement (n=75)

5. total knee replacement (n=59)

RCN Survey 2001

Results - clinical topics

6. myocardial infarction (n=55)

7. asthma (n=54)

8. TURP (n=41)

9. chest pain (n=34)

10. cataract extraction (n=31)

RCN Survey 2001

Results - remaining questions

• 11% of Trusts account for 50% of care pathways

• facilitator in post 59%

• formal evaluation undertaken 19%

• integration with EPR 5.9%

RCN Survey 2001

Results - implications• willingness to share pathways

85% • significant activity in priority

areas

• majority of Trust well short of IfH targets

NeLH care pathway resources - Objectives

• know how resource - peer to peer information on who has done what, where

• reference resources on evidence, literature, good practice, expertise and projects

• support local sharing (of efforts and results), reuse and adaption

Care pathways - future directions

• RCN pursuing research funding (NHS SDO R&D Programme, DH Policy Research Programme)

• Shape NeLH protocols & care pathways

• QIP particularly interested in how care pathways can embed clinical guidelines into routine practice

References• Currie VL, Harvey G. (2000).The use of care

pathways as tools to support the implementation of evidence-based practice. J of Interprofessional Care 14;4:311-324.

• Currie VL, Scrivener R. (2002) Tracking care pathway activity across the UK National Health Service. J of Clinical Excellence. 4;2:231-236.

• NeL Protocols and Care Pathways

http://www.nelh.nhs.uk/carepathways/