Basic Definitions - Developing Care Paths

BASIC DEFINITIONS

Table of Contents:

Algorithm
"Written guidelines to stepwise evaluation and management strategies that require observations to be made, decisions to be considered and actions to be taken" (1). Algorithms help people decide what to do next. They are a schematic representation of guidelines written in a decision-tree format.

Case Management
A clinical system which focuses on the accountability of identified individuals or groups for coordinating a patient’s (or groups of patients) care across the continuum of care.

Care Paths
Related terms: Care Maps, Case Paths, Clinical Pathways, Clinical Paths, Critical Paths, Care Process Models, Care Tracks, Standardized Treatment Guidelines, Collaborative Paths, Treatment Paths

A multidisciplinary tool, which makes explicit the usual patient problem and activities that must occur to facilitate the achievement of expected patient outcomes in a defined length of time (2).

The use of Care Paths has increased in acute care settings over the last decade. They are now being used to support connections along the continuum of care. Many health professionals and organizations are currently involved in and committed to the development, implementation, and evaluation of care paths, and experience and expertise in their use is growing. Literature is plentiful citing benefits such as:

• reduced length of stay,
• reduced costs,
• improved cost-effectiveness,
• improvement in the quality of care and clinical outcomes, and
• improved communication among caregivers and between caregivers and the patient and family.

Definitions, examples and explanations are in: Care Maps & Continuous Quality Improvement, Canadian Medical Association, 1995, published by The Canadian Medical Association.

Clinical Practice Guidelines (CPG’s)
Related terms: Practice Parameters, Practice Policies, Position Papers, Consensus Statements, Practice Opinions

"Systematically developed statements to help physicians and patients make decisions about appropriate health care for specific clinical circumstances" (3). CPG’s offer recommendations for care and are prescriptive in nature. They help the practitioner determine the appropriateness of selected interventions. CPG’s can be either evidence-based (see the Cancer Care Ontario Practice Guidelines Initiative Web site) or non-evidence based.

The CMA Infobase, a section of the Canadian Medical Association Web site, provides access to Canadian CPGs.

Helpful CMA Publications:

• Guidelines for Canadian Clinical Practice Guidelines, Canadian Medical Association, 1994.
• Implementing Clinical Practice Guidelines: A Handbook for Practitioners, Canadian Medical Association, 1997.

Concurrent Variance Analysis
The immediate review by the caregiver of variances from the care path. Variances can be positive or negative. Positive variances occur when the patient progresses at a rate faster than that outlined in the care path. Negative variances reflect a slower rate of progression than expected.

Consensus
The outcome of a consultation process among a group of multidisciplinary caregivers in which unanimous agreement is reached regarding the desired course of action.

Evidence-Based Health Care
Evidence-based health care de-emphasizes intuition, unsystematic clinical experience, and pathophysiologic rationale as sufficient grounds for clinical decision-making and stresses the examination of evidence from clinical research. Evidence-based health care requires new skills of health care personnel, including efficient literature searching and the application of formal rules of evidence for evaluating the clinical literature. (Definition used by Hamilton Health Sciences Corporation Care Management.)

Interesting definitions, information and other resources are available through:

• Cancer Care Ontario Practice Guidelines Initiative
• PubMed *
• Cochrane Collaboration (Prepares, maintains, and promotes the accessibility of systematic reviews of the effects of health care interventions):
• The following book and related articles:
  • The Evidence-Based Medicine Working Group. Guyatt G and Rennie D, editors. Users' Guides to the Medical Literature: A Manual for Evidence-Based Clinical Practice. Chicago: AMA Press;2002.
  • Oxman AD, Sackett DL, Guyatt GH. Users’ guides to the medical literature. How to get started. JAMA 1993; 270(17):2093-5.
  • Sackett DL, Guyatt GH, Cook DJ. Users’ guides to the medical literature. How to use an article about therapy or prevention: are the results of the study valid? JAMA 1993; 270(21):2598-601.
  • Sackett DL, Guyatt GH, Cook DJ. Users’ guides to the medical literature. How to use an article about therapy or prevention: what were the results and will they help me in caring for my patients? JAMA 1993; 271(1):59-63.
  • Jaeschke R, Guyatt GH, Sackett DL. Users’ guides to the medical literature. How to use an article about diagnostic tests: are the results of the study valid? JAMA 1994; 271(5):389-91.
  • Jaeschke R, Guyatt GH, Sackett DL. Users’ guides to the medical literature. How to use an article about diagnostic tests: what are the results and will they help me in caring for my patients? JAMA 1994; 271(9):703-7.
  • Levine M, Walter S, Lee H, Haines T, Holbrook A, Moyer V. Users’ guides to the medical literature. How to use an article about harm. JAMA 1994; 271(20):1615-19.
  • Laupacis A, Wells G, Richardson S, Tugwell P. Users’ guides to the medical literature. How to use an article about prognosis. JAMA 1994; 272(3):234-7.
  • Oxman AD, Cook DJ, Guyatt GH. Users’ guides to the medical literature. How to use an overview. JAMA 1994; 272(17):1367-71.

  * Grateful Med was retired as a site in 2001, and the information is now accessed in general through PubMed.

Key Indicators
Critical events or occurrences contained in a care path that reflect the progress of a patient. Key Indicators or events may also be called 'milestones'.

Medical Directive
"A 'medical directive' or 'medical protocol' is not client specific. It is a prescription for a procedure, treatment or intervention that may be performed for a range of clients who meet certain conditions. The medical directive identifies a specific treatment or range of treatments, the specific conditions that must be met, and any specific circumstances that must exist before the directive can be implemented. A medical directive is always written [as part of hospital policies]" (4).

Outcomes
Changes in health status that occur for a patient or, in aggregate, to a defined patient population following exposure to an intervention.

Patient Populations
In care paths, the procedure or diagnosis defines the patient population.

Protocol

• A written statement which defines the management of broad patient problems or issues
• These statements are directed at managing:
  • patient on non-invasive equipment;
  • patient with invasive lines and equipment;
  • therapeutic, diagnostic and prophylactic measures;
  • common pathophysiological and psychological measures;
  • nursing diagnoses.
• These can be on 3 different levels:
  • dependent or delegated care needing a physician order;
  • independent or autonomous interdependent action;
  • interdependent care (both delegated and autonomous functions)(5).

Retrospective Variance Analysis
The analysis of aggregated variance data for a particular patient population to identify patterns and trends.

Routine Doctor’s Orders
A grouping of physician’s orders for a procedure, diagnosis, or condition, which the physician must review to make treatment decisions for a specific case. Non-applicable orders are crossed out and initialed.

Scope
The range of application or period of care for which the care path is developed.

References

1. Hadorn DC, McCormick K, Diokno A. An annotated algorithm approach to clinical guideline development. JAMA 1992; 267:3311.
2. Sturch C, Weinstein J. Hospital-to-home paths: a tool to ensure quality, continuity & cost effectiveness of care. Ontario Association of Community Care Access Centres 1999.
3. Canadian Medical Association. Guidelines for Canadian Clinical Practice Guidelines. Canadian Medical Association 1994.
4. College of Nurses of Ontario. When, why and how to use medical directives. CNO Communique 1995; (July):10-14.
5. Smith-Marker, CG. Setting standards for professional nursing: the Marker Model. Baltimore, MD: Mosby 1988.