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CLINICAL CARE PATHWAYS
The use of clinical care pathways
is not new, and although widely
referred to in practice across many
different countries including the UK,
USA, Australia, Canada, Europe,
and Asia (Rotter et al, 2010) and
used within other specialist areas,
for example asthma ( Pound et al,
2017) and coronary artery bypass
graft (Kebapci and Kanan, 2017),
there appears to be little consensus
about what a pathway is and how
it is operationalised. Kebapci and
Kanan (2017) suggested that a clinical
care pathway is a multidisciplinary
care plan, based on evidence and
guidelines to provide consistent,
quality care to patients and improve
outcomes. However, Lawal et al
(2016) suggested that while they may
have a common goal — to improve
patient outcomes, such as mortality
rate and others, while containing
costs and without compromising
quality — confusion occurs as there
is a lack of clarity about what is or is
not a pathway, as they are frequently
known by different names, including
care maps, critical pathways, local
protocols or algorithms.
Lawal et al (2016) suggested that
to qualify as a pathway four key
criteria need to be met, namely:
1. It is a structured multidisciplinary
plan of care
2. It is used to translate guidelines or
evidence into local structures
3. It details the steps in a course
of treatment or care in a plan,
pathway, algorithm, guideline,
protocol or other‘inventory of
actions’(i.e. it has timeframes or
criteria-based progression)
4. It aims to standardise care for a
specific population.
Therefore, a clinical pathway
must be based on evidence (where it
exists), multidisciplinary, and describe
the essential steps needed in the care
of a patient with a specific problem.
As such, they are used to translate
guidelines into local protocols or
practice, considering the needs of
local health economy systems and
structures (Rotter et al, 2012).
Within the field of tissue viability,
it seems that pathways exist for two
key reasons:
`
To encourage implementation of
evidence into practice
`
To provide simplicity/structure
where there is too much choice.
A good example of implementing
evidence into practice would be
within the care of patients with
venous leg ulcers, where the need to
carry out good holistic assessment,
exclude arterial disease and apply
compression has been clearly
evidenced since the seminal work
of Moffatt et al in the early 1990s
(Moffatt et al, 1992).Yet, it is clear
that over 25 years later this is not
consistently implemented in practice,
as evidenced within the burden of
wounds studies (Guest et al, 2018). As
research in the field of compression
identifies new ways of applying
compression, such as hosiery, to be
equally effective (Ashby et al, 2014),
several algorithms or care pathways
have been developed to standardise
the approach to application of
this work in practice (Jones, 2014;
Atkin and Tickle, 2016). Atkin and
Critchley (2017) went on to evaluate
the impact of this pathway of care
(Atkin and Tickle, 2016) within their
local community after three months;
demonstrating improvements in the
quality of assessments undertaken,
use of Doppler to determine ankle
brachial pressure index (ABPI),
Jacqui Fletcher, independent nurse consultant
What should a clinical care pathway
look like in wound care?
IN BRIEF
The delivery of care related to wounds by the NHS has been
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Pathways of care help to standardise care delivery and
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Good quality pathways are not always implemented across the
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KEYWORDS:
Wounds
Pathway
Variation
Evidence
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Jacqui Fletcher
Top tip:
Remember: pathways should be
based on good quality evidence
where possible.
12 JCN supplement
2018,Vol 32, No 2