Clinical / Care pathways, also known as critical pathways, care paths, integrated care pathways, case management plans, clinical care pathways or care maps, are used to systematically plan and follow up a patient focused care program.

Clinical pathways are used all over the world [1-3]. Although their wide use, there are many uncertainties involved:

  • Firstly, the terminology and the way they are defined and developed is unclear [4-8].
  • Secondly their impact is unclear. Several reviews on the effect of clinical pathways [4;10-21] describe a variety of outcomes.

De Luc et al [6] found 17 different names describing this concept. In literature most frequently the terms clinical pathway, critical pathway, integrated care pathway and care map are used [4;5].

The National Library of Medicine introduced the term “critical pathway” in 1996. Fifteen different entry terms are used in the medical subheading database. The National Library is using the definition from Mosby’s Medical Nursing & Allied Health Dictionary, 4th Edition: “Schedules of medical and nursing procedures, including diagnostic tests, medications, and consultations designed to effect an efficient, coordinated program of treatment” [9]. A recent literature review [5] identified 84 different definitions in a Medline search between 2000 and 2003.

Based on an international consensus meeting in Slovenia (december 2005) the E-P-A defined a care pathway as:
Care pathways are a methodology for the mutual decision making and organization of care for a well-defined group of patients during a well-defined period. Defining characteristics of care pathways includes:

  1. An explicit statement of the goals and key elements of care based on evidence, best practice, and patient expectations;
  2. The facilitation of the communication, coordination of roles, and sequencing the activities of the multidisciplinary care team, patients and their relatives;
  3. The documentation, monitoring, and evaluation of variances and outcomes; and
  4. The identification of the appropriate resources.

The aim of a care pathway is to enhance the quality of care by improving patient outcomes, promoting patient safety, increasing patient satisfaction, and optimizing the use of resources.

Based on international discussions, the E-P-A summer schools, and on the results of the PhD study of Kris Vanhaecht, a new definition was suggested and adopted:

E-P-A Definition of care pathway

A care pathway is a complex intervention for the mutual decision making and organisation of care processes for a well-defined group of patients during a well-defined period.

Defining characteristics of care pathways include:

  1. An explicit statement of the goals and key elements of care based on evidence, best practice, and patients’ expectations and their characteristics;
  2. the facilitation of the communication among the team members and with patients and families;
  3. the coordination of the care process by coordinating the roles and sequencing the activities of the multidisciplinary care team, patients and their relatives;
  4. the documentation, monitoring, and evaluation of variances and outcomes; and
  5. the identification of the appropriate resources.

The aim of a care pathway is to enhance the quality of care across the continuum by improving risk-adjusted patient outcomes, promoting patient safety, increasing patient satisfaction, and optimizing the use of resources.

Source: Vanhaecht, K., De Witte, K. Sermeus, W. (2007). The impact of clinical pathways on the organisation of care processes. PhD dissertation KULeuven, 154pp, Katholieke Universiteit Leuven.

This definition is nowadays used by the E-P-A in the European Quality of Care Pathway (EQCP), Care Pathway for Acute Coronary Syndrome (CP4ACS) and Care Pathway for Nutritional Problems in Surgical Patients with Gastro Intestinal Cancer (CP4NutriGICan) studies, and forms the basis for all our courses.

A complex intervention combines several ‘active ingredients’ into a working construct. For care pathways, the active ingredients are: overview of evidence based key interventions, feedback on the current care process, strategy to improve current care process.

If you want to find information on internet or on Pubmed about clinical pathways, you can use the following terms: “critical pathway”, “clinical pathway” or “integrated care pathway”. The terminology clinical/critical pathway is used worldwide. Integrated Care Pathway (ICP) is mainly used in the United Kingdom.

Reference List

[1] Zander K. Integrated Care Pathways: eleven international trends. Journal of Integrated Care Pathways 2002; 6:101-107.

[2] Vanhaecht K, Bollmann M, Bower K, Gallagher C, Gardini A, Guezo J et al. International survey on the use and dissemination of clinical pathways in 23 countries. Accepted for Publication in Journal of Integrated Care Pathways, 2006.

[3] Hindle D, Yazbeck AM. Clinical pathways in 17 European Union countries: a purposive survey. Aust Health Rev 2005; 29(1):94-104.

[4] Sermeus W, De Bleser L, Depreitere R, De Waele K, Vanhaecht K, Vlayen J. An introduction to clinical pathways. In: in Devriese S, Lambert ML, Eyssen M, Van De Sande S, Poelmans J, Van Brabandt H et al., editors. The use of clinical pathways and guidelines to determine physicians’ hospital fees prospectively: easier said than done. Brussels: Belgian Healthcare Knowledge Centre (KCE).KCE Reports, Volume 18A, http://www.kenniscentrum.fgov.be/nl/publicaties.html., 2005.

[5] De Bleser L, Vlayen J, Depreitere R, De Waele K, Vanhaecht K, Sermeus W. Defining pathways. 2005. submitted for publication.

[6] De Luc K. Developing care pathways – the handbook. Oxford: Radcliffe Medical Press Ltd, 2001.

[7] De Luc K. Are different models of care pathways being developed? International Journal of Health Care Quality Assurance 2000; 13(2):80-86. [8] Harkleroad A, Schirf D, Volpe J et al. Critical pathway development: An integrative literature review. Am J Occup Ther 2000; 54(2):148-154.

[9] Anderson KL, Anderson L, Glanze W. Mosby’s medical, nursing, and allied health dictionary (4th ed.). St. Louis: Mosby, 1994.

[10] Trowbridge R, Weingarten S. Making health care safer, a critical analysis of patient safety practices. Chapter 52: Critical Pathways. Agency for Healthcare Research & Quality, http://www.ahrq.gov/clinic/ptsafety/chap52.htm . 2001. [11] Kwan J, Sandercock P. In-hospital care pathways for stroke. Cochrane Database Syst Rev 2004;(4):CD002924.

[12] Pearson SD, Kleefield SF, Soukop JR, Cook EF, Lee TH. Critical pathways intervention to reduce length of hospital stay. Am J Med 2001; 110(3):175-180.

[13] Van Herck P, Vanhaecht K, Sermeus W. Effects of Clinical Pathways: do they work? Journal of Integrated Care Pathways 2004; 8:95-105.

[14] Bandolier. Independent evidence-based health care. On Care Pathways. http://www.jr2.ox.ac.uk/bandolier/Extraforbando/Forum2.pdf . 2003.

[15] Hindle D, Yazbeck AM. Report of a survey of clinical pathways and strategic asset planning in 17 EU countries. 1-37. 2004. EU Health Property Network and the Netherlands Board of Health Policy.

[16] Panella M, Marchisio S, Di Stanislao F. Reducing clinical variations with clinical pathways: do pathways work? Int J Qual Health Care 2003; 15(6):509-521.

[17] Renholm M, Leino-Kilpi H, Suominen T. Critical pathways:a systematic review. Journal of Nursing Administration 2002; 32(4):196-202.

[18] Dy SM, Garg P, Nyberg D, Dawson PB, Pronovost PJ, Morlock L et al. Critical pathway effectiveness: assessing the impact of patient, hospital care, and pathway characteristics using qualitative comparative analysis. Health Serv Res 2005; 40(2):499-516.

[19] Darer J, Pronovost P, Bass E. Use and evaluation of critical pathways in hospitals. Eff Clin Pract 2002; 5:114-119.

[20] Bryson A, Browning J. Clinical audit and quality using integrated pathways of care. CA96/01, 1-74. 1999. Edinburgh, CRAG, Clinical Resource and Audit Group.

[21] Dy SM, Garg PP, Nyberg D, Dawson PB, Pronovost PJ, Morlock L et al. Are critical pathways effective for reducing postoperative length of stay? Med Care 2003; 41(5):637-648