Administration & Operations

Clinical Pathways in the ED: To Use or Not to Use?

Rising health care costs and the move towards a value-based health care system has fueled the growth of clinical pathways (CPWs).

While they may seem like a fad, CPWs have actually been used in health care since the 1980s and are now widespread in the U.S., Australia, Canada, Europe, and Asia.1 As a result, there is now extensive literature about their design, implementation, and utilization. Despite this, there remains limited data regarding their true impact on patient care.

So, in the field of emergency medicine where increasing pressures threaten the ability of ED providers to deliver high quality care, the question remains: Can clinical pathways help acute care providers deliver safe, valuable, and standardized care to their patients? To help provide an answer, this article presents arguments for and against their use in an ED setting.

Best Thing Since Sliced Bread
There is extensive literature, and not just in emergency medicine, demonstrating the value of CPWs. First and foremost, they have been shown to improve cost-effectiveness and reduce length of stay by up to 22%.2 With the direct relationship between hospital length of stay and ED boarding, this can have a significant downstream effect on ED care. Additionally, CPWs have been shown to reduce excessive variation in patient care.3 In a practice environment where work-up is driven by variable risk thresholds, CPWs established using evidence-based medicine can decrease this variability. By doing so, they can theoretically reduce over-utilization of resources and redundancy in work-up. Pathways can also help identify systems issues that interfere with effective patient care and facilitate the resolution of system problems that can be irritating to both clinicians and patients. As such, CPWs can simultaneously be used as vehicles for quality assurance and process improvement - which is invaluable in an industry constantly looking to enhance safety, effectiveness, and efficiency.

As with any vehicle for change in health care, CPWs have their share of critics. One major concern is that they are robotic and depersonalized, going away from patient-centered care. While this might be the case in other practice settings, CPWs offer a tremendous benefit for both patients and providers in the ED. In an environment where there is a constant struggle to manage cognitive burden, CPWs allow providers to offload some of this burden by making certain aspects of patient care algorithmic. This, then, allows clinicians to spend intellectual capital on the undifferentiated sick, thereby increasing the overall quality of care delivered.

Close but No Cigar
Make no mistake that CPWs can serve to simplify decision-making. Nowhere is that more valuable than the ED. However, the distillation of the art of medicine to a series of binary choices can result in impersonal and inappropriate care. This “set it and forget it medicine” also creates a form of anchoring bias and reflexive compliance, which can blind providers to alternative or rare diagnoses.4 In a setting where providers are trained to practice within the constricts of limited data, anything that has the potential to create bias and reflexive thinking consequently has the capability to introduce harm.

Furthermore, while nearing ubiquity in medicine today, the implementation of CPWs has yet to be standardized, and their effect hasn’t been objectively proven as the variables remain ill-defined. While certain metrics may be realized, the core tenets of cost, length of stay, and patient and provider satisfaction have yet to be adequately investigated. In fact, some investigations report no direct relationship between using a CPW and the quality of care provided.5

Additionally, CPWs are usually not developed to serve the interests of an individual patient, but rather a patient cohort. Practices that are suboptimal from a patient perspective might be recommended as a way to control costs or protect special interests.6 Guidelines that are inflexible can harm by failing to address the unique patient’s case. In fact, CPWs are not designed for unusual or unpredictable cases, nor do they respond well to unexpected changes in a patient’s condition. Therefore, when used by providers who may not have the expertise to adapt to variability, CPWs can increase risk.

Last, but not least, many patients view pathways as an unacceptable intrusion into the doctor-patient relationship.7 This is especially troublesome when patient-centered care and shared decision-making are considered inalienable rights in the ED.

Summary
There is no denying the theoretical benefit of CPWs in an acute care setting. But reality is much harder to decipher, and evaluation of CPWs is particularly challenging given the wide variability in their implementation and use. So don’t consider CPWs a panacea, but rather an additional tool to help deliver high-quality patient care, and be aware that they must be customized to each practice setting and allow for flexibility in the ED where the uncommon is, well, common.

References
1. Rotter T, Kinsman L, James E, Machotta A, Gothe H, Willis J, et al. The effects of clinical pathways on professional practice, patient outcomes, length of stay and hospital costs: Cochran systemic review and meta-analysis. Eval Health Prof. 2012;35(1):3-27.
2. Cadilhac DA, Dewey HM, Denisenko S, Bladin CF, Meretoja A. Changes in acute hospital costs after employing clinical facilitators to improve stroke care in Victoria, Australia. BMC Health Serv Res. 2019;19(1):41.
3. Algaze CA, Shin AY, Nather C, et al. Applying lessons from an inaugural clinical pathway to establish a clinical effectiveness program. Pediatr Qual Saf. 2018;3(6):e115.
4. Ransom SB, Studdert DM, Dombrowski MP, Mello MM, Brennan, TA. Reduced medicolegal risk by compliance with obstetric clinical pathways: a case--control study. Obstet Gynecol. 2003;101(4):751-755.
5. Gerber AS, Patashnik EM, Doherty D, Dowling C. A national survey reveals public skepticism about research-based treatment guidelines. Health Aff (Milwood). 2010;29(10):1882-1884.
6. Woolf SH, Grol R, Hutchinson A, Eccles M, Grimshaw J. Clinical guidelines: Potential benefits, limitations, and harms of clinical guidelines. BMJ. 1999;318(7182):527–530.

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