Cheah J
Department of Community, Occupational and Family Medicine, Faculty of Medicine, National University of Singapore, Singapore.
Singapore Med J. 2000 Jul;41(7):335-46.
A critical or clinical pathway defines the optimal care process, sequencing and timing of interventions by healthcare professionals for a particular diagnosis or procedure. It is a relatively new clinical process improvement tool that has been gaining popularity across hospitals and various healthcare organisations in many parts of the world. It is now slowly gaining momentum and popularity in Asia and Singapore. Clinical pathways are developed through collaborative efforts of clinicians, case managers, nurses, and other allied healthcare professionals with the aim of improving the quality of patient care, while minimising cost to the patient. Clinical pathways have been shown to reduce unnecessary variation in patient care, reduce delays in discharge through more efficient discharge planning, and improve the cost-effectiveness of clinical services. The approach and objectives of clinical pathways are consistent with those of total quality management (TQM) and continuous clinical quality improvement (CQI), and is essentially the application of these principles at the patient's bedside. However, despite the growing popularity of pathways, their impact on clinical outcomes and their clinical effectiveness remains largely untested and unproven through rigorous clinical trials. This paper begins with an overview of the nature of clinical pathways and the analysis of variances from the pathway, their benefits to the healthcare organisation, their application as a tool for CQI activities in direct relation to patient care, and their effectiveness in a variety of healthcare settings. The paper describes an evaluation of the impact of a clinical pathway on the quality of care for patients admitted for uncomplicated acute myocardial infarction (AMI) through an analysis of variances. The author carried out a one year evaluation of a clinical pathway on uncomplicated AMI in Changi General Hospital (CGH) to determine its effectiveness and impact on a defined set of outcomes. A before and after nonrandomized study of two groups of patients admitted to the Hospital for uncomplicated AMI was done. A total of 169 patients were managed on the clinical pathway compared to 100 patients in the control (historical comparison) group. Outcomes were compared between the two groups of patients. Restriction and matching of study subjects in both groups ensured that the patients selected were comparable in terms of severity of illness. The results showed that the patients on the clinical pathway and the comparison group were similar with respect to demographic variables, prevalence of risk factors and comorbidities. There was a statistically significant reduction in the average length of stay after implementation of the clinical pathway. This was achieved without any adverse effect on short term clinical outcomes such as in-hospital mortality, complication rate and morbidity. There were no significant difference in readmission rates at 6 months after discharge. The paper concludes that clinical pathways, implemented in the context of an acute care general hospital, is able to significantly improve care processes through better collaboration among healthcare professionals and improvements in work systems.
关键路径或临床路径定义了医疗保健专业人员针对特定诊断或程序的最佳护理流程、干预措施的顺序和时间安排。它是一种相对较新的临床流程改进工具，在世界许多地区的医院和各种医疗保健组织中越来越受欢迎。现在它在亚洲和新加坡正逐渐获得发展势头和普及。临床路径是通过临床医生、病例管理人员、护士和其他相关医疗保健专业人员的共同努力制定的，目的是提高患者护理质量，同时将患者的费用降至最低。临床路径已被证明可以减少患者护理中不必要的差异，通过更有效的出院计划减少出院延迟，并提高临床服务的成本效益。临床路径的方法和目标与全面质量管理（TQM）和持续临床质量改进（CQI）一致，本质上是这些原则在患者床边的应用。然而，尽管路径越来越受欢迎，但它们对临床结果的影响及其临床有效性在很大程度上仍未经过严格的临床试验检验和证实。本文首先概述临床路径的性质以及对路径差异的分析，它们对医疗保健组织的益处，它们作为与患者护理直接相关的CQI活动工具的应用，以及它们在各种医疗保健环境中的有效性。本文通过对差异的分析描述了对临床路径对无并发症急性心肌梗死（AMI）患者护理质量影响的评估。作者对樟宜综合医院（CGH）的无并发症AMI临床路径进行了为期一年的评估，以确定其对一组既定结果的有效性和影响。对两组因无并发症AMI入院的患者进行了前后非随机研究。共有169名患者按照临床路径进行管理，而对照组（历史比较组）有100名患者。比较了两组患者的结果。两组研究对象的限制和匹配确保了所选患者在疾病严重程度方面具有可比性。结果表明，临床路径组和比较组在人口统计学变量、危险因素患病率和合并症方面相似。实施临床路径后，平均住院时间有统计学意义的显著缩短。这一成果的取得并未对短期临床结果如住院死亡率、并发症发生率和发病率产生任何不利影响。出院后6个月的再入院率没有显著差异。本文得出结论，在急性护理综合医院的背景下实施临床路径能够通过医疗保健专业人员之间更好的协作和工作系统的改进显著改善护理流程。
