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Critical Pathways as a Strategy for Improving Care: Problems and Potential

Steven D. Pearson, MD, MSc; Dorothy Goulart-Fisher, RN; and Thomas H. Lee, MD, MSc
[+] Article, Author, and Disclosure Information

From Brigham and Women's Hospital, Harvard Medical School, Harvard Pilgrim Health Care, and Partners Community Health-Care, Inc., Boston, Massachusetts. Grant Support: Dr. Lee is an Established Investigator (900119) of the American Heart Association. Requests for Reprints: Thomas H. Lee, MD, Partners Community Healthcare, Inc., Prudential Tower, Suite 1150, 800 Boylston Street, Boston, MA 02199-8001. Current Author Addresses: Dr. Pearson: Department of Ambulatory Care and Prevention, Harvard Pilgrim Health Care, 126 Brookline Avenue, Boston, MA 02215. Ms. Goulart-Fisher: Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115. Dr. Lee: Partners Community Healthcare, Inc., Prudential Tower, Suite 1150, 800 Boylston Street, Boston, MA 02199-8001.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1995;123(12):941-948. doi:10.7326/0003-4819-123-12-199512150-00008
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In an era of increasing competition in medical care, critical pathway guidelines have emerged as one of the most popular new initiatives intended to reduce costs while maintaining or even improving the quality of care.Developed primarily for high-volume hospital diagnoses, critical pathways display goals for patients and provide the corresponding ideal sequence and timing of staff actions for achieving those goals with optimal efficiency.

Despite the rapid dissemination of critical pathway programs in hospitals throughout the United States, many uncertainties remain about their development, implementation, and evaluation.In addition, serious concerns have been raised about their effect on patient outcomes and satisfaction with care, physician autonomy, malpractice risks, and the teaching and research missions of many hospitals. Underlying these concerns is the absence of data from controlled trials to evaluate the effects of critical pathways.

Physicians should understand the potential benefits and problems associated with critical pathways because physicians are increasingly being asked to provide leadership for pathway programs.Physicians and other health service investigators should also develop methods to study pathways in evolving health care settings. Although the promise of reduced costs and improved quality is enticing, the gaps in our knowledge about critical pathways are extensive; therefore, like any new health care technology, pathway programs should be fully evaluated in order to understand the conditions under which that promise may be fulfilled.


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Figure 1.
The first 2 days of a simplified critical pathway for patients who have had cardiac surgery.

This general time-task matrix format, also known as a Gantt chart, indicates for each day of care the corresponding multidisciplinary staff actions and expected patient outcomes. CT equals chest tube; CXR equals chest radiograph; EKG equals electrocardiogram; ET equals endotracheal tube; ICU equals intensive care unit; MD equals physician; PO equals by mouth; POD1 equals first postoperative day; .

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Figure 2.
Documentation of expected actions and outcomes.

A simplified version of a page from a critical pathway for patients who have had coronary artery bypass surgery. This page shows some of the actions and intermediate outcomes that are expected to occur on the day of surgery. A level of detail suitable for nursing documentation is included, but, to encourage physicians to participate, only the two elements that are the most important to them are indicated in bold print: 1) ordering an anesthesia consult as part of an early extubation protocol and 2) adequate pain control with analgesics. D equals day nursing shift; E equals evening nursing shift; N equals night nursing shift; VAR equals variance.

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Figure 3.
Variance documentation.

This figure shows a simplified version of the page of a critical pathway for patients who had had coronary artery bypass surgery that is used if a patient does not achieve the “gateway” of expected transfer from the intensive care unit to an intermediate care bed within 24 hours after surgery. Reasons for the variance are documented by the nurse who is caring for the patient at the beginning of the patient's second day in the intensive care unit, and these data are used in ongoing evaluations of the pathway and the care process. D equals day nursing shift; E equals evening nursing shift; ECG equals electrocardiogram; N equals night nursing shift; VAR equals variance.

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