Emergency Department Care or Clinical Pathways

Authors:

Wendy W. Sun, MD; Obert Xu, MBBS; and Rohit Sangal, MD, MBA, on behalf of the SAEM ED Admin and Clinical Operations Committee.

Overview

A care or clinical pathway is a multidisciplinary care plan in a decision tree format developed by a panel of experts to diagnose, interpret results, and/or treat various presenting complaints and disease conditions (e.g. chest pain, asthma exacerbation, pre-eclampsia, or diabetic ketoacidosis). Care pathways are informed by evidence-based clinical guidelines and are tailored to local institutional practice. While some may exist as a PDF, website link, or in paper format in the emergency department (ED), newer models integrate them into the electronic health record.¹ This integration allows clinicians ease in ordering standardized lab work, imaging, medications, therapies, consults, and follow-ups.

Best practices are often evolving, and communicating with clinicians can be a challenge. Clinical pathways serve as a standard information delivery tool. In the ED setting, care pathways can be initiated by triage nursing staff or by primary clinical providers, with the intent to deliver standardized, value-based, and high-quality care, particularly in an era typified by unprecedented ED boarding and rapidly changing guidelines and therapies to treat disease conditions such as COVID-19.

Potential Benefits and Pitfalls

The benefits of care pathway utilization have been demonstrated in the literature. Clinical pathways:

• support ED and hospital throughput with overall decreased length of stay^2,3,6;
• provide high-quality and timely care through evidence-based medicine that is standardized across providers within a health care network^2-4;
• minimize cost through standardized resource utilization^5,6; and
• reduce health care inequities among patients.⁶

Care pathways have been criticized for resulting in depersonalized and impersonal patient care. Standardization of care can also lead to anchoring bias and missed rare or unusual diagnoses.⁷ Additionally, poorly constructed clinical pathways have been hypothesized to increase cognitive load due to too many and/or ambiguous prompts.⁸ Therefore, clinical pathways must be thoughtfully crafted and instituted to avoid and overcome these possible pitfalls. Some solutions to these possible pitfalls include consensus building, involvement of stakeholders, data analysis for effectiveness, and simulation center testing for click count, eye tracking, and user feedback.

Interested Parties

Due to the overarching impact of clinical pathways, many stakeholders are invested and benefit from the success of a clinical pathway. These include patients; clinicians from different backgrounds, departments, and training levels; pharmacists; the ED clinical operations team; the patient quality and safety officer; the health equity officer; and information technologists. As a downstream effect of the quality and safety of care patients are receiving, regulatory agencies, such as departments of public health and accreditation bodies, may also have an interest. Therefore, when creating clinical pathways, it is important to have a multidisciplinary team and interested parties such as clinicians validate the clinical pathway prior to its formal release. Additionally, it is important to have a plan to continually reassess the pathways to ensure they are up to date.