INTEGRATED CARE PATHWAYS

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• INTEGRATED CARE PATHWAYS
• Jo Hockley RGN MSc PhD
• University of Edinburgh
• Jo.hockley_at_ed.ac.uk
• www.stcolumbashospice.org.uk

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Similarities between TQM and critical pathways
(Zander 1992)

• TQM Principle
• definition of quality
• consumer orientation
• work process focus
• preventative systems
• management by fact
• continuous improvement

• Critical Pathways
• sets process goals
• patient specific paths
• defines services required
• constant variance analysis corrective actions
• documentation of problem corrective action
• ongoing review modifications

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A pathway.

• forms part of the clinical record is
  multi-disciplinary
• it is goal orientated
• includes time intervals in which care is
  planned
• incorporates evidence-based guidelines
• is dynamic and variations from the pathway MUST
  BE documented
• provides a continuous evaluation of clinical
  practice

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An ICP for the last days of life What would
be the objectives for an integrated care
pathway for residents dying in a NH?
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What might some of the objectives be for
developing a care pathway for dying residents in
NHs?

• To monitor or document care being given in the
  last days of life
• To increase communication with the families of
  those residents who are dying when there might be
  a tendency to avoid
• To adopt clinical guidelines into everyday
  practice - practicing evidenced-base practice
• continued/..

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Objectives continued

• To enhance greater multi-disciplinary working
• To increase staff awareness of the process of
  dying
• To improve the holistic care given to the dying
  and their families
• To increase nursing home staff competence in
  caring for the dying and

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Diagnosing dying

• The patient is
• deteriorating without any reversible causes
• semi-comatose
• bed-bound
• taking little food/fluids having difficulty
  with oral medication
• not wishing further investigations/interventions
• (BMA website)

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Commencing a pathway

• Multidisciplinary
• together nurses and the doctor establish whether
  the resident/patient is dying
• Initial Assessment
• Holistic
• Residents and family physical and psychosocial
• Ongoing Assessments
• 4hrly assessments
• pain, agitation, breathlessness, nausea/vomiting,
• mouthcare, pressure areas, bowels/retention of
  urine, bedsides etc
• Daily assessments
• communication with resident/patient family,
  spiritual needs, arrangements for family,
  dressings, bowels psychosocial aspects of care -
  communication with resident/patient family

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Reasons for variance

• Patients clinical condition
• Patients social circumstances
• Associated diagnoses
• Changing technology or techniques
• Clinicians decision not to follow the integrated
  care pathway

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Conclusion - ICPs

• locally agreed
• multidisciplinary
• documents care given
• uses guidelines evidence
• specific patient/client group
• facilitates evaluation
• tool for audit quality improvement

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Changes in Prescribing after ICP implementation
(Hockley et al 2004)
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Change in recording/treating end-of-life
symptoms
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Impact of the development for staff

• Overarching pattern
• DYING WAS LESS PERIPHERAL TO NURSING HOME CARE
• 5 themes
• A greater openness around death dying
• Recognising dying taking responsibility
• Better Teamwork
• Critically using PC knowledge to influence
  practice
• More meaningful communication

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A greater openness around death and dying

• ..its not hushed hushed discussion now it
  is more open the fact that now this personthey
  are on the ICP..OK, were expecting this person
  is going to die quite imminent. It is not as
  hushed hushed now you are talking about it.
  KC. NH.D
• Yes, and instead of shutting people away
  especially in the dementia unit, we used to put
  them in the sitting room with somebody standing
  outside the glass door so that they couldnt
  leave I dont do that at all now. We prepare
  them.. And say, so and so died and theyre going
  away shortly.. KC. NH.E

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Recognising dying and taking responsibility

• I feel better equipped to anticipate problems
  whereas the contrast before the pathwaywe were
  always on the back foot the problems would
  happen and then we would try and deal with them
  and often there was a time lapsegetting drugs to
  deal with it whereas now everything is
  anticipated and you are prepared and so therefore
  you deliver a far better service. KC. NH.C

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Improving Teamwork

• The pathway it draws everybody together,
  everybody is going in the same direction,
  everybody is doing the right thing and it makes a
  huge difference
• SN. NH.C
• Communicating better with the doctors being a
  bit up front about what we might need before we
  need it, we didnt do that before.
• NHM. NH.D

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Critically using palliative care knowledge to
influence practice

• if one of the carers comes and says he sounds a
  bit funny, you know, you wont say, Well, they
  always sound a bit funny when they are dying.
  You say well OK, well go and have a look at
  them. You know so youre getting all the
  information from everybody and youre acting on
  what you are getting I think its been really
  good.
• KC. NH.A

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Deeper more meaningful communication

• not sort of brushing it off with a throw away
  commentshell be fine tomorrow, but actually
  taking the time to sit and say well what is it
  that is making you feel that way? Theres a lot
  more of that stuff that is happening, an awful
  lot more..
• KC. NH.C
• Accepting that death is a natural process in
  older people ..I didnt know how to deal with
  death myself but this has enlightened me, made me
  accept death as a natural thing..
• KC. NH.A

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• ..its a lot more relaxed and people arent so
  frightenedits been a really successful thing in
  bringing death and dying to the fore and not to
  be so frightened of it.
• SN3.NH.H final evaluation

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References

• Riley W (1998) Paving the way. Health Service
  Journal, 108 30-31
• Overill S (2003) The development role and
  integration of integrated care pathways in modern
  day health care. In J Ellershaw S Wilkinson
  (eds) Care of the Dying a pathway to excellence.
  Oxford University Press Oxford
• Ellershaw J Wilkinson S (2003) Care of the
  Dying a pathway to excellence. Oxford University
  Press Oxford
• Zander K (1992) Critical Pathways. In M. Minerva
  Melum M. Kuchuris Sinioris (eds) Total Quality
  Management the health care pioneers. American
  Hospital Publishing Chicago. pp305-314
• Hockley J, Watson J, Dewar B (2004) Implementing
  an integrated care pathway for the last days of
  life into 8 nursing homes. Bridges Initiative
  Report. St Columbas Hospice