For as long as nurses have cared for patients, they have planned patient care. This care planning process has been both formal – the written nursing care plan and informal – the individual nurse’s plan of action for a particular shift. (See Figures 6-1 and 6-2.) Ireson (1997) notes, “Planning care and documenting implementation of the plan consumes an estimated 30% of nurses’ time” (p. 16). With the way managed care is changing the delivery of patient care, a more multifaceted plan of care is called for. This diversified way of planning patient care must incorporate not only the nurse’s plan of care but also physician input and the care plans of all of the other health care disciplines caring for the patient as well. In addition, this multidisciplinary plan of care must include a way to measure patient progress with regard to outcomes; thus, linking the plan of care to continuous quality improvement (CQI) activities.

          This multidisciplinary patient care plan is commonly known as a critical pathway but may also go by other names such as “clinical pathway” or “care pathway.” A critical pathway is “…not a nursing program but a care delivery program that will have impact on every part of the organization” (Strassner, 1997).

          A critical pathway is a written standardized, “…structured, multidisciplinary patient care plan in

which diagnostic and therapeutic interventions performed by physicians, nurses, and other staff for a particular diagnosis or procedure are sequenced on a timeline” (Ireson, 1997). A critical pathway also identifies expected outcomes that must be achieved within a defined time frame (length of stay) as well as the number and sequence of essential resources that need to be utilized to accomplish the set outcomes (Anderson-Loftin et al, 1995; Goode, 1995). “The critical pathway acts as a roadmap to direct each discipline on the essential interventions and outcomes that must be accomplished on a given day or within a given timeframe” (Smith et al, 1994). The “use of critical pathways is a major component of the case management model” (Rawsky) as their use provides the framework for patient care. A critical pathway is a tool used to help “…plan and focus patient care for a given episode of illness or stage of development” (Aronson & Maljanian, 1996). A critical pathway assists the case manager, the physician(s), and the other health care disciplines caring for the patient in providing optimum quality, cost-effective patient care (Strassner, 1997).

The use of critical pathways was developed originally in 1989 at the New England Medical Center in Boston by Karen Zander, RN, MS, CS. The use of these critical pathways “…with incremental patient outcome goals for planning and evaluating patient care…began…as part of a collaborative care planning process called case management” (Ireson, 1997). They were developed as a “…direct result of changes in the financial payments of short-term hospitals by the Health Care Financing Administration (HCFA) in 1982. The first critical pathways were developed for DRG categories that resulted in the greatest losses to the hospital or had the longest lengths of stay…” (Coleman & Zagor, 1998).

The overall goals of a critical pathway are to decrease variations in practice, minimize treatment delays, and reduce the use of resources to contain costs while preserving or bettering the quality of patient care (Ireson, 1997). “Goals most commonly associated with critical pathway programs are to:

·     Coordinate care

·     Increase patient and family satisfaction

·     Measure and improve clinical outcomes

·     Operationalize continuous quality improvement at the patient care level

·     Effectively manage length of stay

·     Decrease resource utilization

·     Decrease cost per admission

·     Decrease risk/losses associated with managed care contracts

·     Integrate and streamline multidisciplinary documentation

·     Conform to Joint Commission on Accreditation of Health Care Organization’s (JCAHO) requirements” (Strassner, 1997).

          The development of critical pathways has come about because of “…federal reform measures, which include encouragement for more standardization of care, and the pressures of operating under the growth of capitated payments” (Goode, 1995). Critical pathways are developed for patients who have comparable clinical pictures and experience like problems requiring similar health care services, treatments, and resources (Smith et al, 1994). Frequently, the clinical pictures of these patients fall into the categories of high risk, high volume, and/or high cost (Vautier & Carey, 1994). “Critical paths and management plans show critical or key events that must occur in a predictable and timely order to achieve an appropriate length of stay within a diagnosis-related group-specific episode of illness” (Sohl-Krieger et al, 1996).

          After identifying a specific case type to develop a critical pathway for, completing a literature search for information regarding that specific case type begins the process of critical pathway evolution (Stiller & Brown, 1996). Once the information is compiled, a multidisciplinary team comprised of the bedside case manager, physician(s), and all other health care disciplines involved in patient care needs to be appointed to review the information about the case type (Chimner & Easterling, 1993; Stiller & Brown, 1996). Once the multidisciplinary team is formed and before starting to develop the critical pathway, the team members need to address:

·     The format to be used.

·     The guidelines for utilizing the critical pathway, including how it will be evaluated.

·     Who will review the content of the critical pathway for accuracy, completeness, and practicality.

          After these issues are addressed, the multidisciplinary team can develop the critical pathway. The critical pathway should include input from all of the multidisciplinary team members and should incorporate any practice standards as well as institution policies and procedures (Stiller & Brown, 1996). The way the critical pathway is mapped out must be easily understood and incorporated into practice. “Although critical pathways for various diagnoses are available from other institutions, it is important for each institution to develop pathways specific to the unique needs of their facility” (Rawsky, 1996). Variables that must be considered when developing a critical pathway include:

·     The authorized length of stay reimbursed by third party payers.

·     Things that would cause a need for adjustment of the critical pathway.

·     The processes and actions necessary for the realization of designated patient outcomes.

          A critical pathway is outcome focused and is thereby designed to assist the patient in completing measurable clinical goals within a set amount of time. “Time frames may be in terms of hours, days, weeks, or stages of development depending on the patient population. The processes and interventions needed in order to reach the outcomes are then outlined” (Aronson & Maljanian, 1996). To alleviate duplication and reduce practice variations, the processes and interventions of a critical pathway can be grouped under the following ten categories:

·     “History and physical – identify risk factors prompting admission or treatment;

·     Consultants – identify the caregivers needed to assess and treat the patient;

·     Test – includes the measurable data that must be reported;

·     Treatments – includes interventions and actions to be performed by members of the health care team;

·     Medications – includes the drugs ordered, along with dosage, time, and method of administration;

·     Diet – describes the patient’s dietary needs;

·     Activities – outlines the patient’s activity level;

·     Teaching – includes the planned interactions aimed to bring about increased knowledge and change in health status;

·     Discharge planning – defines treatment plan and discharge; and

·     Outcomes – expected prior to discharge or problem resolution” (Smith et al, 1994).

The critical pathway also designates which health care discipline is accountable for helping the patient achieve each specific outcome and provides a timeline for outcome completion that begins at admission and ends after discharge. In addition, a critical pathway has a problem list with suitable nursing diagnosis attached to it.  (See Figure 6-3.)

          Many acute care facilities are adopting the use of critical pathways to provide a framework for meeting patient care goals. Nugent (1992) writes, “Ambiguity, confusion, and fragmentation dominates patient care if a common purpose is not understood”. Critical pathways help to alleviate the three problems sited by Nugent by including patient care guidelines with “…predetermined times for patient care to be implemented and definitive outcomes to be achieved” (Christensen & Bender, 1994). “Critical Paths are used on every shift to plan and monitor the flow of care” (Aronson & Maljanian, 1996).

          The use of critical pathways standardizes patient care and ensures consistency of the health care team’s patient care practices. The use of critical pathways also ensures the patient is involved in the provided care and any treatment decisions. Zander (1988) notes that, “patients and their families are being informed about their expected Critical Paths and engaged in new ways to facilitate their care”.

          “NCMs (Nurse Case Managers), working with other nurses and physicians within group practices, use …critical paths to map, track, evaluate, and adjust each patient’s course and achievement of outcomes” (Sohl-Kreiger et al, 1996). Roberts-DeGennaro (1993) notes, “the case manager orchestrates the services of the collaborating providers according to the timetable in the contract; maintains communication with the service providers; and meets on a regular basis with the interdisciplinary team”. When critical pathways are used, each day is mapped out according to a multidisciplinary treatment plan. Using the critical pathway, the health care team members set goals for each individual patient care day. The critical pathways are preprinted, and the anticipated duration and course of patient treatment is documented. The case manager and other members of the health care team are then able to compare the patient’s actual progress against the expected outcomes on the critical pathway. Use of the critical pathway assures timely, quality patient outcomes and the appropriate use of resources in meeting those outcomes. According to Strassner (1997), “Using critical paths is one strategy to manage clinical processes and demonstrate clinical and fiscal outcomes”. Aronson and

Maljanian (1996) list the following as the goals of a critical pathway: “a) plan for the highest quality of care at the lowest cost; b) open lines of communication among caregivers and various departments, thus increasing collaboration and efficiency; c) serve as a streamlined documentation tool; and d) provide a method for data collection for Continuous Quality Improvement (CQI)”.

          When a patient is admitted to the hospital, the bedside case manager assigned to care for that patient chooses the appropriate critical pathway. The critical pathway needs to be addressed with the patient’s physician within 24 hours after the patient’s admission. After the critical pathway is addressed with the patient’s physician, it is shared with the patient and the patient’s support person(s). It is some hospitals’ policy to give the patient a copy of the critical pathway to keep at the bedside. Sharing the critical pathway with the patient and the patient’s support person(s) gives them the knowledge they need regarding the processes, interventions, and time frames included within the critical pathway to actively participate in patient care. Daily, during patient rounds, the patient’s progress is reviewed by the patient, the patient’s support person(s), the patient care team members, the case manager, the physician(s), and the other health care disciplines caring for the patient and compared to the expected outcomes of the critical pathway. Any variances and plans of how to get the patient back on track are also discussed during patient rounds. The outcome of patient rounds and patient progress is communicated to the patient care team members on all shifts via the change of shift reports. Change of shift reports also provide time to discuss any changes in patient status or progress, any variances, and any possible solutions to patient care issues. The patient’s progress and individual patient care activities are documented by members of the health care team (Stiller & Brown, 1996). Once the expected patient outcomes are achieved and all critical interventions have been carried out, the critical pathway is discontinued (Stiller & Brown, 1996).

          According to Coleman and Zagor (1998), using critical pathways to organize “…the care delivered each day of a patient’s stay has proven to result in fewer complications, faster recoveries, lower costs, improved quality and better use of inpatient resources”. Goode (1995) concurs that “…a decrease in length of stay and a decrease in charges (occur) when a critical path is used”. Schoen (1997) agrees that the use of critical pathways results in cost savings, and Zander (1988) acknowledges that the use of critical pathways ensures that both quality and cost outcomes are attained.

          Zander (1988) further notes, “Critical paths are viewed as common sense and helpful by all departments and providers. They have helped place the right intervention at the proper time, so that some of the last-minute nature of complex processes, such as discharge planning, is alleviated”. Coleman and Zagor (1998) note that “evidence has shown that the use of a multidisciplinary critical pathway helps reduce variances in patient care” including those deviations from care that occur when a patient care team member is floated to an unfamiliar unit. With critical pathways in place, the float person will know exactly what needs to be done for the patient and will be able to objectively evaluate precisely what the patient’s progress is.

          Critical pathways allow for the use of objective data versus individual judgements for goal evaluation. The case manager uses the critical pathway, in combination with sound clinical experience and knowledge, to objectively evaluate how the patient is meeting set outcomes. Milne and Pelletier (1994) note, the use of critical pathways also resulted in “…enhanced staff skill in physical assessment, patient/family teaching, and communication with physicians”.

          When the critical pathway is initially reviewed with the patient’s physician, it is individualized for the patient and is modified as needed at that time. The initial review time is the only time that the critical pathway is individualized and/or modified. From that point forward, the departures from the critical pathway would be recorded as variances. However, as the patient’s health care status improves or declines, patient care priorities and interventions are appropriately readjusted to meet those changes (Nugent, 1992).

Patient Care Protocols

          Wojner (1997) defines patient care protocols as “broad research-based practice recommendations (that are) multifaceted (and) may drive specific practices within numerous disciplines. (They) prescribe therapeutic interventions for a specific clinical problem within a sub group of patients (and are) …more specific than a critical pathway”. Protocols are a researched set of specific patient care instructions developed by the institution that contain:

·     Directions regarding the preparation needed prior to completing a particular patient care task.

·     Directions for the actual performance of the patient care task.

·     Documentation requirements regarding the patient care task.

Protocols compliment a critical pathway (Wojner, 1997) and encompass patient care tasks such as the management of a central line, the management of blood and blood products administration, or the management of oxygen therapy.

          Strassner (1997) defines a variance as “…any activity (test, treatment, procedure, or clinical outcome) that does not occur at all or does not occur in the scheduled time period according to the critical path”. Variances show patient and/or care provider and/or system events that can influence patient outcomes (Aronson & Maljanian, 1996). Variances can be positive or negative. For example, if a patient is discharged home earlier than expected, a positive variance has occurred, but if a patient’s hospitalization period is extended beyond the anticipated length of stay due to say a service delay, a negative variance has transpired (Marr & Reid, 1992). According to Milne and Pelletier (1994), “…variances may be related to patient complications, system inadequacies, or caregiver deviations from prescribed interventions”.

          Christensen & Bender (1994) write, “a variance from the critical path is recorded and monitored as a baseline for quality assurance and evaluation of care”. According to Aronson and Maljanian (1996) and Stiller and Brown (1996), it is extremely important to monitor and accurately document any variances, the reasons they occurred, and any actions taken to resolve them as part of the critical pathway process. To determine whether a variance is occurring and to rectify that variance if it is indeed evolving, questions such as the following ones need to be asked.

·     What should the patient, the patient’s support person(s), and/or the health care disciplines caring for the patient be doing at this point in the patient’s hospitalization?

·     Are these actions occurring as they are supposed to be according to the critical pathway?

·     If the actions aren’t happening according to plan, is a variance occurring?

·     If a variance is occurring, what is the cause of the variance?

·     What needs to be done about the variance, and how are the variance and any actions implemented to rectify the variance documented?

“Variance recording (documentation) provides information which can be used to improve quality of care” (Stiller & Brown, 1996, p. 12). Variances are followed for each patient throughout the hospitalization period by the case manager (Marr & Reid, 1992). Patient care conferences, including all members of the multidisciplinary team, are held to identify the cause of the variance and to formulate a plan for resolution of the deviation. The case manager identifies and analyzes any repeated variances so that any needed changes to the critical pathway, to patient care services, or to a specific health care discipline’s practice can be made (Marr & Reid, 1992; Rawsky, 1996).

          A critical pathway provides the framework for tracking patient progress and outcomes. It provides a map of patient care for all members of the health care team to follow. Appropriate utilization of a critical pathway, grounded on a solid knowledge base, assists the members of the health care team in providing optimum quality patient care within set time boundaries at a reasonable cost.


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