This article describes integrated pathways of care. These are plans that describe the care that will be provided to patients with a specific clinical problem. They include details of the care that will be provided by the various health care professionals who will be encountered by the patient, from the initial point of contact with the health care system, through diagnosis and treatments and the progress that can be expected,
Evidence-based practice, professional audit and clinical risk management have been constant themes within the National Health Service for a number of years. These approaches have been given additional impetus by current Government policy, which has seen the introduction of clinical governance and the establishment of the National Institute for Clinical Excellence and the Commission for Health Improvement.
Integrated pathways of care (IPoCs) are being developed as a method of ensuring the evidence base of professional practice. By its very nature this approach is multidisciplinary, and involvement offers pharmacists an almost unique opportunity to confirm their role in the team of professionals required to deliver patient care.
The origins of IPoCs can be traced to the United States, where they are used within insurance-based health care systems to ensure a standardised and cost-effective approach to the delivery of clinical care. The pursuit of cost-effectiveness is increasingly important in all health care systems. However, in the United Kingdom, IPoCs have been introduced primarily as a quality improvement tool designed to integrate evidence-based guidelines into everyday practice, to encourage multidisciplinary team working, and to provide a structured basis for the monitoring of the standards and outcomes of the care provided to patients.
The IPoC approach can be applied to almost any aspect of health care but offers the greatest advantage where processes are complex and/or are provided by a number of different agencies, disciplines or professions. In Doncaster, at least 26 IPoCs have been implemented or are under development. The subjects covered range from prevention of cervical cancer to paediatric dental extraction.
The IPoC approach to delivering clinical care offers a number of advantages.
The first step in IPoC development is a comparison of current practice with the available evidence. A multidisciplinary team selected to represent the major professional inputs to the process normally undertakes early development work.
Retrospective audit is often used as a method of identifying and describing current practice. Evidence is identified from a structured literature search and will include evidence-based guidelines, meta-analyses, primary research, reviews and descriptions of best practice. Clearly, all these types of evidence do not merit the same level of credence and, where there is conflict, precedence has to be judged on the quality of the evidence. This process results in the creation of a discussion document which describes the care pathway in terms of locally applicable protocols, based on the most recent relevant evidence.
The multidisciplinary approach adopted in compiling the discussion document is continued in the next stage of IPoC development. Changes to the document are identified through consultation with all the professional groups that will use it. Often the IPoC will be tested by following an "ideal" patient through the system. After fine tuning, a consensus is reached and the document is signed off by all the professions concerned.
This structured approach to multidisciplinary working facilitates collaboration between different staff groups, by detailing how their separate roles are interdependent and relate to each other, and acts as an aid to communication. Not only will the IPoC detail what needs to be communicated, when and to whom, but the IPoC documentation provides an efficient, structured method for recording key clinical data and as such fulfils a communication function in itself.
The advantages of increased collaboration and improved communication are equally applicable at the interfaces between institutions and between primary and secondary care as they are between professions or even different disciplines with a profession.
Following IPoCs ensures that all patients presenting with a particular complaint will receive the same quality of care and level of access to appropriate professionals and services.
Development of IPoCs is a useful aid in identifying the educational, training and continuing professional development needs of the professionals involved in their delivery. A structured training programme for all pathway users should accompany introduction of a new IPoC.
By providing a clearly written summary of their care plan and expected progress over time, IPoCs provide a structured basis for discussion with patients.
It is usual to make IPoCs available to patients (and, where appropriate, to their families and lay carers). The information they contain about the patient's condition, prognosis and the likely outcome of various treatment options allows professionals to include patients in planning their care. This type of involvement provides a sound basis for patients being able to give true, informed consent to treatment.
Because IPoCs detail planned actions, expected progress, intended outcomes and time-scale they provide an in-built standard against which the care provided together with its results can be compared.
Development of an audit trail is a key element of IPoC design. This enables the data required for audit to be collected as an integral part of documenting care delivery and the progress of the patient's condition. The most common approach is to focus on the variations from the IPoC.
IPoCs are not intended to be inflexible or unchanging diktats for regimented care. Variances from the IPoC may occur for a number of reasons, including coexisting disease which complicates the patient's care, the patient's social circumstances, a clinical decision not to follow the pathway, lack of resources, or changes in technologies or techniques. However, regular analysis of variations in an audit setting can be used to identify and rectify common variations from agreed best practice or to update the IPoC by incorporating agreed changes.
Audit of this type results in evolutionary development of IPoCs. Regular review of the evidence base and training needs of the professionals involved, when coupled with ironing out difficulties in the systems and infrastructure that support the IPoC, will ensure that quality of patient care is constantly maintained.
A simple example of the integration of drug treatment into an IPoC has occurred with the prevention and treatment of pain within the paediatric dental extraction pathway at Doncaster. The process (the benefits of which are shown in the Panel) involved a collaborative approach between the pharmacist, the lead anaesthetist to the dental clinic, and the trust's specialist acute pain nurse.
| Benefits of the paediatric day case dental extraction integrated pathway of care |
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The first stage of the process was to identify what common practice existed and review this against current evidence. This resulted in the identification of a two-level approach to the treatment of pain, depending on the intensity of the surgical intervention.
Patients undergoing simple interventions, defined as the extraction of fewer than five teeth, received a single dose of paracetamol appropriate to their body weight. Those patients requiring the extraction of five or more teeth received an additional dose of either ibuprofen or codeine phosphate depending on their past medical history. Both groups were advised to self-administer paracetamol as required after their discharge.
The evidence reviewed in the literature did not contradict such a treatment strategy, although there was debate about the appropriateness of initiating treatment in the less intensive group of patients with an analgesic regimen of known lesser efficacy. The eventual recommendation was to formalise treatment within the IPoC to reflect current practice, but within the audit process of the pilot implementation reviewing the additional analgesic requirements of both groups as an indicator of relative efficacy.
The simplicity of the treatment regimen, combined with the known lack of medical complexity of patients referred into the paediatric day case service, led to a decision to include routine analgesic treatment as a group protocol. The involvement of the pharmacist at this stage of the process was important for two reasons. First, it ensured that a pharmaceutical review of prescribing practice in an area not routinely scrutinised was achieved. Second, it permitted the pharmaceutical service to discharge its duty of care that drug treatment is appropriate for the individual patient, but at a level commensurate with the relatively low requirements for pharmaceutical care inherent within the particular patient population.
Even in this most simplest of examples, the pharmacist's involvement was important in successful implementation of the IPoC. Most IPoCs describe far more complex treatment plans and where medicines are involved the inclusion of pharmacists in their development and delivery will be key to their operational success.
Currently much is being made of the pharmacist's role in multidisciplinary teams or as part of "health communities". However, in some areas of practice this "inclusion" is less tangible than in others. The collaboration facilitated by the IPoC process can promote a greater awareness of the professional role of pharmacists. Involvement in the development, delivery and audit of IPoCs can provide a useful means of improving communication between pharmacists and medical, nursing and other clinical colleagues, which in turn will improve the care of patients to whom we all provide services.
Initially the success of pharmacists' inclusion in the IPoC process will depend on local professional leadership ensuring that all branches of the profession are included. Once our involvement is established, we must ensure that our contribution in the following areas is included where appropriate.
Pharmacist as first point of contact For many patients community pharmacists are the first point of contact with the health care team. It is important that, where appropriate, IPoCs confirm the evidence base of the health promotion advice given and over-the-counter products recommended by pharmacists. This, together with protocols for referring patients on to medical services, will confirm pharmacists' contribution as an important part of many care pathways.
Involvement in formulary development The pharmacist's expertise in formulary development and prescribing management is well established. This role often involves the development of protocols for drug treatment. However, in the past, our approach has been largely focused on the medicinal products themselves. As the application of IPoCs develops, it will be important to redirect our efforts from the development of formularies and other forms of product-based prescribing guidelines to a more holistic, patient-based process. While it will continue to be important to advise on product selection this will be in the context of identifying the place of medicines in individual care pathways.
Advising patients on the use of their medicines The link between patients' understanding of the appropriate use of their medicines and compliance with treatment regimens is well established. Pharmacists have an important role in educating patients about their medicines, both through formal counselling at the point of dispensing and less formally through their regular contact with patients when they visit community pharmacies. It is important that the advice pharmacists provide to patients can be set in the context of agreed care pathways.
Monitoring drug treatment Increasingly pharmacists are developing a role in monitoring prescribed drug treatments. Identifying adverse effects and the need to adjust doses or change treatment regimens should be a legitimate role of the pharmacist. IPoCs can provide an evidence base for these activities and this approach would provide a structured background for the "dependent prescriber" role suggested for pharmacists in the recent Crown review of prescribing and administration of medicines (Department of Health, March, 1999).
Acknowledgment The authors wish to acknowledge the assistance in preparation of this article provided by Ms Tracy Evans, IPoC co-ordinator at Doncaster Royal infirmary and Montagu hospital.
Andrew Barker is director of pharmacy services and Paul Frosdick is deputy director of pharmacy services at Doncaster Royal infirmary and Montagu hospital NHS trust. Correspondence to Mr Barker at Pharmacy Department, Doncaster Royal Infirmary, Armthorpe Road, Doncaster DN2 5LT