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An integrated care pathway for leg ulcer management

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VOL: 97, ISSUE: 03, PAGE NO: 10

Tracy Evans, Cert HSC, is integrated care pathway coordinator, Doncaster Royal Infirmary and Montagu Hospitals NHS Trust

There is evidence that the type and quality of care delivered to patients with the same condition who are treated in a single health care district will often vary (Macario et al, 1998). Integrated care pathways (ICPs) provide a means of addressing such inequity.

There is evidence that the type and quality of care delivered to patients with the same condition who are treated in a single health care district will often vary (Macario et al, 1998). Integrated care pathways (ICPs) provide a means of addressing such inequity.

ICPs are being used throughout the UK as a tool to standardise clinical care processes and improve patient outcomes and satisfaction (Capuano, 1995; Reiter, 1998; Scranton, 1999).

There is increasing pressure in the NHS to find ways of providing high-quality care while controlling costs. ICP development reflects such tensions, parallelling changes driven by clinical governance that emphasise clinical effectiveness, efficiency, increased use of evidence-based medicine and critical appraisal of clinical practice (Haynes et al, 1995; Kitchiner et al, 1996a; Edwards, 1998).

Definitions
Simultaneous local development has resulted in the generation of a number of different terms and definitions to identify care pathway tools - for example, anticipated recovery paths, clinical pathway, care pathway, managed care and integrated pathway of care.

The National Pathway Association (NPA) has developed a definition based on a consensus view of the NPA membership (Box 1). In simple terms, an ICP constitutes a step-by-step, day-by-day plan which identifies each process, task or investigation that should be undertaken in order for patients to receive the best possible care as they move towards the treatment objective.

The individual needs of the patient provides the focus at each step, thereby complying with recommendations presented in the NHS white paper The New NHS: Modern, Dependable (Department of Health, 1997).

Characteristics
The main aim of an ICP is to improve the quality of patient care. All ICPs therefore will provide the following:

- Consistent care by decreasing variations in practice;

- Comprehensive and continuous care transferable across boundaries and agencies;

- A measurable environment for audit, thereby promoting change in practice through analysis of variations and standards.

They will be:

- Based on evidence and best practice;

- Patient-focused;

- Clinically effective;

- A single multiprofessional record of care;

- An effective use of resources.

A typical case management model aims to provide service excellence, combining service quality and customer satisfaction by fostering interdepartmental team work and linking cost and quality in diagnosis related groups (Newman, 1995).

Variance-tracking is one feature that distinguishes an ICP from other forms of case management. The aim of variance-tracking is to determine where there is variation from the treatment goal and find solutions to any possible delay through analysis of the sequential steps of the ICP. This provides valuable data to support continuous change and improvement of care.

The variance determines positive variation - goals achieved more quickly than expected - and negative variation - goals not achieved on time. Within this form of analysis specific problems can be investigated and the ICP refined in the light of the most recent experience (Kitchiner and Bundred, 1996b; Kitchiner and Wilson, 1996c; Silverestein, 1998).

Types
There are four different types of ICP:

- Elective surgery: for the management of a patient requiring a total hip replacement, for example;

- Emergency: for the management of a patient who has had a myocardial infarction, for example;

- Monitoring: for the management of people with diabetes, for example;

- Prevention: in the management of cervical cancer, for example.

Each type of ICP draws together different patient groups, staff groups and boundaries. For example, when a patient undergoes elective surgery, both primary and secondary care settings are likely to be included in the ICP. An emergency ICP could also involve ambulance services, community and tertiary care. On the other hand, monitoring and prevention ICPs mainly involve primary care services alone.

Legal implications
Concern about the legal implications of ICPs has been raised (Nolin, 1995; Brugh, 1998). However, Tingle (1997) argued that 'practitioners were better protected if they could show that their decision-making was based on care pathways or guidelines, since this would indicate that care had been provided in a controlled environment that supported reflective clinical practice'.

The two highest areas for litigation relate to documentation and communication. However, ICPs address this as they generate paperwork, or a computer record, setting out the minimum standard of care, which is completed as interventions are performed. This single integrated case record is used by all members of the multiprofessional team, improving collaboration and communication between all disciplines involved in the delivery of care.

As long as agreed standards are in place and the delivered care is endorsed by a signature, then no problems should occur (Wilson, 1995).

Quality improvement initiatives and ICPs
There have been many initiatives in the NHS to ensure greater consistency in the availability and quality of services right across the service - for example, the introduction of the Research and Development Programme, the formation of the National Institute of Clinical Excellence (NICE), promoting clinical and cost-effectiveness by producing clinical guidelines with emphasis on evidence-based care, and the Commission for Health Improvement to support and oversee the quality of clinical governance.

The latest initiative is the emergence of National Service Frameworks, which set out the patterns and levels of service that should be provided for patients with certain conditions (Department of Health, 1997; Department of Health, 1998; Department of Health, 2000).

ICPs are an ideal vehicle to implement these initiatives. Not only do they offer a means of evaluating current and best practice to identify areas for improvement, they can also be used to incorporate national and local guidelines and local protocols into routine practice (Overill, 1998; Kitchiner and Pozzi, 1999).

ICPs are also an integral part of long-term service agreements, a new contracting structure to provide an integrated health community approach to service provision, and also provide the data source for audit, performance indicators and monitoring compliance for clinical governance. As suggested by Lowe (1998), 'the ability of ICPs to combine process, practice and audit help them function as tools to assist both commissioners and providers in meeting both quality and business objectives through cost-effective, integrated care'.

Developing an ICP for patients with leg ulcers
The development of an LTSA for vascular services in our trust led to the creation of an ICP for leg ulcers. Initial consultations to develop the LTSA involved representatives from public health, contract and associate managers, the clinical director, consultants and GPs, specialist wound care and vascular nurses and an ICP coordinator who created evidence-based algorithms for all of the vascular service. The leg ulcer algorithm (Fig 1) included standards on referral, investigations, treatment and timings.

Many discussions took place regarding the length of time an ulcer took to heal, and it was decided that if after 12 weeks of graduated compression the ulcer did not heal or deteriorated a referral should be made to the dermatology department.

Once the algorithm had been defined and agreed, the wound care nurse collated the latest evidence in wound care for leg ulcers and presented this to the team for further consultation.

The first step to produce equity in service provision was to create an ICP defining the treatment path of patients with leg ulcers. A multidisciplinary team developed this with members from both acute and primary care sectors (Box 2). After the development of their vision statement their first job was to undertake a retrospective, baseline audit. This identified that, despite the fact that all community nurses received identical training, each area had adopted differing wound care regimens. This meant that patients living next door to each other with the same type of ulcer were getting varying levels of care.

Further consultation noted that some patients were being referred to the acute trust unnecessarily and others, who would have benefited from being referred, were not referred at all.

The treatment guidelines on graduated compression had been updated a couple of months before the start of this project, so these were accepted and agreed. To reduce the time spent developing new paperwork, examples of current paperwork in the trusts and of ICPs from other trusts were gathered and good and bad points of all the collated documentation were discussed.

After identifying what the team considered to be the best parts of the documentation, a provisional care pathway was put together, taking into account the current format of trust documentation and the algorithm.

The most important part of the ICP documentation was considered to be the initial assessment of the wound and follow-up appointments.

The follow-up appointment document was found to be the most difficult to create, especially when trying to keep it as short and straightforward as possible. To overcome this, the team decided that a table format would be advantageous, as progress or deterioration could be seen at a glance over the 12-week healing period.

As a leg ulcer sentinel audit had been carried out annually the criteria were integrated into the pathway as part of the audit trail. This is detachable from the main body of the ICP and can be transferred on to a computer to provide almost 'instant' feedback for the staff. Before the implementation of the pathway into the clinic/home setting, education sessions were set up for all staff involved. These included the aims and benefits of the ICP and an explanation of how to complete each section. The treatment guidelines/protocols on the use of compression for each type of ulcer, with recommended bandage combinations, currently in use were integral to the ICP.

Conclusion
The consistency of approach and definition of care in ICPs, together with the in-built monitoring of variance analysis, help to demonstrate clinical and cost-effective care (Macario et al, 1998; Kitchiner and Pozzi, 1999). ICPs are an on-going process for continuous change and improvement, and provide outcome-based quality health care (Kitchiner et al, 1996a; Kitchiner and Bundred, 1996b; Dowsey et al, 1999; Kitchiner and Pozzi, 1999).

Integration of this quality improvement process with ongoing education and research has led to considerable local benefits at the Doncaster Royal Infirmary and Montagu Hospitals NHS Trust, and it is hoped that others can benefit from our experiences.

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