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Protocol-based care: 2. Developing pathways with effective teams

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Brendan Docherty, MSc, RN, PGCE.

Clinical Manager, Cardiology, Critical Care and Medicine

This paper, the second in a 12-part series (see Box 1; Clark, 2003) examines the context of why integrated care pathways (ICPs) are essential in a modern NHS, and discusses the pathway's development team and its function. We highlight the development of an ICP in our organisation that focused on patients with an acute coronary syndrome (ACS).

This paper, the second in a 12-part series (see Box 1; Clark, 2003) examines the context of why integrated care pathways (ICPs) are essential in a modern NHS, and discusses the pathway's development team and its function. We highlight the development of an ICP in our organisation that focused on patients with an acute coronary syndrome (ACS).

At the Queen Elizabeth Hospital NHS Trust in London, we have to date implemented 17 paper-based pathways, with a further 24 in development, and can draw on some valuable experiences.

An ICP is defined as '... locally agreed, multidisciplinary practice based on guidelines and evidence for a specific patient group ... and facilitates the evaluation of outcomes for continuous quality improvement' (DeLuc, 2001a). Care pathways also 'improve cost effectiveness and maximise quality of care' (Leong et al, 2000).

Many important NHS documents set the context for their development (Box 2). We have also included our own hospital's objectives in the list.

At our trust we see on average 240 patients each day with about 40 attendees to the emergency department admitted to hospital. Trying to implement an ICP in a busy department with its own national targets proved to be a challenge.

Literature search
Medline, Cinahl, Embase, Health Management Information Consortium and Cochrane databases were searched for 1998-2003, using the key words care pathways, acute coronary syndrome, team working, multidisciplinary and multiprofessional. The papers were retrieved and critiqued for rigour using the model provided by Benton and Cormack (2000).

Establishing the need
The World Health Organization's definition of cardiac disease focuses on acute myocardial infarction and non-myocardial infarction diagnoses using cardiac chest pain as the main criterion (Panteghini, 2002).

However, as up to 40% of patients may have inconclusive electrocardiographic changes, and up to a third may present without chest pain, this method of diagnosis has become outdated (Panteghini, 2002). Diagnosis of acute coronary syndrome with the aid of biochemical protein markers (troponin) was not commonplace in modern health care until 2001 (Castle, 2002), and has altered the diagnosis of unstable angina to that of acute coronary syndrome (Joint ESC/ACC Committee, 2000). The diagnosis and treatment of patients who present with classical signs, symptoms and electrocardiogram changes diagnostic of acute myocardial infarction is relatively straightforward (NICE, 2002).

However, with troponin markers, a group of patients who in the past may have been discharged from the emergency department are now admitted to reduce the risk of an acute coronary event, and for further investigation. It is also possible to triage patients as 'low risk'; potentially reducing admission rates for patients with 'innocent' chest pain. We can also prompt access to our rapid access chest pain clinic for further investigations.

The cardiology multidisciplinary team decided that an acute coronary syndrome ICP to replace the existing acute myocardial infarction ICP would be desirable to ensure clinically relevant and evidence-based medical and nursing management plans, and serve as a practice development, education, training and audit tool.

With frequent changes in junior medical staff and problems recruiting nurses, it is always a risk in any speciality that non-specialist department staff may not have the many skills required to care for a host of patients with complex needs and conditions.

One retrospective analysis of emergency department cardiac patients with difficult-to-diagnose acute coronary syndrome demonstrated that long-term mortality rates were higher than those with easy-to-diagnose myocardial infarction, and that there was a significantly higher chance of adverse cardiac events in those patients awaiting outpatient diagnostic testing (Manini et al, 2002).

At Queen Elizabeth Hospital we had a shared vision that the ICP for acute coronary syndrome would help practitioners identify signs, symptoms and classification of acute cardiac chest pain and aid a speedy and correct diagnosis for most patients. ICPs also give a comprehensive, well-organised and patient-focused approach to interdisciplinary care (Sulch et al, 2000).

With this in mind, we appointed an acute coronary syndrome nurse specialist to act as a facilitator of best practice care development within the emergency department, using the ICP. The nurse specialist, ICP co-ordinator and three clinical governance facilitators from the quality development department would provide ongoing ward support. The development of this pathway came from:

- A need to manage changing cardiac care

- A desire to help diagnose cardiac conditions in a busy department with competing priorities

- A need to meet National Service Framework targets to ensure thrombolysis times for those indicated patients happened within 20 minutes

- Through the ICP, to ensure that all patients received equitable evidence-based care by way of a multidisciplinary framework.

Organisational capability
From an organisational perspective, it is of great benefit if the executive team is committed to the development of ICPs, and values the role of the ICP in organising health-care for patients (DeLuc, 2001b), as at this trust. ICPs are an effective and safe tool in both inpatient and outpatient care. They help define specific patient groups (Vinson and Berman, 2001) and, for this reason, they are usually well supported by health-care managers.

At the Queen Elizabeth Hospital NHS Trust, all new staff receive ICP training during their induction. It has also recently been made mandatory for most staff groups to undertake training and this is already making a difference to how health-care staff view ICPs.

The dissemination of ICP-related information is seen as an important communication link across the trust. An ICP link role has been developed to assist this. Each clinical area has a nominated member of staff to help with this information cascade and meet regularly with the ICP co-ordinator.

Bimonthly ICP reports, which are a breakdown of every ICP in the programme, are circulated widely to promote awareness and information sharing. However, before designing a pathway, the items listed in Box 3 need to be present.

Forming a group
Volunteers with a genuine interest in an ICP project rather than nominated individuals should be sought to become members of the group. Groups should be neither too small nor too large, and should ideally consist of about 10-14 people (DeLuc, 2001b). These professionals should be the people using the ICP in practice, thereby ensuring it is consistent with what they do. Ownership aids dissemination, implementation and utilisation (DeLuc, 2001b).

Non-clinical staff should also form part of the group, and these could come from administrative and ancillary staff; as well as any outside agencies which may be involved from a primary or tertiary care perspective.

We chose a top-down approach to this ICP as we required expert practitioners and service managers in the group due to the abundance of new evidence about acute coronary care and cardiology care. However, we circulated the drafts of the ICP widely to allow others to comment and to gain some ownership of the content.

The group consisted of consultant medical staff and senior nurses from cardiology, general medicine and the emergency department. In addition, representatives from other departments were also invited, including pathology and pharmacy. Other individuals gave the group the benefit of their expertise on specific topics, for example establishing a best-practice protocol for people with diabetes and acute coronary syndrome was developed in partnership with the diabetes nurse specialist.

Group function
Relationships in the work environment are thought to be weaker than those of friendship and intimacy, though friendship can often be created by a working relationship. However, when considering group interaction for the development of an ICP, working towards a common goal will strengthen working relationships, and if goals are not shared, hostility and conflict among group members may prevail (Mina, 2001).

This is also true in a group where there are many layers of hierarchy, as it may be perceived that work is being criticised by others who are perceived to be more senior and experienced, preventing individuals from interacting and participating fully (Anonymous, 2000; Wheeler and Grice 2000).

Effective teams have the following characteristics (Anonymous, 2000):

- Clear objectives

- High levels of participation among the team members with a clear focus on quality

- Reflexivity - team reflects critically on ways of working and is flexible enough to make changes

- Clear communication between the team, with effective leadership.

The ICP group who developed the acute coronary syndrome ICP at Queen Elizabeth Hospital agreed nine objectives, which were based around the National Service Framework for Coronary Heart Disease (DoH, 2001) requirements. An example of the objectives set by the group were:

- Call/door to needle time and causes of delay to be documented as part of the ICP

- Start of/discharge on appropriate drug therapy

- Capture data to measure performance against milestones and standards for monitoring of the CHD NSF

- Use of multidisciplinary documentation promoting better communication.

Managing meetings
A productive, goal-oriented meeting is essential in ICP development, and a process-mapping exercise should be carried out in advance (DeLuc, 2001b; Wheeler and Grice 2000). In Process mapping the journey of the patient is trailed through health-care services - documenting their personal feelings and thoughts as they travel through the system. The aim is to improve the process from the patient's experience and/or identify process flaws that require adjustment to enhance the service and the patient's perception of the service (DeLuc, 2001b; Wheeler and Grice, 2000).

The first ICP development meeting should include (DeLuc, 2001b):

- Introductions and agreement of individual team members' roles, with the chairperson identified

- Agreement of ground rules and working practices: for example meetings may be the same time on the same day each week

- Meetings should be minuted and action points clearly identified, including the name of the person responsible for the action, and its targeted completion date

- Agreement of the topic area and scope of the ICP group. For example, will it begin in primary care, through the secondary care phase, and end back in the community? It is also helpful to review ICPs from areas of the organisation, or other organisations.

- Identify barriers and process issues that may be important. For example, would nurse-led thrombolysis help achieve the 20 minutes door-to-needle target? Is this desirable and achievable in a busy emergency department?

Action points at meetings and an ICP project monitoring form are useful tools for keeping the team focused and on target. See Box 4 for an example form.

It is also imperative to communicate - who, what, where and how - at all steps in the ICP development process (Wheeler and Grice 2000; Carney, 2002).

In our experience, unfortunately, meetings were often poorly attended due to urgent clinical commitments. Decisions made would not always meet the approval of those who were not present. It was not possible to include in the ICP exactly what every clinician requested, and negotiation was required to achieve a consensus.

Action points agreed by certain team members were sometimes not carried out by the expected time, posing potential delays in the developmental stages of the ICP. Often a quick telephone call a few days before the meeting to remind the individuals of action required would remedy this.

The first acute coronary syndrome ICP was reviewed three months after its implementation. Changes were required, as some staff found it cumbersome to use.

The development team began work on reconfiguring the document, taking into account the opinions of those using the ICP most - the junior medical and nursing staff. However, there always seemed to be more suggestions for alterations, and the proposed date for launching the second version of the pathway was postponed on two occasions while final amendments were made and agreed by the team.

Managing change
It is often better to have an organisation-wide group that ratifies ICPs at the end of their development, and before they reach the clinical setting (Richardson et al, 2001). Education sessions for practitioners should be organised before launching a pathway and should include the items listed in Box 5.

Ideally, the group who developed the pathway should undertake the training and education component of the implementation (DeLuc, 2001b) and should consider the following:

- How practitioners decide to start a pathway ICP for a particular patient and how they then conclude the pathway, that is, remove the patient from it. In our trust the emergency department is the primary area where patients are placed on the ICP, but it can also be used for existing inpatients who develop chest pain

- Provide examples of a well-completed pathway

- Provide working examples of variances and how they then help to audit and measure care effectiveness

- Provide working examples of a poorly-completed pathway and discuss the reasons for it

- The need for signing entries and how that is achieved. In our trust all practitioners sign the signature record page and then use initials throughout the document to indicate accountability for care provision

- Where the document is kept. This will depend on local circumstances and may be in the patient's bedside folder, but is usually with the health-care records. The pathway should be stored in chronological order with the rest of the health-care records on discharging the patient from the ICP.

ICPs should not be seen as a replacement for clinical judgement and therefore must not be used to dictate care (DeLuc, 2001a). Any change or deviation from the anticipated plan of care mapped out within an ICP needs to be recorded as a variance. Variances from the anticipated plan should be documented as they happen and, at our trust, are audited and analysed retrospectively. Wilson (1997) describes the aims of analysis and these are listed in Box 6.

An example of reporting a variance with the ACS ICP could be when a patient has had a slower recovery time from an acute myocardial infarction, spending longer than 48 hours in the coronary care unit.

After the launch of the first and second version of the acute coronary syndrome ICP, strong links were maintained with the pathway group. It was then used in the clinical area to provide continuous feedback and follow the patient's journey along the pathway. This enabled prompt troubleshooting and support for clinical staff and feedback to the ICP group of the 'fruits of their labour'.

Involving patients
Patient/user involvement is integral to service evaluation and development in the modern NHS (DoH, 2000). We have regular feedback on our care provision from the Patient Advice and Liaison Service (PALS) within the trust, and the cardiology division also holds regular patient experience workshops in the cardiac rehabilitation programme and feeds back relevant user perceptions through the clinical governance structures.

Obtaining feedback from PALS and from patient experience groups to incorporate into appropriate acute coronary syndrome ICP interventions is part of our trust's clinical governance plan. Elsewhere in the trust patient-held diaries are being trialled for recording their experiences. These diaries are then analysed and information incorporated into the pathway interventions. In the future each new version of an ICP launched in the trust will have a patient information leaflet mirroring the ICP interventions and goals, to enable maximum involvement of the patient in their care.

Conclusion
Strong leadership and ownership of this or any ICP is paramount for its success. Champions need to be identified to act as a driving force to promote ICPs. Mandatory training and the ICP link role have been invaluable with maintaining the necessary high profile.

Relationships within the ICP group are also key to its success. Careful facilitation and setting and adherence of ground rules are paramount. The ICP facilitator needs be assertive and a good communicator to ensure that the agreed project plans are achieved, and that they can deal with the opinions of strong personalities.

The ICP group must be prepared for potential delays with the project and be kept fully informed of all developments. ICP objectives/goals must be SMART oriented (Specific, Measurable, Achievable, Realistic, Timely) to maintain momentum, and they should be audited and reviewed regularly.

Sharing and celebrating is important for the team when these objectives are achieved. The acute coronary syndrome ICP is a continuously evolving document, which aims to fulfil patient expectations, as well as government and trust objectives.

Providing a speedy diagnosis and evidence-based care in a timely fashion by a suitably equipped and trained multidisciplinary team, most in the trust view the acute coronary syndrome ICP as an invaluable and worthwhile document.

Acknowledgement
The authors would like to thank the acute coronary syndrome integrated care pathway development group at Queen Elizabeth Hospital, London.

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