Best strategies to implement clinical pathways in an emergency department setting: study protocol for a cluster randomized controlled trial.

Mona Jabbour,Shannon D Scott,Janet Curran,David W Johnson,Astrid Guttman,Francine M Ducharme,Alison Paprica,M Louise Mcnaughton-Filion,Terry Klassen,Mark Shafir,M Diane Lougheed,Thomas Rotter,Amanda Newton,Monica Taljaard,Jeremy Grimshaw

doi:10.1186/1748-5908-8-55

Abstract

BackgroundThe clinical pathway is a tool that operationalizes best evidence recommendations and clinical practice guidelines in an accessible format for ‘point of care’ management by multidisciplinary health teams in hospital settings. While high-quality, expert-developed clinical pathways have many potential benefits, their impact has been limited by variable implementation strategies and suboptimal research designs. Best strategies for implementing pathways into hospital settings remain unknown. This study will seek to develop and comprehensively evaluate best strategies for effective local implementation of externally developed expert clinical pathways.Design/methodsWe will develop a theory-based and knowledge user-informed intervention strategy to implement two pediatric clinical pathways: asthma and gastroenteritis. Using a balanced incomplete block design, we will randomize 16 community emergency departments to receive the intervention for one clinical pathway and serve as control for the alternate clinical pathway, thus conducting two cluster randomized controlled trials to evaluate this implementation intervention. A minimization procedure will be used to randomize sites. Intervention sites will receive a tailored strategy to support full clinical pathway implementation. We will evaluate implementation strategy effectiveness through measurement of relevant process and clinical outcomes. The primary process outcome will be the presence of an appropriately completed clinical pathway on the chart for relevant patients. Primary clinical outcomes for each clinical pathway include the following: Asthma—the proportion of asthmatic patients treated appropriately with corticosteroids in the emergency department and at discharge; and Gastroenteritis—the proportion of relevant patients appropriately treated with oral rehydration therapy. Data sources include chart audits, administrative databases, environmental scans, and qualitative interviews. We will also conduct an overall process evaluation to assess the implementation strategy and an economic analysis to evaluate implementation costs and benefits.DiscussionThis study will contribute to the body of evidence supporting effective strategies for clinical pathway implementation, and ultimately reducing the research to practice gaps by operationalizing best evidence care recommendations through effective use of clinical pathways.Trial registrationClinicalTrials.gov: NCT01815710

Highlights

The clinical pathway is a tool that operationalizes best evidence recommendations and clinical practice guidelines in an accessible format for ‘point of care’ management by multidisciplinary health teams in hospital settings
This study will contribute to the body of evidence supporting effective strategies for clinical pathway implementation, and reducing the research to practice gaps by operationalizing best evidence care recommendations through effective use of clinical pathways
Developed by a multidisciplinary team of clinical and research experts, as well as end users, each Clinical Pathways (CPs) was designed for broad dissemination for use in the emergency care of pediatric patients in any emergency department (ED) setting

Summary

Introduction

The clinical pathway is a tool that operationalizes best evidence recommendations and clinical practice guidelines in an accessible format for ‘point of care’ management by multidisciplinary health teams in hospital settings. While knowledge syntheses and clinical practice guidelines (CPGs) have emerged as rigorous means to translate and make research more accessible for practitioners, these may not be sufficient to change practice behavior in complex settings, such as the chaotic environment of an emergency department (ED) [9,10] where there is exceeding demand to achieve favorable wait times and patient throughput [11]. This pressure threatens the quality and safe care that are important to health providers who must contend with a diverse population of varying ages, medical conditions, and treatments. CPs are being increasingly used in health settings and recommended by broader health systems internationally as a form of quality improvement [23,24]

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