Clinical Pathways

Children's Hospital Colorado set out to help clinicians deliver evidence-based care for children with uncomplicated community-acquired pneumonia in 5 emergency departments and 5 urgent care facilities in their network. The two-part intervention included an order set and a revised EHR-integrated clinical pathway that aligned with American Academy of Pediatrics recommendations.

• Order set implementation had no effect on pediatric community-acquired pneumonia prescribing.
• After pathway revision, amoxicillin prescribing increased from 60.6% to 70.9%, azithromycin prescribing decreased from 12.5% to 3.7%, and durations for 5 days or fewer increased from 2.0% to 66.1%.

To address sepsis, Vanderbilt aimed to increase compliance with a six-hour (SEP-1) bundle, starting in the main adult ED (Vanderbilt University Medical Center). The initiative had two key interventions: (1) an EHR-based treatment pathway (AgileMD) that incorporated components of the SEP-1 metrics and (2) a targeted best practice alert for initiation of sepsis protocols when pre-specified criteria were met.

• Compliance of the SEP-1 bundle improved across the four-hospital system: 23% to 62% at the main adult ED with similar improvements in SEP-1 compliance mirrored at three community sites.
• Key drivers included timely antibiotics, repeat lactate orders, and initial 3-hour bundle compliance.

YNHHS implemented an inpatient COPD pathway to address variable hospital care and underutilization of pulmonary rehabilitation (PR).

• Bivariate analyses demonstrated lower LOS (5.4 days v. 7.1 days, p=0.001) and total costs ($5,756 v. $8,781, p< 0.001) with pathway use.
• In multivariable analysis, pathway use was associated with greater PR referrals (OR 5.76 95% CI 2.47-13.45, p<0.001) and discharges to home (OR 1.96 95% CI 1.13-3.39, p=0.016).

In order to improve end-of-life care and decrease healthcare costs, Yale New Haven Health implemented a clinical pathway in the emergency department that asked the Surprise Question (SQ): “Would I be surprised if this patient died in the next six months?” The goal was to help trigger early palliative care (PC) consultation and study the impact.

• Following pathway implementation, the average time from admission to PC consult decreased by 1.1 days (5.7 to 4.6 days)
• The average hospital LOS among the PC-consult cohort was reduced by 3.3 days (16.2 to 12.9 days)
• Reduced time to PC consultation and hospital LOS, led to an estimated cost savings of $1,256 per patient, representing a total cost savings of $7,611,300.

YNHHS implemented a pulmonary embolism (PE) pathway to standardize diagnostic and therapeutic interventions. The pathway included risk stratification, criteria for PE Response Team (PERT) activation, indications for thrombolysis and catheter-directed therapy, and guidance for transition to enteral therapy.

• Patients in whom the pathway was utilized were more likely to receive catheter-directed therapy (CDT) (OR, 5.1; 95% CI, 3.1-8.3, p< 0.0001).
• Pathway patients had a 1.5-day reduction in hospital length of stay (HLOS) (95% CI -2.7 to -0.2, p=0.02).
• The reduction in HLOS for pathway patients translates to an annual cost avoidance of $189,000.

UCHealth developed a goals of care pathway that leveraged ED social workers and palliative care.

• More patients were identified as appropriate for hospice, social work consultations for hospice evaluation increased, and more patients were discharged from the ED with hospice.
• ED length of stay (LOS) for qualifying patients decreased by a median of 2.9 hours.
• Admission LOS decreased by a median of 18.4 hours.

Through the implementation of an enteral access clinical pathway (EACP), YNHHS hoped to increase nutrition consults and decrease Emergency Department (ED) visits, readmissions, and overall length of stay.

• Those in the performance group were more likely to receive a nutrition consult (52.4% vs 48.0%, P < .01)
• They were less likely to re-present to the ED (31.9% vs 42.6%, P < .001),
• They were less likely to be readmitted to the hospital (31.0% vs 41.6%, P < .001.

The inpatient care team at UCM developed an opioid use disorder (OUD) workgroup, consult service, and pathway to guide clinicians on appropriate prescribing of buprenorphine-naloxone or methadone and monitoring parameters.

• Under the new program, 296 OUD consults occurred from July 2020 to April 2021.
• 35% received and were discharged with buprenorphine.
• 40% were managed with methadone and linked to outpatient care.
• Naloxone dispensing at discharge increased to over 65%.
• Patients with OUD who did not receive a consult had higher readmission rates (14.9% vs. 18.1%).

UCHealth compared the effectiveness of their EHR-embedded clinical pathway to a paper-based one on outcomes for patients presenting to the ED with suspected acute coronary syndrome (ACS).

• The frequency of hospital admission (unadjusted 28.2% to 20.9%, P < 0.001) and stress testing (unadjusted 15.8% to 12.7%, P < 0.001) significantly declined after the electronic pathway (ePATH) implementation.
• The pathway was associated with a significant reduction in hospital admissions (-10.79%, P < 0.001) and stress testing (-6.05%, P < 0.001).