Clinical Pathways

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.

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).

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.

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 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.

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).