Massimiliano Panella

Health Care Professionals as Second Victims after Adverse Events A Systematic Review

Adverse events within health care settings can lead to two victims. The first victim is the patient and family and the second victim is the involved health care professional. The latter is the focus of this review. The objectives are to determine definitions of this concept, research the prevalence and the impact of the adverse event on the second victim, and the used coping strategies. Therefore a literature research was performed by using a three-step search procedure. A total of 32 research articles and 9 nonresearch articles were identified. The second victim phenomenon was first described by Wu in 2000. In 2009, Scott et al. introduced a detailed definition of second victims. The prevalence of second victims after an adverse event varied from 10.4% up to 43.3%. Common reactions can be emotional, cognitive, and behavioral. The coping strategies used by second victims have an impact on their patients, colleagues, and themselves. After the adverse event, defensive as well as constructive changes have been reported in practice. The second victim phenomenon has a significant impact on clinicians, colleagues, and subsequent patients. Because of this broad impact it is important to offer support for second victims. When an adverse event occurs, it is critical that support networks are in place to protect both the patient and involved health care providers.

An overview on the history and concept of care pathways as complex interventions

Care pathways, also known as clinical pathways, critical pathways or integrated care pathways, are used all over the world. Although they are used internationally, there are still a large number of misunderstandings. The goal of this paper is to provide an overview on the history of pathways and how pathways are actually perceived and defined. Pathways are more than just a document in the patient record. They are a concept for making patient-focused care operational and supporting the modelling of patient groups with different levels of predictability. Pathways are a method within the field of continuous quality improvement and are used in daily practice as a product in the patient record. This paper explains these different issues and provides an extensive list of references that should support pathway facilitators, clinicians, managers and policy-makers in their search for excellence.

Supporting involved health care professionals (second victims) following an adverse health event: A literature review

BACKGROUND One out of seven patients is involved in an adverse event. The first priority after such an event is the patient and their family (first victim). However the involved health care professionals can also become victims in the sense that they are traumatized after the event (second victim). They can experience significant personal and professional distress. Second victims use different coping strategies in the aftermath of an adverse event, which can have a significant impact on clinicians, colleagues, and subsequent the patients. It is estimated that nearly half of health care providers experience the impact as a second victim at least once in their career. Because of this broad impact it is important to offer support. OBJECTIVE The focus of this review is to identify supportive interventional strategies for second victims. STUDY DESIGN An extensive search was conducted in the electronic databases Medline, Embase and Cinahl. We searched from the start data of each database until September 2010. RESULTS A total of 21 research articles and 10 non-research articles were identified in this literature review. There are numerous supportive actions for second victims described in the literature. Strategies included support organized at the individual, organizational, national or international level. A common intervention identified support for the health care provider to be rendered immediately. Strategies on organizational level can be separated into programs specifically aimed at second victims and more comprehensive programs that include support for all individuals involved in the adverse event including the patient, their family, the health care providers, and the organization. CONCLUSION Second victim support is needed to care for health care workers and to improve quality of care. Support can be provided at the individual and organizational level. Programs need to include support provided immediately post adverse event as well as on middle long and long term basis.

Do pathways lead to better organized care processes

AIM Clinical pathways are used worldwide to (re)organize care processes. They are used by multidisciplinary teams in their search towards excellence. The goal of this study is (1) to assess differences in the perception of health professionals in their evaluation of care processes; (2) to assess whether care processes supported by clinical pathways perform better than those not supported by clinical pathways; and (3) to assess the sensitivity and specificity of clinical pathways in predicting well-organized care processes. METHODS A cross-sectional, multi-centre study was performed comprising 309 healthcare workers, 103 care processes and 49 hospitals. The Care Process Self Evaluation Tool (CPSET) was used to score care processes according to their organization. Processes were also scored according to the level of pathway implementation. RESULTS (1) Significant differences between healthcare professionals were found on two of five CPSET subscales. No significant differences were found among the overall CPSET scores. (2) Care processes supported by pathways had the highest CPSET scores. Nonetheless, continuous follow-up is necessary. (3) Clinical pathways have significant impact on the coordination of care (odds ratio: 8.92), follow-up (odds ratio: 6.65) and overall CPSET score (odds ratio: 4.26). Clinical pathways have a positive impact on the organization of care processes. Not all pathways have high CPSET scores, and care processes without pathways can also be well organized. Continuous evaluation is essential. This is the first study to analyse how healthcare teams perceive the organization of care processes with respect to clinical pathways. Our findings are important for other quality improvement methods.

Better interprofessional teamwork, higher level of organized care, and lower risk of burnout in acute health care teams using care pathways: a cluster randomized controlled trial.

Background:Effective interprofessional teamwork is an essential component for the delivery of high-quality patient care in an increasingly complex medical environment. The objective is to evaluate whether the implementation of care pathways (CPs) improves teamwork in an acute hospital setting. Design and Measures:A posttest-only cluster randomized controlled trial was performed in Belgian acute hospitals. Teams caring for patients hospitalized with a proximal femur fracture and those hospitalized with an exacerbation of chronic obstructive pulmonary disease, were randomized into intervention and control groups. The intervention group implemented a CP. The control group provided usual care. A set of team input, process, and output indicators were used as effect measures. To analyze the results, we performed multilevel statistical analysis. Results:Thirty teams and a total of 581 individual team members participated. The intervention teams scored significantly better in conflict management [&bgr;=0.30 (0.11); 95% confidence interval (CI), 0.08 to 0.53]; team climate for innovation [&bgr;=0.29 (0.10); 95% CI, 0.09 to 0.49]; and level of organized care [&bgr;=5.56 (2.05); 95% CI, 1.35 to 9.76]. They also showed lower risk of burnout as they scored significantly lower in emotional exhaustion [&bgr;=−0.57 (0.21); 95% CI, −1.00 to −0.14] and higher in the level of competence (&bgr;=0.39; 95% CI, 0.15 to 0.64). No significant effect was found on relational coordination. Conclusions:CPs are effective interventions for improving teamwork, increasing the organizational level of care processes, and decreasing risk of burnout for health care teams in an acute hospital setting. Through this, high-performance teams can be built.

Key interventions and outcomes in joint arthroplasty clinical pathways: a systematic review

UNLABELLED SUMMARY RATIONALE, AIMS AND OBJECTIVES: Clinical pathways are globally used to improve quality and efficiency of care. Total joint arthroplasty patients are one of the primary target groups for clinical pathway development. Despite the worldwide use of clinical pathways, it is unclear which key interventions multidisciplinary teams select as pathway components, which outcomes they measures and what the effect of this complex intervention is. This literature study is aimed at three research questions: (1) What are the key interventions used in joint arthroplasty clinical pathways? (2) Which outcome measures are used? (3) What are the effects of a joint arthroplasty clinical pathway? METHOD Systematic literature review using a multiple reviewer approach. Five electronic databases were searched comprehensively. Reference lists were screened. Experts were consulted. After application of inclusion and exclusion criteria and critical appraisal, 34 of the 4055 publications were included. RESULTS Joint arthroplasty clinical pathways address pre-admission education, pre-admission exercises, pre-admission assessment and testing, admission and surgical procedure, postoperative rehabilitation, minimal manipulation, symptoms management, thrombosis prophylaxis, discharge management, primary caregiver involvement, home-based physiotherapy and continuous follow-up. An overview of target dimensions and corresponding indicators is provided. Clinical pathways for joint arthroplasty could improve process and financial outcomes. The effects on clinical outcome are mixed. Evidence on team and service outcome is lacking. CONCLUSIONS A set of key interventions and outcome measures is available to support joint arthroplasty clinical pathways. Team and service outcomes should be further addressed in practice and research. Meta-analysis on the outcome indicators should be performed. Future studies should more rigorously comply with existing reporting standards.

Have We Drawn the Wrong Conclusions About the Value of Care Pathways? Is a Cochrane Review Appropriate?

Care pathways are used increasingly worldwide to organize patient care. However, different views exist about their effectiveness. One of the reasons for this is that pathways are complex interventions. A recent Cochrane review was published which reported positive results, but although the Cochrane team performed excellent work with an enormous commitment, the conclusions may be inappropriate. To fully understand the potential and problems of care pathways, it is important to define (a) exactly what we are talking about (b) whether the study methods are appropriate, and (c) whether we can properly define the outcomes.

Indicators for follow-up of multidisciplinary teamwork in care processes: results of an international expert panel.

In order to study the impact of interventions on multidisciplinary teamwork in care processes, relevant indicators need to be defined. In the present study, the authors performed a Delphi survey of a purposively selected expert panel consisting of scientific researchers and hospital managers. Thirty-six experts from 13 countries participated. Each participant rated a list of team indicators on a scale of 1–6. Consensus was sought in two consecutive rounds. The content validity index (CVI) varied from 8% to 92%. A final list of 19 indicators was generated: 5 on team context/structure, 8 on team process, and 6 on team outcomes. Most relevant team indicators were as follows: “team relations,” “quality of team leadership,” “culture/climate for teamwork,” “team perceived coordination of the care process,” and “team vision.” Scientific researchers and hospital managers that want to study and improve multidisciplinary teamwork in care processes should primarily focus on these team indicators.

The impact of care pathways for exacerbation of Chronic Obstructive Pulmonary Disease: rationale and design of a cluster randomized controlled trial

BackgroundHospital treatment of chronic obstructive pulmonary disease (COPD) frequently does not follow published evidences. This lack of adherence can contribute to the high morbidity, mortality and readmissions rates. The European Quality of Care Pathway (EQCP) study on acute exacerbations of COPD (NTC00962468) is undertaken to determine how care pathways (CP) as complex intervention for hospital treatment of COPD affects care variability, adherence to evidence based key interventions and clinical outcomes.MethodsAn international cluster Randomized Controlled Trial (cRCT) will be performed in Belgium, Italy, Ireland and Portugal. Based on the power analysis, a sample of 40 hospital teams and 398 patients will be included in the study. In the control arm of the study, usual care will be provided. The experimental teams will implement a CP as complex intervention which will include three active components: a formative evaluation of the quality and organization of care, a set of evidence based key interventions, and support on the development and implementation of the CP. The main outcome will be six-month readmission rate. As a secondary endpoint a set of clinical outcome and performance indicators (including care process evaluation and team functioning indicators) will be measured in both groups.DiscussionThe EQCP study is the first international cRCT on care pathways. The design of the EQCP project is both a research study and a quality improvement project and will include a realistic evaluation framework including process analysis to further understand why and when CP can really work.Trial Registration numberNCT00962468

Is there still need for confusion about pathways

Care pathways are at the heart of quality and patient safety. This was the conclusion of the editorial in the previous issue of the International Journal of Care pathways. Although pathways can be of major importance to guide multidisciplinary teams – including clinicians, managers and patients – in enhancing their daily operations, there is still a lot of confusion about this structured care methodology. The question arises if there is still need for confusion about pathways? The European Pathway Association (E-P-A), started in 2005, an international task force on defining a consensus definition of care pathways. A literature study on pathway definitions helped the taskforce in evaluating the available information from literature and the taskforce members compared it to their own national frameworks during a workshop in Slovenia. Although ‘clinical pathway’ is still the most used term in Medline, and ‘critical pathway’ is still used as a Medical SubHeading, it was decided to use ‘care pathway’ as the overall term because of confusions between ‘clinical’ and ‘hospital’ in several languages (e.g. Dutch, Italian, French and German). Based on the 2005 E-P-A survey, the involvement of the association in multicentre research studies, and knowledge sharing during national and international conferences on pathways and organization of care processes, the actual pathway definition, as published in 2007, states: ‘A care pathway is a complex intervention for the mutual decision-making and organisation of care processes for a well-defined group of patients during a welldefined period. Defining characteristics of care pathways include: (i) An explicit statement of the goals and key elements of care based on evidence, best practice, and patients’ expectations and their characteristics; (ii) the facilitation of communication among team members and with patients and families; (iii) the coordination of the care process by coordinating the roles and sequencing the activities of the multidisciplinary care team, patients and their relatives; (iv) the documentation, monitoring, and evaluation of variances and outcomes; and (v) the identification of the appropriate resources. The aim of a care pathway is to enhance the quality of care across the continuum by improving risk-adjusted patient outcomes, promoting patient safety, increasing patient satisfaction and optimizing the use of resources’. This definition is actually used during the yearly international conference on pathways in London and the European Quality of Care Pathway studies. Because pathways are defined as a complex intervention, pathways are more than only the structure of a care process and a part of the (electronic) patient record. Pathways are a patient-focused concept, a tool to model the care, a quality and efficiency improvement process and a product in the patient record. The patient-focused care concept is a topic that we find in nearly every mission statement of a hospital or care organization; every policy-maker worldwide is talking about it during international meetings, and it is not a coincidence that we use the word ‘talking’. Pathways are one of the tools to bring patient-focused care into daily practice by bringing the service line per patient group or medical condition to the foreground, and the professional disciplines and business units as processes or centres to the background in support of this service line. Michael Porter describes this as organizing care around medical conditions and care cycles to be able to create value-based competition based on results. Not all patient groups are predictable enough to model the care with a structured care methodology like a care pathway. Next to the predictability of care, the agreement within the multidisciplinary care team is important. Based on these two variables (level of predictability and level of agreement) chain, hub and web models can be described. Care pathways are mainly used to make chain models operational, but can also be used in hub models. Next to the concept and model the pathway process is of major importance. The logical plan-do-study-act cycle, as described by Edwards Deming, is usable for pathways. Although different pathway methodologies exist, the pathway complex intervention should be defined by its active ingredients. Active ingredients of the complex care pathway intervention are the feedback on the actual organization of the care process, the availability of evidence-based key interventions and outcome indicators and the continuous quality and efficiency improvement process which takes place within the multidisciplinary team. Recent multicentre research describes that during the pathway development, even before the implementation of the pathway, the organization of the care process can be improved. Over time the team will improve the quality and efficiency of the care process by analysing the actual organization and performance of the care process. Based on the bottlenecks the team will improve the process by using the plan-do-study-act cycle for continuous improvement with respect to patient characteristics and expectations. The changes in the organization of the care process are standardized by implementing the pathway product. This pathway product is the fourth and last item of the four diagrams in Figure 1. The pathway product is the final product of the whole pathway development process. The product has four levels as follows: a model pathway (international/ national/regional level, prospective and not organization specific), the operational pathway (local level, prospective and organization specific), the assigned pathway (patient level, prospective and organization and patient specific) and the completed pathway (patient level, retrospective and organization and patient specific). Within the new International Journal of Care Pathways we want to use the term ‘care pathways’, the above-described pathway definition and focus on each of the four parts of Figure 1. Because of this complexity we need a journal dedicated to pathways and the organization of care processes. Care pathways can help to implement evidence-based care