Svin Deneckere

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.

Inhospital management of COPD exacerbations: a systematic review of the literature with regard to adherence to international guidelines

Rationale Chronic obstructive pulmonary disease (COPD) exacerbations are a leading cause of hospitalization. Suboptimal inhospital management is expected to lead to more frequent exacerbations and recurrent hospital admission, and is associated with increased mortality. Aims To explore inhospital management of COPD and to compare the results with recommendations from international guidelines. Methods A literature search was carried out for relevant articles published 2000-2009 in the databases Medline, Cochrane Library, Cumulative Index for Nursing and Allied Health Literature and Invert. In addition, the reference lists of the selected articles were examined. Main inclusion criteria were as follows: COPD, exacerbation, hospitalization, description of inpatient management, and clinical trials. Assessment and treatment strategies in different studies were analysed and compared with American Thoracic Society-European Respiratory Society and Global Initiative for Chronic Obstructive Lung Disease guidelines. Outcomes were analysed. Results Seven eligible studies were selected. Non-pharmacological treatment was infrequently explored. When compared with international guidelines, diagnostic assessment and therapy were suboptimal, especially non-pharmacological treatment. Respiratory physicians were more likely to perform recommended interventions than non-respiratory physicians. Conclusions Adherence to international guidelines is low for inhospital management of COPD exacerbations, especially in terms of non-pharmacological treatment. Further investigation is recommended to explore strategies like care pathways that improve performance of recommended interventions.

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

The Effect of Care Pathways for Hip Fractures: A Systematic Review

We performed a systematic review for primary studies on care pathways (CPs) for hip fracture (HF). The online databases MEDLINE-PubMed, Ovid-EMBASE, CINAHL-EBSCO host, and The Cochrane Library (Cochrane Central Register of Clinical Trials, Health Technology Assessment Database, NHS Economic Evaluation Database) were searched. Two researchers reviewed the literature independently. Primary studies that met predefined inclusion criteria were assessed for their methodological quality. A total of 15 publications were included: 15 primary studies corresponding with 12 main investigations. Primary studies were evaluated for clinical outcomes, process outcomes, and economic outcomes. The studies assessed a wide range of outcome measures. While a number of divergent clinical outcomes were reported, most studies showed positive results of process management and health-services utilization. In terms of mortality, the results provided evidence for a positive impact of CPs on in-hospital mortality. Most studies also showed a significantly reduced risk of complications, including medical complications, wound infections, and pressure sores. Moreover, time-span process measures showed that an improvement in the organization of care was achieved through the use of CPs. Conflicting results were observed with regard to functional recovery and mobility between patients treated with CPs compared to usual care. Although our review suggests that CPs can have positive effects in patients with HF, the available evidence is insufficient for formal recommendations. There is a need for more research on CPs with selected process and outcome indicators, for in-hospital and postdischarge management of HF, with an emphasis on well-designed randomized trials.

Eight-step method to build the clinical content of an evidence-based care pathway: the case for COPD exacerbation

BackgroundOptimization of the clinical care process by integration of evidence-based knowledge is one of the active components in care pathways. When studying the impact of a care pathway by using a cluster-randomized design, standardization of the care pathway intervention is crucial. This methodology paper describes the development of the clinical content of an evidence-based care pathway for in-hospital management of chronic obstructive pulmonary disease (COPD) exacerbation in the context of a cluster-randomized controlled trial (cRCT) on care pathway effectiveness.MethodsThe clinical content of a care pathway for COPD exacerbation was developed based on recognized process design and guideline development methods. Subsequently, based on the COPD case study, a generalized eight-step method was designed to support the development of the clinical content of an evidence-based care pathway.ResultsA set of 38 evidence-based key interventions and a set of 24 process and 15 outcome indicators were developed in eight different steps. Nine Belgian multidisciplinary teams piloted both the set of key interventions and indicators. The key intervention set was judged by the teams as being valid and clinically applicable.In addition, the pilot study showed that the indicators were feasible for the involved clinicians and patients.ConclusionsThe set of 38 key interventions and the set of process and outcome indicators were found to be appropriate for the development and standardization of the clinical content of the COPD care pathway in the context of a cRCT on pathway effectiveness. The developed eight-step method may facilitate multidisciplinary teams caring for other patient populations in designing the clinical content of their future care pathways.

The European Quality of Care Pathway (EQCP) Study: history, project management and approach

The European Quality of Care Pathway (EQCP) study is the first, international, cluster randomized controlled trial launched to study the effect of the implementation of care pathways and to study why and under what circumstances pathways work. The study will be performed in Belgium, Italy, Ireland and Portugal and will include individual studies: a trial including chronic obstructive pulmonary disease patients, a trial including proximal femur fracture patients and a trial focusing on multidisciplinary teamwork within both populations. The study is managed by the European Pathway Association in close collaboration with a multidisciplinary team of the Catholic University Leuven (Belgium), the University of Eastern Piedmont (Italy), the National School of Public Health Lisbon (Portugal) and the Health Services Executive in Dublin (Ireland). This paper will describe the history, project management and overall approach of this international study.

The European quality of care pathways (EQCP) study on the impact of care pathways on interprofessional teamwork in an acute hospital setting: study protocol: for a cluster randomised controlled trial and evaluation of implementation processes

BackgroundAlthough care pathways are often said to promote teamwork, high-level evidence that supports this statement is lacking. Furthermore, knowledge on conditions and facilitators for successful pathway implementation is scarce. The objective of the European Quality of Care Pathway (EQCP) study is therefore to study the impact of care pathways on interprofessional teamwork and to build up understanding on the implementation process.Methods/designAn international post-test-only cluster Randomised Controlled Trial (cRCT), combined with process evaluations, will be performed in Belgium, Ireland, Italy, and Portugal. Teams caring for proximal femur fracture (PFF) patients and patients hospitalized with an exacerbation of chronic obstructive pulmonary disease (COPD) will be randomised into an intervention and control group. The intervention group will implement a care pathway for PFF or COPD containing three active components: a formative evaluation of the actual teams’ performance, a set of evidence-based key interventions, and a training in care pathway-development. The control group will provide usual care. A set of team input, process and output indicators will be used as effect measures. The main outcome indicator will be relational coordination. Next to these, process measures during and after pathway development will be used to evaluate the implementation processes. In total, 132 teams have agreed to participate, of which 68 were randomly assigned to the intervention group and 64 to the control group. Based on power analysis, a sample of 475 team members per arm is required. To analyze results, multilevel analysis will be performed.DiscussionResults from our study will enhance understanding on the active components of care pathways. Through this, preferred implementation strategies can be defined.Trail registrationNCT01435538

Impact of care pathways for in-hospital management of COPD exacerbation: A systematic review

BACKGROUND In-hospital management of COPD exacerbation is suboptimal, and outcomes are poor. Care pathways are a possible strategy for optimizing care processes and outcomes. OBJECTIVES The aim of the literature review was to explore characteristics of existing care pathways for in-hospital management of COPD exacerbations and to address their impact on performance of care processes, clinical outcomes, and team functioning. METHODS A literature search was conducted for articles published between 1990 and 2010 in the electronic databases of Medline, CINAHL, EMBASE, and Cochrane Library. Main inclusion criteria were (I) patients hospitalized for a COPD exacerbation; (II) implementation and evaluation of a care pathway; (III) report of original research, including experimental and quasi experimental designs, variance analysis, and interviews of professionals and patients about their perception on pathway effectiveness. RESULTS Four studies with a quasi experimental design were included. Three studies used a pre-post test design; the fourth study was a non randomized controlled trial comparing an experimental group where patients were treated according to a care pathway with a control group where usual care was provided. The four studied care pathways were multidisciplinary structured care plans, outlining time-specific clinical interventions and responsibilities by discipline. Statistic analyses were rarely performed, and the trials used very divergent indicators to evaluate the impact of the care pathways. The studies described positive effects on blood sampling, daily weight measurement, arterial blood gas measurement, referral to rehabilitation, feelings of anxiety, length of stay, readmission, and in-hospital mortality. CONCLUSIONS Research on COPD care pathways is very limited. The studies described few positive effects of the care pathways on diagnostic processes and on clinical outcomes. Though due to limited statistical analysis and weak design of the studies, the internal validity of results is limited. Therefore, based on these studies the impact of care pathways on COPD exacerbation is inconclusive. These findings indicate the need for properly designed research like a cluster randomized controlled trial to evaluate the impact of COPD care pathways on performance of care processes, clinical outcomes, and teamwork.