Critical Care Medicine - List

Critical Pathways and Critical Care

Presented by David Crippen

Last night while hanging around the ED , one of the nurses asked me a question about the new "critical Pathways" they are developing. I must confess that I don't know much about these things. The only critical pathways I know are the ones floating around inside my head. They seem to be writing these things down.

As I looked over this document (this one for the treatment of acute asthma), it struck me that this was simply an algorithm, like the ones everyone memorizes for the Advanced Cardiac Life Support thing (then forget in a few minutes). It seemed to be reasonable; do this when that is present and so on.

I was wondering what the group thinks about these things in the ICU. I hear that they are in the works.

I guess my concern is the classic paradox:

  1. If everyone follows the critical pathway, what use is the attending physician?

  2. If the attending physician has the option of deviating from the critical pathway, what use is the critical pathway?

  3. If If the physician deviates from the critical pathway for any reason, and there is a bad outcome, and a trial attorney gets ahold of the deviation, what is the standard of care, the pathway or the physician's opinion........?

Does anyone have an opinion on this?

Jim Cox:

What use do seasoned airline captains make of critical paths to fly folks from the USA to they just float around in their heads?

How often does the correct critical path float in your brain to the correct action? How consistent are you in your application of the correct clinical pathway? Do you have the objective data to support your opinion?

David Crippen:

I am an instrument rated pilot and I once made a panic emergency landing on the gauges in zero visability at an airport I had no familiarity with in a thunderstorm with the stall warning buzzer screaming bloody murder (it was a hardware malfunction). I can assure you that the algorithm in my head saved my life, not the algorithm in the Piper Cherokee users manual. The check list in the users manual is there to insure nothing is forgotten in the elective checkout of the plane and as a memory refresher. When the chips are down and the sh** is flying, no one remembers where the manual is stashed. Besides....Australia is such a desirable place to visit, the planes find their own way there. The pilots sleep like babies the whole trip.

If a "garden variety" asthmatic comes into the ED (seems most of them are female recently for some reason), I think the Clinical pathway is a nice, general outline of how to deal with her. If I were a moonlighting dermatologist in a generic emergency department in a 50 bed hospital in Lower Podunk, South Carolina I think I might develop a sharply clinical interest in such a document. But, as it turns out, that ain't the case. I happen to be riding fairly high on the hog in a tertiary referral center. I do happen to have a fair amount of experience and savvy in dealing with respiratory failure. That's why they pay me the big bucks (Ho Ho).

I can also assure you that when a really bad asthmatic comes in and is in serious trouble, the ability of an algorithm to guide you is fairly limited. When the upper fringe is reached, and you're flying by the seat of your pants on the white knuckle express, there ain't but two things get you out of the soup: 1) experience and, 2) field expediency. Things happen quick and if you are standing there with a book in your hand, you are very much behind the curve. And in acute respiratory failure, if you are very much behind the curve, your patient will be very dead very quickly.

It strikes me that Clinical Pathways are meant to provide a general outline for those who are unfamiliar with the subject matter, assuring bare minimum of quality assurance, in an arena where any physician can pretty much do whatever they want. The thing that worries me is how to define the standard of care for the upper limits of sick patients in an era of cookbook treatment.

Every single time I have ever been contacted by an attorney to render an expert opinion on a malpractice case, they always ask the exact same question: "Did this physician adhere to the standard of care as you understand it?" If there is a Clinical Pathway in evidence, and if it is in writing, does this not constitute the gospel of standards? If there is a bad result, because of complications from severe disease, what is the plaintiffs attorney going to have you read on the stand, the Clinical Pathway or your own unique judgement while in the clinch. Is it possible that the practice of medicine will be dumbed down to a cookbook recipe. If you deviate from it a millimeter, you are no longer adhering to the standard of care that will be read to you on the witness stand?

Ken Mattox:

I think critical pathways are inherently evil. The process of bringing people together to discuss such may be a communication tool, but the product is BAD. It is a device for control and the practice of medicine by nurses, managed care organizations and government (without a medical liscense).

They health care system needs critical pathways more than does the medical community. These discussions are diversions to focus away from the real problems in health cost shifting.

Kelly Randolph:

I agree with K Mattox on this. Any physician that has a managed care contract should be able to identify with the concepts of 'benchmarking', or the tracking of expenditures and procedures....etc. Critical Pathways are the mirror which your practice habits will be reflected against, and if you deviate repeatedly my guess is that you'll have some explaining to do.

Avi Roy-Shapira:

Critical pathways are a bad thing for the thinking physician. In 1983, I was a PGY-II surgery resident, when I was called to manage a code. I refused to give bicarb without getting the ABG's first. The patient eventually died. At the time the ACLS protocol called for loads of bicarb at the initial resuscitation. I knew better, since I had attended a lecture by HM Weil in 1978 on resuscitation (I was a young IDF Navy surgeon) and read Chubin and Weil papers on the subject. I have to say that I was in loads of trouble, and was reported to the program chairman. I came to the hearing armed with about 4 or 5 papers, and the actual ABG's which proved there was no need for bicarb, and was aquitted.

Interstingly, the ACLS protocol changed in 1985, based on papers that were published in the early 70's. It took some 8 or 9 years for the bicarb breakthrough to make it to the ACLS protocols. Who knows how many patients died of severe alkalosis in the interim. Critical pathways are attractive to administrator types who have something to hang on to, and hang you with, if you fail to follow them. Once there, it takes an act of god, or a decade of frustration to change them, should new data show that they are wrong.

Ken Mattox:

We have been using the principles of "standards of practice" for thousands of years in medicine. For one disease process there may even be several "correct" pathways of standards. This is what the textbooks are all about. It is what all of our lectures in medical school are all about. The "pathways" for the evaluation and treatment of headache, for example, can follow many judgement routes. What is so new and innovative with the "critical pathways", "clinical pathways" and whatever new terminology is now being marketed by nurses, administrators, HMOs etc to be the salvation of medicine. Yes, we can become more efficient. Yes, we have ordered too many tests in the past. Yes, we have given more medications than are required. The system of the times encouraged this overordering and medicine responded.

The one thing that this new wave of "cookbook" medicine does NOT address is judgement. Often a driving force behind the development of pathways is to lower costs. Furthermore, once these guidelines get in place, they become set in stone and become rules, standards, policy and LAW. Then they can almost never be changed. New and emerging treatments and technologies are at risk of being eliminated under the pathway feeding frenzy. This is a technique of control! Be very careful in buying into this new mind set. I remind the readers, that like CME, critical pathways and its cousin clinical pathways have NEVER been tested scientifically to determine if better clinical outcomes result in this concept. Furthermore, physician behavior is the target of this new wave. If ANYTHING needs to have critical pathways assigned to it, it is the hospital administration, HMO management, government health spending, ordering of appropriate supplies, nursing scheduling, health management layering, etc. etc.

Put into focus why we are all here. We are here after many years of preparation in order to exercise judgement in the application of the ART and science of extending a helping health hand to someone who says, "Please, help me feel better." Critical (Clinical) pathways are outside this construct.

Vlad Kvetan:

Completely agree with Mattox that it is time for physicians to test a critical pathway on appropriate amount and efficiency of management.I recently managed to show our institution that the 83 committees in place cost us millions in staff time,and only a part of this is actually required to monitor quality and stay legally in bussiness.They retaliated by trying to make me chair of committee on committees;I complied ,met myself and resigned from all as a cost containement move.

It seems to me that when managed care takes over,they immediatelly have docs put pathways in place,and then the docs get terminated by the truckload. Lets turn the tables.Lets construct pathways which would define how much administration by non-MDs is actually required,and have docs monitor this. The most irritating thing to me is not to be able to get hold of an administrator or administrative senior nurse because they are "in a meeting".Let them bullshit around after work is done,and have their meetings at 6pm.

Gerd Deutschinoff:

In our ICU svereal standards e.g. on myocardial infarction have been developed. IMHO they are good if a physician is new on the job and he does not know what to do after he primarily treated the patient (e.g. after thrombolysis). But they are not suggested to be a sort of "law" in treating a patient, because (luckily) not every human is the same. But these standards give a feeling of safety both to the patient and the doctor. Theoretically withdrawal of life support could be done by a critical pathway ("if this and this happens, you have to switch off the ventilator"), but in my opinion no one can suggest such a thing seriously.

Don Chalfin:

Critical pathways ... now there's something that in theory work but in practicality, often fail, because they are simplistically viewed as mere lists of steps that can be enforced by anyone at anytime, regardless of qualifications, training, or experience.

Their usefulness depends upon how they are designed and the environment in which they are implemented. The protocols that have been described in the current thread have probably failed because they did not have any room for clinical input by the bedside clinicians. For any critical pathway, clinical judgement needs to reign supreme provided that there is a mechanism to follow these overrides and revise the protocols accordingly. This factor in fact is so vital yet all too often it is grossly neglected. In essence then, protocols fail and become algorithmic cookbooks when they are blindly followed and interpreted as a static, unchangable process rather than as a dynamic process to facilitate uniformity (not conformity), minimize stylistic variability, and facilitate meaningful data acquisition and analysis.

Again protocols should part of an environment which is based upon a true commitment to CQI and meaningful change, not just blind steps in an algorithmic chart.

David Ryon:

In the end, there is no management tool that can approximate having an experienced intensivist in the ICU 24 hours a day. In such a setting I do not see a role for such pathways, unless if used for teaching purposes to housestaff.

What about institutions not politically mature enough or endowed enough to provide such a service? The idea behind the pathway strategy is to take advice from the people who do the job best and pass that wisdom on to those who are less efficient. Because not everyone is open-minded to the fact that they could do better by considering the pathway, some encouragement needs to be provided to get the information into use. In this idealistic scenario, I think pathways are helpful for well defined clinical or surgical events. A well structured pathway program ought never presume that the clinician's judgement is being substituted.

I agree that caution is indicated to prevent pathways from becoming protocol, policy, and law. But in the real world unpredictable events are so common that off-pathway management should be expected to occur in a substantial minority of patients. There is no belittlement of the role of the physician, but the wager is that the use of the pathway for the more common and predictable clinical events will generally improve and streamline care. Am I being an idealist?

Malcolm Fisher:

I teach the medical students about fluids. I have done it for 20 years. And I still grapple with algorithm versus thought. Charting versus prescribing. Routines versus thought.

I believe you could teach them algorithms or you could teach them appropriate understanding and thought processes that enable them to work out what is going on and how to respond appropriately. With the first approach I think I would see less drowning and hyponataemia. But no ability to indidualise treatment.

Thus I think this gambit may be useful if it says Patient X is not as good as she should be and sounds an alarm which makes you look may have merit. But in reality it is just another may of measuring what doctors do to save money and corporatise medicine, introduced with none of the evidence reqired to introduce a new drug for example.

And it all comes back to THE Buddha's Management Principles.

Information management.

  1. Management information is not like scientific information: ,it does not have to be accurate, just plausible.

  2. How you use information is more important than its accuracy.

  3. People who request information from you are not trying to find ways of improving your share of resources.

  4. You must have your own data.

  5. You must know the flaws in their system.

  6. They must not know the flaws in yours.

  7. DRGs,Critical pathways,managed care,HMOs, are all about control.

Sun tzu says. "The enemy must not know where I intend to attack. For if he does not know where I intend to attack, he must defend in many places. The more places he defends, the more scattered are his forces, and the weaker is his force at any one point." Sun Tzu says. "Know your enemy, know yourself, and your victory will not be threatened. Know the terrain,know the weather,and your victory will be complete"

Dick Burrows:

Not so very many years ago it was thought that if you sailed towards the sun (didn't matter wich way) you would fall off the edge of the Earth if you didn't stick to the critical pathways around the coast. It took people like Copernicus, Kepler and Gallileo to theorise (at considerable personal risk) that the critical pathways were a load of s*** and people like Columbus, Vasco da Gama and Cook (irreverently moidered in the antipodean a** hole of the world :-]) to supply the empiric scientific evidence that the critical pathways were, in fact, a load of codswallop.

Critical pathways are the sign of a flat earth society!

Phil Maiorano:

Critical pathways, eh? Yes - these have been described to me as a method of establishing a "minimum standard" and a method of "mapping care" so that cases that are "outlyers" can be identified and analyzed as to what the reasons may have been for this. I was also told these would help nursing staff anticipate needed therapies and try to be sure that the physicians at least consider certain diagnostic inquiries (such as echocardiogram in CHF) or therapeutic measures (addition of ACE inhibitor in CHF or aspirin in MI) at the times when they should be initiated. A sort of means to ensure that everyone is "on the same page" one might say.

Those among the paranoid who feel that insurers and other administrative types would love to cut costs by minimizing physician involvement as yet another area to reduce spending and increase profit which is very consistent with many of the trends that seem to be directed at "simplifying medicine" as a cost containment means.

I have been familiar with some attempts to institute this concept - it works well when used as a collaborative teaching tool - excellent for educational purposes and for understanding individual differences and a potential spectrum of therapeutic responses. It becomes a problem when people are submitted to an inquisition each time they fall off the map - or in those rare instances where the individuals involved in the care of the patient are too concrete to appreciate the guideline as flexible.

The more one tries to follow such trends and establish a universally applicable plan, the more one sees just how important individual differences can be. If we were at a point at which the total fucntioning of the human physiologic system were now competely defined with all potential variants identified - every single cytokine and every other functional molecule or element - and their interactions all known in totality with every possible predictable outcome known - then and only then can such concepts be safely applied.

It seems that much of the trending in cost containment revolves around that old statistic (didn't it come from the insurance industry in the first place) that 90% of problems go away on their own - or something like that???

Louis Brusco:

I think critical pathways are a great thing, but not in the way that you mentioned. We have developed a few at our hospital, and really all that they are are compillations of the way things are usually done in order to make sure that nothing is forgotten and everything is done as expediently as possible. For example, a patient who presents with chest pain and meets certain criteria gets a request faxed to our nuclear cadiology department on admission in the ER for their stress test, which is done a precise number of hours from admission. A simple step like that, and others that notify such services as home care, social work, rehab medicine, etc., serve to shave uneccessary delays off, and also to coordinate things so that you don't have a situation where, for example, a rehab consult is postponed a day because the patient is at nuclear cardiology, etc. All of the paths that we have done do NOT stick their noses into the physician's management of the medical aspects of the case, and are at any time cancelleable by the attending. But if 80% of patients in a given category get a certain thing done at the same part on their hospitalization, it makes sense to notify the people who have to do it as soon as possible.