Best Strategies to Implement Clinical Pathways in an Emergency Department Setting
Principal Applicant: Mona Jabbour
Summary of Research Proposal
RATIONALE: The clinical pathway (CP) is a tool that operationalizes best evidence recommendations
and clinical practice guidelines in an accessible format for “point of care” management by
multidisciplinary health teams in hospital settings. High quality, expert-developed CPs have many
potential benefits, including improved patient care, patient safety, decreased health care costs and
efficiency through standardized care processes that can be anticipated by interprofessional health teams.
To date, however, CP impact has been limited by variable implementation strategies and sub-optimal
research designs, so best strategies for implementing pathways into hospital settings remain unknown.
This study will seek to develop and comprehensively evaluate best strategies for effective local
implementation of externally developed expert clinical pathways.
RESEARCH PLAN: We will conduct a 3-year mixed methods health services research project with four
study objectives. Objective 1: To design a theory-based and knowledge user-informed intervention
strategy to successfully implement two provincial pediatric emergency clinical pathways into practice in
community Emergency Departments (EDs). To design this strategy, we will use Michie’s Theoretical
Domains Framework (TDF) to identify and organize CP-relevant behaviours. We will conduct
qualitative interviews, guided by the TDF and involving knowledge users from participating sites, to
identify barriers and facilitators for change relevant to the proposed CP implementation. Experience
from other implementation initiatives will also be used to guide the intervention. An intervention
mapping technique will be used to select and organize appropriate strategies to affect behaviour
changes. Further input will be sought from knowledge user site partners. The intervention will begin
with a site visit to assess readiness for adoption, infrastructure requirements, and ability to implement
the pathway. Objective 2: To evaluate the effectiveness of this implementation strategy, using a cluster
RCT design, through measurement of relevant clinical and process outcomes in 16 community EDs in
Ontario. Using a balanced incomplete block design, we will study this implementation intervention with
two clinical pathways: i) Asthma and ii) Vomiting & Diarrhea (V&D). We will recruit and randomize
16 community EDs to receive the intervention for one of the CPs and serve as control for the alternate
pathway. Primary clinical outcomes for each CP include the following: i) Asthma: the proportion of
asthmatic patients with moderate to severe exacerbation who received steroids within 60 minutes from
ED presentation; and ii) V&D: the proportion of children with mild to moderate dehydration treated
with oral rehydration therapy. The primary process outcome measure will be the presence of an
appropriately completed CP, as per pre-defined criteria, on the chart for relevant patients. Secondary
clinical outcomes include disease-specific treatments, ED length of stay, revisits and hospitalizations.
Secondary process outcomes include CP use based on shift-level data relating to the busyness of the ED.
A mixed methods evaluation will be used to assess clinical and process outcomes. Data sources include
chart audits, administrative databases, environmental scans and knowledge user interviews. Sample size
calculations for the primary process outcome yielded the highest number of required charts. A total
sample size of 6400 patient charts is required to detect an absolute difference of 12% between control
and intervention hospitals using a two-sided test at the 5% level of significance. Objective 3: To conduct
a process evaluation to assess the implementation strategy. A process log will be used to track progress
with site deadline targets, implementation issues, degree of uptake, local adaptations and adherence.
Objective 4: To conduct an economic analysis to evaluate implementation costs and benefits.
Comparisons of CP implementation and health care costs will be done for all patients with Asthma or
V&D in the pre and post implementation phases at all sites. Additional costs and outcomes will be
synthesized in an incremental cost-effectiveness ratio (ICER) comparing intervention and control sites.
Cost-effectiveness analyses (CEAs) will be done to relate ICERs to the primary clinical outcome for
each CP.