Abstract: Clinical pathways are one of the main tools employed across health care to manage quality and consistency. Pathways are also useful for the reduction of variability in cancer care. Clinical pathways in cancer care have primarily focused on treatment guidelines and standardization, to ensure that patients receive evidence-based care whenever possible. However, clinical pathways may be equally useful when more broadly applied to other areas within the treatment experience. This paper explores the growing trend of clinical pathways for symptom management—including how they can be applied across cancer care and the positive downstream effects of pathways for symptom control—by examining the implementation of symptom management clinical pathways at one treatment center.
Clinical pathways are one of the main tools employed across health care to manage quality and consistency.1 They provide practitioners with the tools they need to ensure standardization and deliver efficient, organized, and evidence-based care for every patient. Pathways also reduce the variability of how patients are treated.2 In cancer care, clinical pathways have been mostly comprised of treatment guidelines that ensure patients receive standardized and evidenced-based treatment protocols whenever possible.3
But clinical pathways, when considered in broader terms, could be very useful to other aspects of care in the oncology sphere. As we move to a value-based delivery system with a focus on improving quality and reducing costs, standardization of cancer care delivery will become an increasingly important part of the conversation. When pathways are more broadly applied, they can do even more to reduce variability and costs and improve the patient experience during active cancer treatment.
Symptom management has emerged as a particular area for the application of clinical pathways, in an effort to reduce variability of care. Symptom management pathways enable nurses to perform a thorough evaluation and determine a course of action in an efficient and effective way. By responding to prompts and following branching logic, the nurse is guided down the appropriate path, providing appropriate and standardized care.
Additionally, these pathways allow practices to empower nurses with standing orders for approved interventions, enabling nurses to provide immediate care. This immediate intervention means better care of the patient being triaged, while simultaneously decreasing interruptions in the clinic for the doctor and other staff, by allowing them to focus on the patients in the office. The focused intervention may decrease erroneous visits to primary care physicians for matters that can be managed by the nurse, without the patient ever leaving home.
Symptom management, like all aspects related to the diagnosis and treatment of cancer, can be complicated.
It can also have a major impact on outcomes.4 As it stands today, symptom management can be done in a variety
of ways, depending clinic flow. The management of
symptoms is largely left up to each individual provider’s training and experience. Although drawing out what a patient really needs certainly requires a human element, relying on people to navigate symptoms, evaluate each patient case by case, and document and report in an efficient way could also result in missed opportunities to optimize the patient experience and deliver more comprehensive care.
Improving the Patient Experience
What if clinics could consistently evaluate symptoms and provide the care or intervention that was indicated by best practices? If the care team is equipped with the most current information related to care and intervention,
it would be the equivalent of having the clinical pocketbook at their fingertips. Providers would not need
to search for a particular symptom and pathway. In addition to standardizing treatment of patients, pathways also help the care team evaluate the symptom in a comprehensive manner.
Patients with cancer tend to underreport symptoms,5 because they assume adverse events are to be expected. Pathways can help uncover information that may be important to factor into the decision-making process. Advanced cancer is often accompanied by multiple symptoms and comorbidities. Instead of relying on the care team to pinpoint the exact course of treatment for that specific combination of symptoms, pathways can assist with those determinations. A triage nurse who uses symptom management pathways said of her experience: “Using a clinical pathway helps me to do a ‘virtual head to toe assessment’ so I can correctly triage whether the patient needs immediate assistance in the emergency department [ED] or clinician assistance.”
With pathways, the care team can maximize their time without minimizing patient care. Uniform management also results in better outcomes across the board, which is vitally important. If you can preemptively manage symptoms and keep patients healthier during chemotherapy, outcomes are better and costs can be lowered.
When a member of the care team is speaking to a patient, they can use pathways to ask pregenerated questions and follow branching logic based on the patient’s response. Through these methods, they can ultimately land on the most appropriate intervention, and ensure that all possible risk factors have been thoroughly addressed.
The Center for Cancer and Blood Disorders (CCBD; Fort Worth, TX), a Navigating Cancer clinical partner, developed a suite of symptom pathways and has been using them for more than 2 years.6 When they were developing the pathways, they worked with experienced oncology nurses to create a list of the most common reasons patients call triage, then developed a comprehensive assessment of each symptom. They further added trigger points for the nurse to pause and evaluate important details throughout the pathway.
One of the triage nurses at CCBD compared telephone triage as doing a nursing assessment by braille, visualizing everything in your head. Having a pathway to follow enabled her to complete a full assessment without worrying she might miss something. The implementation of a standardized pathway allows nursing staff to ask the pertinent questions; as a result, the workflow can be more effective. Although certain answers may lead the nurse to initiate emergency services, a different intervention is more often chosen.
Before implementing symptom pathways at CCBD, the organization realized that care was being delivered very inconsistently. A nurse at one location might give one set of instructions to manage diarrhea, whereas another nurse in a different clinic might do something else entirely. The patient could call after hours and receive yet another message. Many of the messages were dependent on how the physician at each location practiced. Not only is this model inconsistent, but it also leads to confusion for the patient and could potentially have a very negative impact on treatment. Further, documentation of information discussed on triage calls was often not all inclusive of the conversation.
After implementing standardized symptom management pathways, CCBD has seen several improvements beyond quicker interventions. They now deliver consistent education and instructions for patients across nine clinic locations. They also reported a lower learning curve for new staff members, and can now ensure that the patient perception of care is seamless and is easy to reinforce. Documentation is thorough and consistent: any member of care team can jump in and know what has been done for the patient. Physicians and administration can access the reporting features to evaluate a number of areas to look for quality improvement opportunities. Positive changes have occurred related to staff productivity, patient outcomes, ED utilization, and improvement of patient education pretreatment.
The perception of clinical pathways as a potential tool for improved patient-centered care will become even more important as we move toward value-based practices across the oncology spectrum. Practices must look for ways to increase efficiency, improve communication with patients, increase communication between staff, and track outcomes to continue to be viable in the ever-changing health care environment. Standardized symptom management could be one of the most important element to reduce hospitalizations and readmissions, and clinical pathways enable a quick and effective method to manage adverse events through early intervention.
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4. Stapleton SJ, Holden J, Epstein J, Wilkie DJ. A systematic review of the symptom distress scale in advanced cancer studies. Cancer Nurs. 2016;39(4):E9-E23.
5. Bruner DW, Movsas B, Basch E. Capturing the patient perspective: patient-reported outcomes as clinical trial endpoints. Am Soc Clin Oncol Educ Book. doi: 10.14694/EdBook_AM.2012.32.139
6. Navigating Cancer and the Center for Cancer and Blood Disorders partner to deliver a new triage pathways solution for patient-centered care. Navigating Cancer website. https://www.navigatingcancer.com/provider/%E2%80%A8navigating-cancer-and-the-center-for-cancer-and-blood-disorders-partner-to-deliver-a-new-triage-pathways-solution-for-patient-centered-care/. Published March 8, 2016. Accessed October 3, 2017.