Jane Lavelle, MD, an attending in the Division of Emergency Medicine, is director of CHOP’s Clinical Pathways Program.

In 2005, a 16-month-old with severe factor VIII deficiency presented to the CHOP Emergency Department 2 hours after falling off a bed and hitting his head on a nightstand and then the wooden floor. No factor replacement was administered prior to his arrival at 6:50 AM. A CT scan performed at 7:05 AM revealed a subdural hematoma. A 100% correction with factor VIII was infused at 7:30 AM. The child was admitted for observation and further correction. It was an unusually quiet early morning, allowing care to proceed expeditiously. Our patient did well. However, as intracranial hemorrhage is the leading cause of death in children with hemophilia, we recognized that factor VIII correction should have been our first priority. ED clinicians partnered with Hematology experts to work on improving ED care processes. This work resulted in the first ED Clinical Pathway, posted on our intranet in 2005.

Over the last decade, the complexity of bedside care has increased markedly, as has the quantity and pace of new medical knowledge. Consistent delivery of effective high-value care requires teams of clinicians with different expertise to work collaboratively, sharing knowledge seamlessly. Clinical pathways help address this challenge by providing a standard, detailed process of care for patients with a particular chief complaint or clinical problem. A clinical pathway translates existing evidence, guidelines, and expert consensus into a practical tool that can be used at the bedside by all clinicians.

To develop a pathway, clinical leaders and frontline clinicians select a high-priority condition that has known practice variation, substantial existing evidence, quality concerns, and, importantly, a will for change. A multidisciplinary group of relevant stakeholders led by strong clinical MD/RN champions work together to review existing evidence, generate expert consensus, and develop an algorithm that defines the steps of care. Supplementary guidance is provided via hyperlinks to specific decision nodes. The algorithm becomes the foundation for the care process. This shared model supports adherence to current best practice, aligns expectations of providers, and strengthens teamwork and communication.

CHOP’s Pathway Program now lives in the Office of Clinical Quality Improvement, led by Ron Keren, MD, MPH. Pathway teams receive support from an improvement adviser, a data analyst, and an EPIC decision support expert who bring improvement principles, measurement, and decision support tools for effective implementation.

Pathways bring all CHOP clinicians and staff together to meaningfully discuss complex care issues and provide a venue to put solutions into place—solutions that include the perspectives of all team members. This innovative work brings order and reason into our hectic clinical environment.

To further our mission of assuring quality care for all children, our pathways are now available on the Internet, readily accessible to clinicians everywhere. Check them out at www.chop.edu/pathways, and tell us what you think.