Critical pathways of care (CPCs): used as the tools for provision of care in a case management system. It brings together all the professional groups involved in patient care to arrive at a consensus about standards of care and expected outcomes for selected patient groups.

1. CRITICAL PATHWAY OF
CARE
PRSESNTED BY
M.VELVEENA
MSC NURSING 1ST YEAR
CON/,AIIMS,BBSR

2. INTRODUCTION
• Critical pathways of care (CPCs): used as the tools for provision of
care in a case management system.
• It brings together all the professional groups involved in patient
care
• to arrive at a consensus about standards of care and expected
outcomes for selected patient groups.

3. CONTD..
• It is anticipated care placed in an appropriate time frame, written and
agreed by a multi-disciplinary team
-Welsh National Leadership and Innovation Agency for Health care(2005)
• Abbreviated plan of care that
• provides outcome-based guidelines
• for goal achievement
• within a designated length of stay.

4. CP CONCEPT:
RESOURCE
EFFICIENT
CLINICALLY
APPROPRIATE
SHORTEST LENGTH
OF STAY
VALIDATE CARE
DELIVERED
COMBINATION OF CLINICAL
PRACTICES

5. GOALS OF CRITICAL
PATHWAY
Selecting the best practice.
Defining the standards for
the expected duration of
hospital stay
Examining the inter-relations
among the different steps
to find the ways to
coordinate or decrease the
time frame.
common game plan to
understand their various
roles.

6. GOALS OF CRITICAL
PATHWAY
Providing a framework for collecting data
on the care process .
Decreasing
documentation
burdens.
Improving patient
satisfaction with care by
educating patients and
their families about the
plan of care.

7. CRITICAL PATHWAY
DEVELOPMENT
 Select a topic
Topic selection in general should concentrate on high volume, high
cost diagnosis and procedures.

8. SELECT A CPC TEAM
NURSE CASE
MANAGER
PSYCHIATRIST
CLINICAL
NURSE
SPECIALIST
PSYCHOLOGIST
SOCIAL
WORKER
DIETITIAN
OCCUPATIONAL
THERAPIST
RECREATIONAL
THERAPIST

9. CPC TEAM
• The team decides what categories of care are to be
performed, by what date, and by whom. Each member of the
team is then expected to carry out his or her functions
according to the time line designated on the CPC.
• The nurse, as case manager, is ultimately responsible for
ensuring that each of the assignments is carried out. If
variations occur at any time in any of the categories of care,
rationale must be documented in the progress notes.

10. CPC TEAM
• Each member of the team stays in contact with the nurse
case manager regarding individual assignments.
• Ideally, team meetings are held daily or every other day
to review progress and modify the plan as required.
• CPCs can be standardized, as they are intended to be
used with uncomplicated cases. A CPC can be viewed as
protocol for various clients with problems for which a
designated outcome can be predicted.

11. CONTD..
Evaluate the current process of care
In this step, data, rather than anecdotal records are key to understand current
variation. For systems with electronic medical records, this process may be more
automated. For other systems, a careful review of medical records is necessary to
identify outcomes.
Evaluate medical evidence and external practices
After key rate-limiting steps have been identified, the critical pathway team must
evaluate the literature to identify evidence of best practices. For most rate-limiting
steps, there are few data available to define optimal processes of care.
Determining the critical pathways format

12. HOW CPC IS CARRIED OUT
• The team decides what categories of care are to be performed, by what
date and whom
• Each member of the team is then expected to carry out his or her
functions according to the time line designated on the CPC
• The nurse as case manager is ultimately responsible for ensuring that
each day of assignments is carried out
• If variations occur at any time in any of the categories of care, rationale
must be documented in the progress notes
• The nurse contacts psychiatrists to inform him or her of the admission

13. HOW CPC IS CARRIED OUT
• The psychiatrist performs additional assessments to determine if
other consultations are required
• Within 24 hours, the interdisciplinary team meets to decide on
other categories of care
• Completion of the CPC, and make individual care assignments from
the CPC
• Each member of the team stays in contact with the nurse case
manager regarding individual assignments.
• Ideally team meetings are held daily or every other day

14. CHARACTERISTICS OF CPC
Pathway is a projection of
the client’s entire length of
treatment
Includes detailing of
interdisciplinary
intervention or processes
and client outcomes each
day from admission to
discharge
Pathway may be extended
to include transfer to home
care or another treatment
facility

15. VARIANCES:
• A variance is defined as an unexpected client response that
“falls off” the pathway, requiring separate documentation and
further investigation by the interdisciplinary team.
 When there is a discrepancy between expected and actual events
on a CP this is known as variance from the pathway.
 This is the only care documentation that should be carried out
with a consequent substantial saving in time .
 The time thus freed up from writing down routine material for
every patient can then be devoted to dealing with individual
problems or variances .

16. CAUSES OF PATHWAY VARIANCE
• Client or family
• Caregivers
• Hospital
• Community
•Payer(including insurance companies, health maintenance organizations, or
managed care organizations)
A simple procedure is to underline or circle the relevant piece of the CP and mark it
‘V1’ ‘V2’, etc. . while maintaining a record on a separate sheet of what happened in
each case.

17. CONTD..
Document and analyze variance
• Variances are patient outcomes or staff actions that do not meet the
expectation of the pathway.
• In general, variance in clinical pathways is a result of the omission of an
action or the performance of an action at an inappropriate (often, a late)
time period.
• Because the critical pathway is a series of time-associated actions, this
analysis of variance can be overwhelmed by multiple data points.

18. BASELINE FOR A WRITING A CRITICAL
PATHWAY
AREA OF CARE DAY 1 DAY 2 DAY3
Assessments and
consultations
Tests
Treatments
Medications
Diet
Activity
Teaching
Discharge plans

19. CARE IS PLOTTED IN TERMS OF:
• X Axis- Time
• Y Axis: Various areas of care
• The multidisciplinary team agrees in advance what should be
happening for each area of care at each day on the pathway.
• 1. Process: What should be done and when
• 2. Outcomes: What the patient should achieve at set times
• A key step in writing a pathway is to decide the length of the pathway
first and then work backwards in time from the end-point .

20. BASIC QUESTIONS:
• 1.What does each discipline require in terms of patient outcomes
• 2. What is the best way of achieving these outcomes
• 3. Who should be accountable for seeing that the outcomes are
achieved
• 4. How does care need to be restructured to meet the
requirements of the first three questions
The CP forms a guide to care delivery and expected outcomes

21. COMPONENTS OF A CRITICAL PATHWAY:
A Timeline
Categories of care or activities
and their interventions
Intermediate and long-term
outcome criteria
Variance record

22. TECHNIQUES OF CRITICAL
PATHWAY
Define the processes
Timing of these processes
Note target areas that were critical
Measure variations, and make improvements
Re-measurement

23. CRITICAL PATHWAY OF CARE FOR CLIENT
IN ALCOHOL WITHDRAWAL
• ESTIMATED LENGTH OF STAY : 7Days
• NURSING DIAGNOSIS: Risk of Injury related to CNS agitation
• OUTCOME : Client shows no evidence of injury obtained during
alcohol withdrawal.

24. DAY 1 DAY 2 DAY 3 DAY 4 DAY 5 DAY 6 DAY 7
Referrals Psychiatrist
Assess need for :
Neurologist
Cardiologist
Internist
Discharge with
follow up
appointments
required
Diagnostic
studies
Blood alcohol
level
Drug screen(urine
and blood)
Chemistry profile
Urinalysis
Chest X-Ray
ECG
Repeat of
selected
diagnostic
studies as
necessary

25. Additional
assessme
nts
• Vital signs q4h
• I&O
• Restraints p.r.n. for client
safety
• Assess withdrawal
symptoms :
• Tremors ,
nausea/vomiting/tachyc
ardia, sweating ,high
blood pressure ,
seizures, insomnia,
hallucinations.
• Vital signs q8h if
stable
• I&O
• Restraints p.r.n.
for client safety
• Assess
withdrawal
symptoms :
• Tremors ,
nausea/vomitin
g/tachycardia,
sweating ,high
blood pressure ,
seizures,
insomnia,
hallucinations.
•
• Vital signs
q8h if stable
• I&O
• Restraints
p.r.n. for
client safety
• Assess
withdrawal
symptoms :
• Tremors ,
nausea/vom
iting/tachyc
ardia,
sweating
,high blood
pressure ,
seizures,
insomnia,
hallucinatio
ns.
•
• I&O
• VS
bid;remain
stable
• Restraints
p.r.n. for
client safety
• Assess
withdrawal
symptoms :
• Tremors ,
nausea/vom
iting/tachyc
ardia,
sweating
,high blood
pressure ,
seizures,
insomnia,
hallucinatio
ns
• Marked
I&O
VS bid;remain
stable
Restraints
p.r.n. for client
safety
Assess
withdrawal
symptoms :
Tremors ,
nausea/vomiti
ng/tachycardi
a, sweating
,high blood
pressure ,
seizures,
insomnia,
hallucinations
DC I&O
VS
bid;remain
stable
Restraints
p.r.n. for
client safety
Assess
withdrawal
symptoms :
Tremors ,
nausea/vom
iting/tachyc
ardia,
sweating
,high blood
pressure ,
seizures,
insomnia,
hallucinatio
ns.
VS bid;remain stable
Restraints p.r.n. for
client safety
Assess withdrawal
symptoms :
Tremors ,
nausea/vomiting/ta
chycardia, sweating
,high blood pressure
, seizures, insomnia,
hallucinations
Discharge ; absence
of objective
withdrawal
symptoms.
DAY 1 DAY 2 DAY 3 DAY 4 DAY 5 DAY 6 DAY 7

26. Medications • Librium * 200mg
in divided doses
• Librium p.r.n.
• Maalox pc&hs
• *Note : Some
physicians may
elect use Serax
or Tegretol in the
detoxification
process.
• Librium
p.r.n.
• Maalox
pc&hs
• Librium
160mg in
divided
doses.
• Librium
p.r.n.
• Maalox
pc&hs
• Librium
120mg in
divided
doses.
• Librium
p.r.n.
• Maalox
pc&hs
• Librium *
80mg in
divided
doses..
• Librium
p.r.n.
• Maalox
pc&hs
• Librium
40mg
• Librium
p.r.n.
• Maalox
pc&hs
• Discont
inue
Librium
• Maalox pc&hs
• Discharge; no
withdrawal
symptoms.
Client
Education
• Discuss
goals of
AA and
need for
outpatien
t therapy
• Discharge with
information
regarding AA
attendance or
outpatient
treatment
DAY 1 DAY 2 DAY 3 DAY 4 DAY 5 DAY 6 DAY 7

27. PROBLEMS OF CPC:
1. There were difficulties in
selecting the right patients
to put on the pathway as the
diagnosis was sometimes
not clear on admission. 2. There were significant delays in
moving patients along CP.

28. STEPS IN INTRODUCING A CP:
• 1. Identify a group of patients with a common health problem or to
undergo a specific medical intervention. There should be reasonably
predictable series of events for majority of patients in the group.
• 2. Convene a multidisciplinary team meeting to secure the
agreement of all parties.
• 3. Set the time line be agreeing the length of the CP and work
backwards from the agreed end- point.

29. STEPS IN INTRODUCING A CP:
• 4. Write the necessary interventions and desired outcomes for each
hour/ day/ week of the CP.
• 5. Decide how variances will be monitored, recorded and actioned
together with who will have accountability for the management of
variances.
• 6.Make changes to care and amend the CP as needed.

31. BENEFITS OF CPC
• Support the introduction of evidence-based medicine and use of clinical
guidelines
• Support clinical effectiveness, risk management and clinical audit
• Improve multidisciplinary communication, team work and care planning
• Can support continuity and co-ordination of care
• Provide explicit and well-defined standards of care

32. CONTD..
• Help to improve clinical outcomes
• Ensure quality of care and provide a means of continuous quality
improvement
• Help to improve communication between different care sectors
• Disseminate accepted standards of care
• Provide baseline for future initiative
• Reduce costs by shortening hospital stays

33. DEMERITS OF CPC
• Adaptability-on complicated case CPC becomes large and detailed,
cumbersome and ineffective
• Crash action-changes from scheduled plan in a timeline, crash
action involving reprioritizing each step
• Resource allocation-when resource don’t match CPC map, CPC
begins to unravel

34. DISADVANTAGES
 Differences between unique patients.
 Overburdened with administrative cost.
 Problems of introduction of new technology.
 Require commitment from staff and establishment of an
adequate organizational structure.
 May take time to be accepted in the workplace.
 Need to ensure variance and outcomes are properly
recorded, audited and acted upon.

35. ROLE AS NURSE MANAGER
 Assess quality improvement.
 Effective planning.
 Evaluate quality.
 Interdepartmental Communication.
 Educating the staff of other departments about the pathway role and
responsibilities.
 Provides patient care.
 Follow critical pathway and note any deviation in care.

36. CONCEPT MAPPING

37. INTRODUCTION
 Concept mapping is a diagrammatic teaching and learning strategy that
allows students and faculty to visualize interrelationships between medical
diagnoses, nursing diagnoses, assessment data, and treatments.
 The concept map care plan is an innovative approach to planning and
organizing nursing care. Basically, it is a diagram of client problems and
interventions.
 Compared to the commonly used column format care plans, concept map
care plans are more succinct.
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38. CONTD..
 They are practical, realistic, and time saving, and they serve to enhance
critical-thinking skills and clinical reasoning ability
 The nursing process is foundational to developing and using the concept
map care plan, just as it is with all types of nursing care plans.
 Client data are collected and analyzed, nursing diagnoses are formulated,
outcome criteria are identified, nursing actions are planned and
implemented, and the success of the interventions in meeting the outcome
criteria is evaluated.
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39. CONTD..
 The concept map care plan may be presented in its entirety on one page, or
the assessment data and nursing diagnoses may appear in diagram format
on one page, with outcomes, interventions, and evaluation written on a
second page.
 In addition, the diagram may appear in circular format, with nursing
diagnoses and interventions branching off the “client” in the center of the
diagram.
 Or, it may begin with the “client” at the top of the diagram, with branches
emanating in a linear fashion downward.
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40. CONTD,..
 A line between the nursing diagnoses should be drawn to show the
relationship.
 Concept map care plans allow for a great deal of creativity on the part of the
user, and permit viewing the “whole picture” without generating a great
deal of paperwork. Because they reflect the steps of the nursing process,
concept map care plans also are valuable guides for documentation of client
care.
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42. CONCLUSION
• Critical care in psychiatric nursing refers to providing specialized
nursing care to individuals with severe mental illness who require
immediate medical attention due to life-threatening conditions
such as suicidal ideation, self-harm, or substance abuse.
• The nursing process in critical care involves rapid assessment,
diagnosis, and treatment to prevent deterioration and promote
recovery.
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43. JOURNAL REFERENCE
The use of critical pathways in caring for schizophrenic patients in
a mental hospital
Abstract
• To provide quality health care and at the same time, to control cost, literature suggests that using
critical pathways as a tool can enhance resource management, increase collaborative practice,
and benefit patient care. This study describes the processes of developing a critical pathway in
caring for schizophrenic patients in a mental hospital in Hong Kong. The perceived benefits and
difficulties in using the critical pathway are discussed from a nursing perspective. Nurses believed
that the use of critical pathways could improve the coordination and effectiveness of care. Also,
nurses' autonomy and professional status improved. However, inadequate knowledge and
resistance from other disciplines were barriers to the implementation. Recommendations are
given to overcome the barriers.
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44. REFERENCES
 Townsend M. C., Morgan K. I. (2020), Psychiatric Mental Health Nursing Concepts of Care in Evidence-
Based Practice (Ninth Indian Edition), Jaypee Brothers Medical Publishers (P) Ltd, Page no: 147-54.
 Sreevani R. (2016), A Guide to Mental Health & Psychiatric Nursing (4th Edition), Jaypee: The Health
Sciences Publisher, New Delhi, Page no: 104-106.
 https://www.scribd.com.
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