Pengembangan dan evaluasi clinical pathway: studi kasus pada stroke

Rizaldy Pinzon SMF Saraf RS Bethesda Yogyakarta

The Path:

Alur perawatan

pasien sejak dari

IGD sampai

dengan keluar

rumahsakit

12

Figure6:

Evidence-basedmedicine

Clinical practiceguidelines Clinicalpathways

Source of medicineEg.lierature Recommendations

There are studies ongoing that the amalgamation of the tools used for Clinical Practice Improvement and theEvidence-based Medicine, respectively can bring about a dynamic change in clinical practice. It has beendemonstrated that evidence-based medicine has significantly contributed to improving the outcomes of thepatients, and Clinical Practice Improvement has a large role to play as a process to discuss various clinicalissues and in finding the ways to resolve the issues wherein solutions can work out. Clinical Pathways alsoserve as a source of communication with the patients regarding their specific care plan and progress overtime in the form of systematic and clearly sketched out summary of the process of disease management.This is possible because Clinical Pathways form a part of the patients medical record and summary sheet.Clinical Pathways document the potential steps in the diagnosis and treatment of a condition or a procedurefor individual patients to improve the outcomes of the disease or procedure management.

11. Areas implementing the Clinical Pathways [Figure 7]A care/clinical pathway is an integrated strategy of care for a specific user group based on clinical guidelinesand evidence, where available. It determines locally agreed, multi-disciplinary practice and outlines theoptimal sequencing and timing of interventions (McQueen and Milloy 2001). The intention of the pathway isto chart a clinical process from start to the end, including the time anticipated to complete key activities inthe process.

A prerequisite for clinical pathway is chain management which reflects a strategy of managing carepathways, guaranteeing continuity of care, safeguarding best quality of care, ensuring the appropriate use ofresources (considering that there are different responsibilities involved) and managing the provision of care.

Out of all the multiple areas listed where we can evaluate the impact of the Clinical Pathways in theoutcomes of the patient management, we will look in detail at two areas, which have implemented the use ofClinical Pathways:1. Stroke2. Chest pain and STEMI (ST-elevation myocardial infarction)

Since knowledge management means doing the right things instead of doing things right, we will try tofocus the insinuation of the Clinical Pathways into clinical practice and their mapping into a strain ofknowledge useful for the improvement of the patient management and outcomes in the field of medicine.

1. Stroke: Clinical Pathways are integrated care strategies that offer a means of achieving betterintegration among practitioners, community-based services, and other health and social care services.(Tiziano Vecchiato)

The main areas of concern for the patients of stroke are the treatment and outcomes and discover the waysfor the optimum management of a stroke patient. There is a certainty that if the patients with stroke receiveorganized care, they will surely have better outcomes and prognosis. In a hospital setting, the well-trainedstaff and multidisciplinary approach to treatment and care characterize the stroke unit. The core disciplinesfor such multidisciplinary teams are: medical treatment, nursing, physiotherapy, occupational therapy,speech and language therapy and social work.

The Clinical Pathways ensure a goal-defined, making certain a well-defined efficient diagnosis,organized and time-specified plan of treatment of the patients with stroke, which can ascertain evidence-based practice and an improvement in the quality of outcomes at a lower cost. (Sulch & Kalra, Age andAgeing). They are designed to explicitly define what kind of continuity of care the patients should receive, atwhat time they should receive this care and what are the roles of the various multidisciplinary teams in thepatient care. It has been seen, without much of much evidence to support this, which integrated care

Evidence based practice: kendali mutu dan kendali biaya

WWW.GUIDELINE.GOV

WWW.CMA.CA/CPGS

WWW.ACADMED.ORG.MY

Latar%Belakang% Pelayanan%stroke%adalah%salah%satu%unggulan%di%RS%Bethesda%Yogyakarta%

Clinical pathway sebagai perangkat kendali mutu dan biaya

Evidence Based Medicine!

Evidence Based Clinical Practice Guideline!

Clinical pathway!

Stroke iskemik akut!

Proses pelayanan!Varian!

Luaran klinik!

- Kendali mutu!- Kendali biaya!- Pengingat!- Perangkat komunikasi multidisiplin!

Audit dan register!

- Faktor demografik!- Faktor klinik!- Komorbiditas!- Komplikasi!- Proses pelayanan!

Case manager!

Telaah pustaka

Clinical pathway dikembangkan berdasar clinical practice guideline

dengan metode konsensus

80

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Sebelum diberlakukan secara penuh, maka draft clinical pathway tahap ketiga

dievaluasi untuk menilai apakah clinical pathway stroke RS Bethesda Yogyakarta,

memiliki komponen-komponen yang diperlukan untuk suatu clinical pathway yang

efektif dan efisien. Kajian Vanhaect (2007) menunjukkan ada beberapa perangkat untuk

menilai suatu clinical pathway. Alat evaluasi yang dipilih adalah Integrated Clinical

Pathway Appraisal Tools/ ICPAT yang memuat 6 dimensi dan 99 pertanyaan dengan

jawaban Ya/ Tidak (Whittle, dkk, 2004). Tabel berikut menunjukkan evaluasi terhadap

draft akhir clinical pathway RS Bethesda Yogyakarta.

81

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Clinical pathway dimulai di IGD lalu dilanjutkan di unit stroke dan bangsal

sampai dengan pasien keluar RS

Pencatatan indikator proses dan luaran

Clinical pathway

Register stroke

Indikator kinerja stroke Mengacu pada canadian stroke network

CT scan pada semua pasien stroke

Rehabilitasi mulai pada 48 jam pertama

Esesmen menelan pada waktu di IGD

Anti platelet pada stroke iskemik saat keluar RS

Anti koagulan pada pasien stroke dengan AF

96

Tabel 12. Perbandingan indikator proses pelayanan di IGD antara kelompok pasien yang menjalani clinical pathway dan tanpa clinical pathway

Karakteristik Clinical Pathway (%) p Ya (n = 119) Tidak (n=123)

Oksigenasi 0.004 U+! 118!@99.2C 112!@91.1C W36+&! 1!@

97

sesegera mungkin setelah diagnosis stroke iskemik ditegakkan. Tiga kasus tidak

mendapat terapi anti platelet di IGD disebabkan oleh karena perdarahan saluran cerna

pada 2 kasus, dan tidak diketahui alasannya pada 1 kasus.

4.3. Karakteristik proses pelayanan di bangsal antara kelompok clinical pathway

dan non clinical pathway

Indikator proses yang dinilai pada pelayanan stroke iskemik adalah pemberian

anti platelet seawal mungkin, pemberian statin pada dislipidemia, program rehabilitasi

seawal mungkin, konsultasi gizi, dan konsultasi bagian terkait. Tabel 13 menunjukkan

indikator proses pelayanan selama di bangsal.

Tabel 13. Perbandingan indikator proses pelayanan di bangsal antara kelompok sebelum dan sesudah clinical pathway

Karakteristik Clinical Pathway (%) p Ya (n = 119) Tidak (n=123)

Anti Platelet 1 U+! 117!@98.3C 121@98.4C W36+&! 2!@1.7C 2!@1.6C

Statin pada kasus dengan dislipidemia 0.344 U+! 86@72.3C 82@66.7C W36+&! 33!@27.7C 41!@33.3C

Fisio terapi dalam 48 jam pertama 0.001 U+! 107@89.9C 91!@74.0C W36+&! 12@10.1C 32!@26.0C

Konsultasi Gizi 0.006 U+! 115!@96.6C 107!@87C W36+&! 4!@3.4C 16!@13C

Konsultasi bagian terkait 0.073 U+! 64!@53.8C 52!@42.3C W36+&! 55!@46.2C 71!@57.7C

Hasil penelitian menunjukkan bahwa ada perbaikan dalam hal proporsi pasien

yang mendapat tindakan rehabilitasi (fisioerapi, terapiwicara, dan terapiokupasi) sesegera

101

mandiri saat keluar RS dibanding pasien tanpa clinical pathway. Tidak ada bea dalam hal

kejadian komplikasi pasca pemberlakuan clinical pathway.

Tabel 16. Perbandingan indikator luaran stroke antara kelompok sebelum dan sesudah clinical pathway

Karakteristik Clinical Pathway (%) p Ya (n = 119) Tidak (n=123)

Meninggal 0.117 U+! 3 (2.5) 0 W36+&! 116 (97.5) 123 (100)

Status fungsional saat keluar RS

Kesimpulan Clinical pathway yang dikembangkan dapat

mampu laksana

Clinical pathway memperbaiki indikator proses

Belum tampak nyata perbaikan indikator luaran

Register bermanfaat sebagai perangkat bantu evaluasi