Tuesday, 3 June 2008


Do you have Integrated Pathways of Care (an IPOC) or Integrated Care Pathways (ICP) as protocols, governance frameworks, audit tools and clinical records all rolled in to one?

I used to write on blank paper. Life was simple.

Now we've care pathways for oodles of things. Each has its own booklet to fill in with squillions of boxes. Have you documented that you've assessed capacity in the Capacity box? Have you signed and dated this? Have you initialled and dated the "discussed managed choice" bit and listed what options were proffered? Have you recorded biochemical indices before initiating an antipsychiotic? Have you commented on the ECG you then invariably undertook, since the patient's on an antipsychotic?

I can see the point of them. They focus in on what one version of best practice is, lists every single element of this, then guides you through each and every step which you document, laboriously.

Much of the paperwork is redundant (do I really need a list of approved abbreviations for each care pathway in each set of filed documentation each time it's started?) making them lengthy. Case notes have increased in size appreciably.

But, not just case notes. I see a patient in their home, do I start care pathway documentation in the community? I guess I probably should. Hang on, then, how's my CPN going to follow it up since she won't have my written medical notes (since the CMHT have their own electronic records). What about day hospital attendance when things are fiddled with? Or in-patient episodes? Gah, the care pathway isn't one record with continuity and contemporaneous documentation at all then, is it?

What if a patient has, say, hypomania? They're admitted informally and receive help. But the documentation becomes hideous. We've a care pathway for the admission, a care pathway for the antipsychotic, a care pathway for the mood stabiliser, a care pathway for the discharge. We've care pathways for ECT. Each care pathway requires, at length, that every element of every step of care is documented, timed/dated and signed.

I hate it.

Not the framework, per se, more the compartmentalised documentation. I look at an antipsychotic pathway then find in the notes the one for lithium use, then the admission one with physical comorbidity and medication and so on, information's scattered all over the place. That, above all else, is what I loathe about care pathways. This fixation with form and process loses the context and detail.

What's it like for the person, today compared to yesterday? What's changed, in terms of how they're now able to sit having a fag in the garden and chatter to folk about what lumpy custard we had at lunchtime (when last week behavioural repetoire was much more constricted). What does their nearest and dearest reckon's changed? Where does it allow us to document that, now, there's a desire to choose ones own clothing when offered a choice? There're lots of bits to document suicidality, but nowhere does it allow documentation of ataxia and falls risks, or dysthmic changes and feeling hacked off and irritable, or consequences such as delirium or akathisia causing wandering at 5.00am in a night dress across and along a main road.

Information is now incomplete since only what's requested is documented and other (more relevant) information is no longer documented. Information is fragmented, being compartmentalised in to different areas. Information is factual and procedural and specific, so lacks context.

Having started using care pathways a year or so ago, I've managed to avoid them totally this year. We're in to June now, half way through, and nobody's told me off yet. Hopefully I can get away with it for another few decades, eh?


WardBunny said...

I've not yet found a Doctor yet that likes ICPs. Mostly if they refuse to write in them it's taken as a protest and nobody says much.
We have no choice. No matter how pointless we think it is.

Dragonfly said...

Good old medical bureaucracy. I think the idea was originally to protect the patient. I was in a hospital where patients had to fill in forms about any overseas travel they had ever done, both at the beginning and at the end of their admission. Go figure.

marcella said...

I agree the aim is probably laudable. The result appears to be that the vast majority of slots on the form are left empty and most of the stuff I scan in daily (copies for GPs) consists of pages and pages of forms, the useful information on which could probably be summarised in a couple of sentences.

Am Ang Zhang said...

That is why they only want those with less than 3 Cs for medical school. What have we become: form filling clerks? Also it is so easy to miss the most important things in the multitude of forms. When are we having the new Republic?

The Cockroach Catcher

Oliver Smith said...

This is unrelated to what you've discussed above.

Someone said the following to me today and I wanted your opinion.

"Why would you want to go into psychiatry? It is a dying bread. They've lost a lot of credibility

Petronius said...

CC, The New Republic is at the end of the link in my name above. You'd better take a couple of nurses, and don't mention ICP's or eCPA's.

Medically Brunette said...

why have they been introduced? Presumably there has been criticism of some doctor's notetaking?

Surely you can rustle up a revolution?!

Elaine said...

I remember these being discussed some 12 years ago, particularly in the first instance for surgical, orthopaedic patients. The idea was partly a costing exercise (now, there's a surprise), but also to examine the patients whose care didn't lie on the pathway: whast was going wrong?

Could be used to identify failings in outcomes to judge the quality of care given.

At that time, not just doctors were to be involved, but nurses and other health care professionals, so it included a guide of sorts as to what care should be carried out when.