How to appraise a Patient Care Pathway
This section outlines the step-by-step process to appraise the environmental sustainability of patient care pathways, with a worked example for reference. A downloadable pdf is attached here This is derived and adapted from the guidance documentation which covers this in more detail. The full list of downloadable guidance documents can be found in the Sustainable Care Pathways Guidance section.
We have developed specific help for assessing maternity care pathways, available here.
1. Define the care pathway to be assessed
This should include the specific patient group and pathway being appraised and the reason for the appraisal.
Example:
Our objective is to undertake a high-level appraisal of the adult elective laparoscopic cholecystectomy pathway i.e. via the outpatient referral route. We will choose 10 patients to obtain a representative sample of our pathway.
The reason for the appraisal is to identify carbon hotspots within the pathway to target for quality improvement initiatives to reduce the overall carbon footprint of the whole pathway.
2. Create a detailed outline of all activities forming the care pathway
In order to fully appraise a patient care pathway, all clinical interactions and activities within the pathway must be mapped. This includes all distinct healthcare-related events performed for, on behalf of, or by a patient.
Example:
Outpatient elective laparoscopic cholecystectomy pathway
• Patient presentation to GP with suspected biliary colic – patient travel, staff travel, consultation + assessment
• GP refers patient for diagnostic tests – patient travel, ultrasound scan, blood tests
• Follow-up appointment with GP – patient travel, staff travel, consultation + assessment
• Specialist surgical outpatient clinic – patient travel, staff travel, consultation + assessment
• Pre-operative assessment clinic – travel, consultation + assessment, basic observations, blood tests
• Elective admission for laparoscopic cholecystectomy – patient travel, staff travel, anaesthesia, surgery, post-operative recovery
• Follow-up specialist surgical outpatient clinic – patient travel, staff travel, consultation + assessment
3. Group activities into modules
To simplify the appraisal process and identification of hotspot areas, linked activities can be grouped together into care pathway modules. These modules form the building blocks which make up the total care pathway.
Example:
Outpatient elective laparoscopic cholecystectomy pathway
4. Choose an appraisal method
Once the care pathway modules have been mapped, an appraisal of environmental sustainability can be performed in several different ways, depending on the data available and objective of the appraisal.
We have identified three main methods which each serve different purposes – these range from a high-level overview of the whole pathway to a detailed, granular analysis of an area of interest. These can be performed in a standalone fashion or sequentially, as outlined below.
5. Calculate the carbon footprint
High level appraisal:
In this type of appraisal, the user will not be collecting or calculating carbon emission data specific to their pathway. This approach uses existing published data to represent average estimates for generic/generalisable activity modules. To support this process, we have collated this data to assign to the following patient modules:
⇒ GP consultation
⇒ Emergency Department visit
⇒ Patient travel
⇒ Surgical procedure
⇒ Inpatient admission
⇒ Patient self-management
The carbon footprint associated with each of these modules can be found in the Carbon Factors Table this can be used for a manual calculation (see below). Alternatively, the module carbon footprints can be calculated online using our Carbon Calculator Tool. The tool allows for an additional layer of granularity if extra data is available (e.g. energy usage, travel data etc.), but this is not a requirement. The correct multiples of modules should be added together to obtain an overview of the pathway as a whole.
The carbon factors listed provide broad estimates of the carbon impact of healthcare activities. Using this approach should not be used or seen to capture all emissions within a care pathway or specific module. To quantify this we recommend following the detailed appraisal approach.
* We do not currently have detailed guidance documentation for Diagnostic Testing or Specialist Consultation. We recommend using the GP consultation emission factor as a surrogate for any routine (non-procedural) outpatient consultations. We have included emission factors (taken from published literature) for different diagnostic imaging modalities given the likely essential presence in many patient care pathways. This data must however be used with caution due to variability in research methodology.
Example:
Detailed appraisal for a module of interest:
Performing a detailed appraisal for a specific pathway module requires an in-depth analysis of all corresponding activities, events and products and then subsequent calculation of the associated carbon footprint using published carbon emission factors. To do this you will need to undertake comprehensive data collection for your module of interest. The steps required for this type of appraisal are beyond the scope of this webpage – please read the guidance documents (specifically the Main Document and individual Module Documents) in the Sustainable Care Pathway Guidance section.
The example below demonstrates the activities and components required for the In-Centre Haemodialysis Treatment module for a patient on a Chronic Kidney Disease Pathway (produced by the renal team at Newcastle upon Tyne Hospital – see Case Studies).
Example:
Hybrid Approach:
A hybrid approach allows the user to tailor the level of detail required, so that in-depth carbon footprinting is reserved for predicted hotspots where the greatest impact can be made. An initial high-level appraisal will act as a materiality assessment for likely hotspot identification.
As the high-level approach utilises the generic module-level emission factors and provides only an approximation of carbon footprint, the subsequent detailed modular analysis may not match the previously calculated estimates. In this situation, the original pathway assumptions may need to be revisited to ensure that the correct modules are being targeted.
6. Interpret and report the findings – take action
Following calculation of the carbon footprint, you can interpret the results and identify any likely carbon hotspots within the pathway. For the highlighted example (elective laparoscopic cholecystectomy pathway), the hotspot area appears to be the surgical procedure – this may be where you choose to identify carbon saving initiatives to implement. We have included a selection of resources and case studies for Decarbonising Patient Care Pathways to signpost users where to get started.
For a high-level appraisal the calculated footprint represents an estimate for the patient pathway. The carbon emissions we have allocated to each module have been obtained from a number of sources, each with a different approach to calculating emissions with varying degrees of scope, data quality and collection methods. For this reason we recommend a degree of caution when performing comparisons and advise that this type of appraisal be primarily used to create a baseline for your pathway in order to track the progress of subsequent carbon reductive actions.