Open Access Open Badges Study protocol

Best strategies to implement clinical pathways in an emergency department setting: study protocol for a cluster randomized controlled trial

Mona Jabbour123*, Janet Curran4, Shannon D Scott5, Astrid Guttman678, Thomas Rotter9, Francine M Ducharme1011, M Diane Lougheed1213, M Louise McNaughton-Filion141516, Amanda Newton17, Mark Shafir1819, Alison Paprica20, Terry Klassen2122, Monica Taljaard2324, Jeremy Grimshaw2526 and David W Johnson272829

Author Affiliations

1 Division of Emergency Medicine, Children’s Hospital of Eastern Ontario, Ottawa, Canada

2 Departments of Pediatrics and Emergency Medicine, University of Ottawa, Ottawa, Canada

3 Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Canada

4 IWK Health Centre, Halifax, Canada, School of Nursing, Dalhousie University, Halifax, Canada

5 University of Alberta, Edmonton, Canada

6 Institute for Clinical Evaluative Sciences, Toronto, Canada

7 Division of Paediatric Medicine, Hospital for Sick Children, Toronto, Canada

8 Department of Paediatrics and Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada

9 College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Canada

10 Departments of Pediatrics and of Social and Preventive Medicine, University of Montreal, Montreal, Canada

11 Research Centre, CHU Sainte-Justine, Montreal, Canada

12 Departments of Medicine (Respirology), Biomedical and Molecular Sciences (Physiology) and Community Health and Epidemiology, Queen’s University, Kingston, Canada

13 ICES-Queen’s University, Kingston, Canada

14 University of Ottawa, Ottawa, Canada

15 Montfort Hospital, Ottawa, Canada

16 Champlain Local Health Integrated Network, Ottawa, Canada

17 Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada

18 Department of Emergency Medicine, Cambridge Memorial Hospital, Cambridge, Canada

19 Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Canada

20 Ontario Ministry of Health and Long-Term Care, Toronto, Canada

21 Faculty of Medicine, University of Manitoba, Winnipeg, Canada

22 Manitoba Institute of Child Health, Winnipeg, Canada

23 Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Canada

24 Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, Canada

25 Ottawa Hospital Research Institute, Ottawa, Canada

26 Department of Medicine, University of Ottawa, Ottawa, Canada

27 Division of Emergency Medicine, Alberta Children’s Hospital, Calgary, Canada

28 Alberta Children’s Hospital Research Institute, Calgary, Canada

29 Department of Pediatrics, Physiology and Pharmacology, University of Calgary, Calgary, Canada

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Implementation Science 2013, 8:55  doi:10.1186/1748-5908-8-55

Published: 22 May 2013



The clinical pathway is a tool that operationalizes best evidence recommendations and clinical practice guidelines in an accessible format for ‘point of care’ management by multidisciplinary health teams in hospital settings. While high-quality, expert-developed clinical pathways have many potential benefits, their impact has been limited by variable implementation strategies and suboptimal research designs. Best strategies for implementing pathways into hospital settings remain unknown. This study will seek to develop and comprehensively evaluate best strategies for effective local implementation of externally developed expert clinical pathways.


We will develop a theory-based and knowledge user-informed intervention strategy to implement two pediatric clinical pathways: asthma and gastroenteritis. Using a balanced incomplete block design, we will randomize 16 community emergency departments to receive the intervention for one clinical pathway and serve as control for the alternate clinical pathway, thus conducting two cluster randomized controlled trials to evaluate this implementation intervention. A minimization procedure will be used to randomize sites. Intervention sites will receive a tailored strategy to support full clinical pathway implementation. We will evaluate implementation strategy effectiveness through measurement of relevant process and clinical outcomes. The primary process outcome will be the presence of an appropriately completed clinical pathway on the chart for relevant patients. Primary clinical outcomes for each clinical pathway include the following: Asthma—the proportion of asthmatic patients treated appropriately with corticosteroids in the emergency department and at discharge; and Gastroenteritis—the proportion of relevant patients appropriately treated with oral rehydration therapy. Data sources include chart audits, administrative databases, environmental scans, and qualitative interviews. We will also conduct an overall process evaluation to assess the implementation strategy and an economic analysis to evaluate implementation costs and benefits.


This study will contribute to the body of evidence supporting effective strategies for clinical pathway implementation, and ultimately reducing the research to practice gaps by operationalizing best evidence care recommendations through effective use of clinical pathways.

Trial registration NCT01815710

Clinical pathways; Key interventions; Intervention strategy; Pediatric emergency care; Theory-based strategy; Process outcomes; Clinical outcomes