Critical Path Network
Flowcharts are basis for symptom-based tools in the ED
Health care providers have access to plenty of flowcharts and algorithms designed to guide the treatment of patients with particular diagnoses, but many of them aren’t designed for use in the emergency department (ED). What good is a flowchart for pneumonia if you don’t know what’s wrong with the patient yet?
To address that problem, the ED team at Overlook Hospital in Summit, NJ, has developed what it calls "flow-gorithms" for commonly seen illnesses.
The difference between the flow-gorithms and the other tools commonly available is that the flow-gorithms are symptom-based rather than diagnosis-based, says Patricia Gabriel, RN, BSN, CEN, nurse manager of the ED. "All of the things we look at in terms of pathways and patient management are all diagnosis-driven. That doesn’t help us from an ED perspective because patients don’t come in with labels that say, I have pneumonia.’"
The flow-gorithm is a symptom-driven tool that guides the entire ED team — physicians, nurses, and others — to a proper diagnosis and ensures that the best testing and treatment are provided along the way.
The flow-gorithm is fairly simple in design and easy to use, Gabriel says. It looks much like a typical flowchart that leads the user from one step to the next, depending on the patient’s symptoms, she says.
The triage nurse usually is the first to use the flow-gorithm and matches the patient’s symptoms to those listed at the top of the flow-gorithm. For example, if the patient reports fever, cough, shortness of breath, and increased sputum, that fits the pneumonia flow-gorithm, and the triage nurse will attach a copy to his or her chart.
When patients come in by ambulance, they bypass the triage nurse and go directly to an exam room. In that case, the nurse responsible for that room initiates the flow-gorithm. (See sample flow-gorithm.)
The flow-gorithm gives specifics as to whether the patient should be triaged as emergent or urgent, and lists other steps and questions for others. Some steps have spaces to initial and indicate the time that an action was taken. At several points, the results of the examination may lead the clinician out of the decision tree by indicating that the patient does not have pneumonia and should be treated accordingly.
"It lets you work through the symptoms and processes without always having to have physician input up front," she says. "Then if the physician says the X-ray shows pneumonia, we use the flow-gorithm to tell them what blood work needs to be done and which of the antibiotic groups they can pick from."
The first flow-gorithm, for pneumonia, was developed about four months ago, and then the team developed one specifically for geriatric pneumonia. A flow-gorithm for chest pain was developed more recently, and the team plans to develop one for potential stroke patients.
Pneumonia was a good place to start because its symptoms are clearly defined and straightforward, Gabriel says. The ED team also wanted to improve the way it treated patients presenting with suspected pneumonia. "We have a strict time frame to give them antibiotics — just four hours from presentation," she says.
"On a busy day in the ED, if a middle-aged person comes in with cough and fever, and the pulse oximetry was alright, they were not going to be high on the list for acuity. If you don’t get the chest X-ray done right away, the clock is ticking, and you’re not going to get the antibiotics to them in four hours if it does turn out to be pneumonia."
The team also found that elderly patients often slipped through the system and didn’t get antibiotics in time because their pneumonia presented with very different symptoms than the average patient. "If you fell in the 18 to 65 range, almost 100% of the time, you got your antibiotics within four hours," she says. "If you were in the 65 to 85 range, maybe 65% of the time you got your antibiotics within four hours. If you were 85, forget it. You didn’t get your antibiotics for a while because you didn’t present with symptoms that we recognized as pneumonia."
So the flow-gorithm for geriatric pneumonia includes "change in normal activity tolerance" as a symptom that should trigger the use of the flow-gorithm. "If the patient presents with that, that automatically moves them up on the list and we order a chest X-ray," Gabriel says.
The flow-gorithms are based on commonly accepted practice guidelines, but they also are tailor-made to the needs of the Overlook Hospital ED staff. For instance, the flow-gorithm for chest pain addresses a common problem that the staff encountered concerning how much aspirin to administer. No one could ever remember whether to count the patient’s daily aspirin dose or aspirin administered by the paramedics when figuring the dosage. "So it says right on there to give aspirin unless they got a certain amount from the paramedics," Gabriel says. "And it says to give the aspirin even if they took their normal maintenance aspirin."
For more information, contact:
- Patricia Gabriel, ED Nurse Manager, Overlook Hospital, 99 Beauvoir Ave., Summit, NJ 08043. Telephone: (908) 522-2000.
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