QI approach to pathway development: Multidisciplinary and cross-continuum
Small, rural hospital dramatically improves CHF outcomes
A Delaware hospital was having problems with its management of congestive heart failure (CHF) patients. More than 90% of the CHF patients returned to the hospital within a year, and their average length of stay (LOS) was 11 days.
This was a problem ripe for a quality improvement effort that eventually developed a cardiac team and started clinical pathways that followed the patient from the hospital into home care and outpatient services.
The results have been remarkable, says Heidi LeGates, MSN, RN, clinical outcomes specialist for Milford (DE) Memorial Hospital a 180-bed community hospital that serves a small town and rural area.
After one year of the program, only two out of 29 CHF patients returned to the hospital, she says. This translates into a 6.8% recidivism rate. And none of the patients were treated for myocardial infarction. The LOS fell from 11 days to four. LeGates says one of the hospital’s strategies is to increase referrals to home health. So referrals to home health have increased from fewer than 30% to more than 51%.
Also, the number of CHF patients who return to the hospital after being admitted into home health care has dropped, says Barbara Peterson, RN, MSN, EDD, director of home health services for Milford Memorial.
From home care, the patients are referred to outpatient cardiopulmonary rehabilitation. Before the program started, patients were treated at home for three months. Now they are referred to outpatient rehabilitation within two to three weeks, says Cathy Schenker, RN, BSN, manager of home health for Milford Memorial.
The CHF clinical pathway has worked so well that Milford Memorial also has set up pathways for pneumonia, orthopedic, asthma, cerebral vascular accident, and other diseases.
Here is how the multidisciplinary quality improvement team succeeded:
• The team looked at data from other hospitals.
"Everyone in the group was looking at benchmarked data," LeGates says. They looked at clinical studies from Voluntary Hospitals of America (VHA Inc.) in Dallas and guidelines from the American Heart Association, also in Dallas, as well as other data. Team members also compared Milford’s data on CHF patients with guidelines published by the American Health Care Policy Resources through National Health and Social Services.
The team decided to adopt these guidelines and compare them to patient charts. "From that we devised a clinical pathway," LeGates says.
•Each discipline contributed to the pathway.
Nurses looked at nursing care; physical therapists contributed their segment, and X-ray technicians, laboratory workers, dietitians, and other therapists also added sections to the pathway.
Milford’s home health providers, for example, met with the cardiopulmonary rehabilitation providers to discuss how the home health portion of the pathway would lead patients to the rehabilitation portion, Schenker says.
Specific criteria established for CHF patients
"We said, If our goal is to have our patients come to you as quickly as possible, what criteria do they have to meet so they can do that?’" Schenker adds. They came up with a list of eight criteria that would have to be met for three consecutive visits. (See CHF criteria, p. 27.)
The pathway was divided into sections, and each subgroup had a goal of what should be the expected outcomes of the patients upon discharge, LeGates explains. "Then we’d build the pathway around physician orders as well. The team worked with physicians to see what would be the best practice."
The team met weekly at first, and later the meetings slowed to biweekly and finally once a month.
The pathway’s components include lab testing, the emergency department process, patient education and home health care, nursing, and respiratory care. Physicians were a part of the overall group.
Numerous other hospital committees reviewed the pathway to make sure it met legal criteria, and then they presented it to the medical staff.
•The team worked to obtain buy-in from medical staff.
"Rather than present this as a pathway, which is sometimes mistaken for cookbook medicine, this was presented as a new standard for care," LeGates says.
Some were reluctant to try pathway
Some physicians, including those in family practice, embraced it immediately, she adds. But some of the internal medicine physicians, who had been in practice for a long time and who had not adapted to thinking in termsof managed care, were reluctant to try the pathways.
Team members continued to lobby staff to try it. They focused on how the pathway was based on national standards, and the pathway only asked providers to do the things that the patients need to have done anyway, LeGates adds. "We can’t tell them how to practice medicine, but we practice nursing so that we deliver the same standard of care whether a physician has ordered the pathway or not."
•Team created a version of the pathway for patients.
The team developed a chart version and a patient version, which is written at a sixth-grade reading level. "So patients have in their hands from the time they are admitted what is expected of them and what is expected of their staff," LeGates says.
The patient’s pathway, for instance, might say that the patient should get out of bed on a certain day and try walking. Or it might show the patient what type of tests the nurses will need to conduct on certain days.
The patient’s pathway also includes the following information:
what the discharge plan will be;
how the hospital will communicate with the insurer;
how to take medicine;
what activities the patient should do;
who the provider will be when the patient returns home;
when the home care provider will visit.
"We make an educational assessment of what the patient needs to know and what the patient doesn’t know, and then we collaborate with the home health providers so the information is sent to them," LeGates explains.
• Team implemented the pathway and educated staff.
The hospital started a pilot project with the CHF pathway, starting with outpatient services. It lasted two months and involved six patients. Then the hospital started a six-month trial of the entire pathway, involving 18 patients.
The outpatient pathway works as follows: If someone is admitted to the emergency department and needs to be treated aggressively with diuretics, the patient is admitted to the hospital on an observation basis for 12 to 24 hours to see how well he or she is responding to treatment, LeGates says.
If the patient’s CHF is not severe and the patient’s condition improves after treatment, then the patient will be discharged and referred to home health care.
Staff trained to meet pathway requirements
Hospital staff on the intermediate care unit had to undergo eight hours of inservice education and were given an extensive review of cardiopulmonary physiology and assessment, LeGates says.
"The nurses on this pathway are expected to measure jugular venous distension, which means you’ve got a right-sided heart failure," she explains.
They were taught to listen to heart sounds in more detail than they did before and to measure the circumference of patients’ ankles, rather than to continue using subjective measurements for ankle edema.
The home health nurses also underwent eight hours of education, and the hospital held multiple inservices for staff over a two-month period. "The intermediate care staff and home health nurses were required to attend the inservices, but we had interest from the medical-surgical nurses as well," LeGates adds.
[For additional information, contact: Heidi LeGates, MSN, RN, Clinical Outcomes Specialist, Milford Memorial Hospital, P.O. Box 199, Milford, DE 19963. Telephone: (302) 424-5596.
Barbara Peterson, RN, MSN, EDD, Director of Home Health Services, Milford Memorial Hospital Home Health Services, 104 NE Front St., Milford, DE 19963. Telephone: (302) 424-5590. Fax: (302) 424-5976.
Cathy Schenker, RN, BSN, Manager of Home Health, Milford Memorial Hospital Home Health Services, 104 NE Front St., Milford, DE 19963. Telephone: (302) 424-5590.]
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