Lap choly pathway leads to efficiency, savings
Nurses love to document on pathway
Promina Gwinnett Health System in Lawrenceville, GA, has found the road to efficiency through clinical pathways. A pathway on laparoscopic cholecystectomy, for example, has helped the system's two same-day surgery programs standardize supplies and some physician practices and implement documentation by exception, says Judy Addy-Keller, RN, MSN, CS, director of coordinated care. (See copy of the pathway, inserted in this issue.)
While a cost-analysis has not been completed of the pathway's impact, Addy-Keller notes that there have been some clear cost benefits. For example, Promina Gwinnett Health System eliminated the use of sequential compression devices, which are used to prevent clotting or deep vein thrombosis for patients who are bedridden, for a savings of $200 a day per patient, she says. Promina Gwinnett Health System's lap choly patients are admitted to an observation area for just a 23-hour stay.
Because of the low risk of infection related to the procedure, routine use of pre-op antibiotics also has been curtailed, Addy-Keller says.
Nurses particularly appreciate the time-savings the pathway provides, she says. "Everybody likes the idea of documentation on the pathway, says Addy-Keller. Exceptions to the pathway are noted on a variation sheet, she says. The pathway includes physicians' standing orders, and any changes must be noted by the physician, she says.
The lap choly pathway, which has been in place for about a year, includes preadmission and the pre-op and post-op phases. Promina Gwinnett Health System is developing a complete perioperative pathway, including the intraoperative phase that could be used for most outpatient procedures, Addy-Keller says.
A reduction in paperwork will be one major advantage of the perioperative pathway, says Mary Nash, RN, CNOR, director of outpatient perioperative services. "Sometimes when we're doing these very short cases, it takes longer to do the documentation than it does to do the procedure," she says. "[The nurses] are looking forward to spending less time on documentation, so they'll have more time with their patients."
Nash and Addy-Keller are developing the pathway with the help of a team including representatives from the same-day surgery centers at both Promina Gwinnett hospitals, the director of inpatient surgery services, two performance improvement chairpersons, the laser/endoscopy coordinator, a surgical clinical nurse specialist, and a nurse educator. Addy-Keller also seeks input from each physician.
Most physicians have adapted well to the lap choly pathway, but Addy-Keller acknowledges that gaining physician acceptance isn't always easy. While some are "champions" of the effort to improve both efficiency and quality, others are resistant to change, she says. Physicians are not required to use the pathways, she says.
Some physicians fear that the pathways remove their autonomy, Addy-Keller says. "This isn't taking away their autonomy," she says. "It's standardizing practice." Physicians still make individual decisions about patients as necessary.
To gain physician acceptance, Addy-Keller often meets with physicians one on one. She also posts a list of physicians who are using the pathway and its standing orders, which provides some peer pressure. *
For more information about clinical pathways, contact:
* Judy Addy-Keller, Director of Coordinated Care, Promina Gwinnett Health System, P.O. Box 348, Lawrenceville, GA 30246. Telephone: (770) 995-4643. Fax: (770) 682-2249.
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