Hospital redesign complements new PTCA pathway
By Barbara King, RN
Clinical Pathway Coordinator
Valley Hospital
Las Vegas
Medical staff at Valley Hospital in Las Vegas took advantage of a hospital restructuring project to develop a clinical pathway to reduce a five-day length of stay (LOS) for percutaneous transluminal coronary angioplasty (PTCA) patients to two days.
The PTCA clinical pathway is the result of a six-month multidisciplinary team effort. Although the pathway was completed in October 1995, it was not implemented until early 1996 because of a unit redesign at our 396-bed community hospital. The redesign included the development of a new cardiac care step-down unit that needed to be incorporated into the PTCA pathway. (To see what treatments and actions occur during the step-down phase of care, see the Day 1 Post-Procedure CCU2 column of the PTCA clinical pathway, pp. 40-41.)
High-resource procedures, including PTCA and coronary artery bypass graft (CABG), were identified in the summer of 1995 for pathway development. Ten case managers were hired in January 1996 to supervise pathway implementation for each of the hospital's 16 patient care areas. Daily pathway use and documentation is handled by patient care managers who report variance information to the unit case manager.
The hospital's redesign eliminated a PTCA patient's transfer to the general medical/surgical unit before being discharged. A stay in the cardiac care unit (CCU) following surgery also was eliminated because the development team decided patients did not require the level of care provided in the unit. A stay in the CCU added unnecessary costs to the patient's charges. Patients now go from surgery to the step-down unit to discharge. That, plus other efficiencies to the care process, have cut the LOS from five days to two.
The PTCA pathway development team consisted of cardiologists and representatives from the following departments:
* admissions;
* laboratory;
* operating room;
* utilization review;
* general/medical nursing;
* catheterization lab;
* cardiac care unit.
Problems that contributed to a longer LOS at Valley were identified during the pathway development process. For example, delays in patient transfers from one unit to another created additional days for a patient's stay. Also, instructions for home care were not given to patients at discharge, prompting patient calls to the hospital and physicians' offices.
Additional delays preceding surgery are eliminated with the use of a preoperative procedures checklist. The pre-op surgery checklist includes the following:
* operative consent signed;
* medical history and physical complete;
* height;
* weight;
* allergies;
* nothing by mouth as ordered;
* pre-op sedation (hour of sleep and oral medications);
* 18-gauge needle for right arm;
* patient identification and blood banking armbands on right arm;
* lab, X-ray, and electrocardiogram (EKG) results on chart;
* cardiac cath results on chart;
* advance directives on chart;
* anesthesia pre-op interview;
* verify no heparin/Coumadin;
* pre-op surgery nurse verified above complete.
Physicians referring patients to Valley for PTCA surgery provide patients with a letter explaining the procedure and ask that they schedule an appointment for preadmission testing. Also as part of the preadmission process, patients view a 15-minute video explaining the surgery and recovery while participating in an EKG test.
A decision point was added to the pathway to accommodate physicians who prefer heparin as a treatment following surgery. Day two includes a reminder for sheath removal for heparin patients.
Variance information is documented using a numeric coding system. Departments in the hospital are represented by an assigned number to identify which department identified or noted the variance. Information is analyzed monthly for quality improvement purposes. Variances fall under system, physician, or patient categories. Additional information regarding reasons for a variance are documented on the back page of the pathway.
Pathway development is ongoing
Pathway development at Valley occurs over a month-long process involving weekly team meetings. Physicians are involved in two or three meetings during the development process to minimize their time commitment. The multidisciplinary team meets each week during an hour-long lunch to develop a pathway. All pathways are approved by the medical staff before being implemented.
In addition to PTCA and CABG, other pathways being developed include the following:
* total hip replacement;
* pneumonia -- simple and complicated;
* gastrointestinal hemorrhage;
* congestive heart failure;
* myocardial infarction;
* cerebrovascular accident;
* pediatric asthma;
* vaginal delivery;
* newborn.
To help staff learn about clinical pathways, all pathways contain a standard set of instructions. For example, shaded areas on the pathway indicate a treatment or action requiring review and signature from a physician. All disciplines involved in patient care are allowed to document on clinical pathways, which are part of the patient's permanent medical record.
A clinical pathway manual currently is being developed for each unit of the hospital, including admissions and the emergency department. Included in the manual are sample copies of each pathway used at Valley, policies regarding pathway usage, and instructions on how paths are used. Pathway manuals also will be distributed to primary care physicians who practice at Valley. *
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