Staircase’ replaces traditional pathways
A flexible, uncomplicated option
Case managers at an Arizona hospital have improved the clinical pathway process for cardiac surgery by developing a "staircase to wellness" that is less rigid than traditional pathways and allows for individual patient differences. Physicians like the new system because it allows them more flexibility in ordering diagnostic procedures, and nurses like it because it’s uncomplicated to implement.
Suzanne Anders, RN, CCRN, clinical case manager at Carondelet St. Mary’s Hospital in Tucson, AZ, says in the past, there were strict criteria for each day of the patient’s hospital stay. "On day one, you’d see CBC, ABG, chest X-ray, EKG being ordered," she explains. "But the physicians didn’t like that."
Anders says one of the cardiovascular surgeons told her that he disliked critical paths because when patients showed a variance, he felt it showed up as his error.
"He said that maybe he didn’t always want to order an ABG on a certain patient," she explains. "The patient may be really sick and on a ventilator for three days and the physician wanted to order ABGs on the third day. He said that showed up as a variance, but it’s really not a variance because it was appropriate for that patient. He saw variances as being a negative thing rather than being just a deviation from the routine."
Instead, Anders says case managers and other team members decided to develop a clinical path that reflected the patient’s own actual progression.
"All patients go through [cardiac surgery] at different rates," she explains. "Some of them are 40 years old, and some of them are in their 60s and 70s. So saying you’re going to do the same thing for everybody at the same time didn’t make a lot of sense."
The staircase uses a cardiac surgery wellness flowsheet that eliminates the traditional day-by-day approach, says Anders. Unlike a traditional pathway, the staircase approach only maps out steps to recovery for patients, and doesn’t distinguish on which day those steps should occur. That allows for individual goals to be set for patients, says Anders.
(See sample flowsheet, pp. 149-150.) The flowsheet contains a preoperative step, an intensive step, a recovery step, and a discharge step, and whether the different actions listed under each step were met.
"Because it’s based on the patient’s physiology and his [or her] ability to move and progress from one step to the next level, if he’s not able to progress, he falls off as a variance," she explains.
During preoperative teaching, nurses assess the patient’s condition and base his or her steps to discharge on an individual basis.
"If the patient is in his [or her] 80s and has had a stroke in the past and is going in for valve replacement [surgery], then we’d tone it down a little," Anders says. "We’d tell the patient This is what you should be able to do.’"
A benefit of the staircase to wellness is that it helps new nurses who aren’t yet familiar with cardiac surgery patients.
"It gives her [or him] an outline of what to expect most patients to be able to do in their phase," says Anders. "It’s a consistent framework to follow patients’ courses through their continuum."
In addition, the staircase can be used as a reporting tool. For example, a patient has had surgery and the nurse followed his or her course in the intensive care unit (ICU) for three days. Then the nurse was off duty until the patient’s seventh day of hospitalization, when he or she was being transferred to the stepdown unit. The patient was in the ICU for longer than usual; by following the wellness flowsheet, the nurse can tell what variances occurred and how to report them.
"If you’re not in there day in and day out, then you don’t get the whole patient’s history," Anders explains.
She recommends that other case managers who would like to develop a similar staircase system start by involving all appropriate staff members to develop it. Team members at Carondelet who helped develop the staircase included respiratory therapists, physical therapists, patient educators, dietitians, and the surgical director of cardiovascular services. Various nurses from surgical ICU, stepdown units, telemetry floors, and med/surg floors were included, as well.
"The nursing staff is especially important," Anders says. "Even though the nursing staff’s piece of this is one part of the team, if they don’t buy into the value of the critical path, they’re not going to use it. It’s just going to be another piece of paper that they have to attend to, and they don’t like that."
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