Indiana hospital revamps path for continuum care
Streamlining doctors’ order sheets aided buy-in
Case managers at Community Hospitals Indianapolis (CHI) admit that when they first implemented a clinical pathway for pneumonia in 1992, they overestimated the amount of physician support and interest in the pathway project. Consequently, the path was "probably not successful," says Susie Wheeler, RN, MS, team leader for clinical quality improvement at CHI.
Learning from past mistakes, however, case managers at CHI have overhauled the pneumonia pathway, building in physician involvement and developing a continuum approach to care that encompasses the emergency department, acute care, and home health. As a result of the changes, costs per case have dropped $500 and length of stay has shortened by almost two days, Wheeler reports.
One reason for the greater degree of physician involvement in the new pathway was simply the greater acceptance of critical paths in health care. "When you look at the whole field of medicine, where there are now more clinical practice guidelines by recognized organizations, it lends better credence because you have more expert opinion and research to draw upon," says Wheeler.
CHI also formed a Medical Patient Care Process Team, including nurses from emergency services, acute care, and home care, as well as representatives from pharmacy, laboratory, respiratory care services, case management, utilization management, and quality improvement. In updating the pneumonia pathway, team leaders recognized that physicians had been dissatisfied with the length of the doctors’ orders for pneumonia, which many considered cumbersome, says Betty Parks, RNC, MSN, a clinical nurse specialist who led the pathway writing team.
Physicians wrote typical set of orders
"The doctors’ orders were very difficult to use, and physicians could never figure out which page we were on," says Parks. Recognizing that the orders must be shortened, Parks sent a memo to all of CHI’s top physician admitters for pneumonia, soliciting their input. "I asked them to write me a set of orders for the typical pneumonia patient they admit," she says. "We incorporated in the new doctors’ order sheet all the things listed by all the physicians who responded. That way, they could actually say we had their input."
The team also deleted a number of items that were "nice to know" but not essential, or moved them to other parts of the pathway. For example, nursing interventions were taken off the doctors’ order sheet but left on the pathway as a nursing order. These efforts at revision shortened the doctors’ order sheets from five pages to one. (See excerpts from clinical pathway, p. 64.)
Other improvements to the original pathway included the following:
• The emergency department became an active player in the pathway process.
Originally, the pneumonia pathway was updated so implementation began in the emergency department. Team leaders felt that was an important step because they identified major variations in the administration time for the first dose of antibiotics. Since the original update, the pathway has been further revised. Now, the emergency department has a separate pathway for respiratory symptomology.
"That [pathway] covers up to the point where they make the differential diagnosis," says Wheeler. "Dependent on that diagnosis, the patient will be put on a specific pathway, such as pneumonia. But the importance of having the antibiotics started there is the timeliness of the intervention. The sooner you get the antibiotics started, hopefully you can get a better outcome. I mean, if you look at the desired time frame that the patient is here, do you really want to go much beyond two to four hours before they get their first dose of antibiotic?"
• Physicians and pharmacists streamlined antibiotic choices for pneumonia.
Physicians and pharmacists provided input in redesigning the physician order sheet to include recommended antibiotic choices based on severity and suspected organism, says Wheeler. Pharmacy was especially crucial in providing information on various antibiotics. "They’re a great adjunct to the team from the standpoint of all the data they collect that really do make process improvement possible," says Parks. The pathway team also developed criteria for conversion of intravenous antibiotics to oral antibiotics.
Parks notes that individual physicians retain the option of choosing an antibiotic not on the list of recommended choices. "And a lot of them do," she says. "But we’re trying to use that certain grouping of antibiotics that they would customarily use, and trying to look at what’s cost-effective and will get the job done."
• Collection of sputum specimens was improved.
Data from the initial pneumonia pathway indicated that for most patients, collecting sputum samples provided low-yield results that rarely affected treatment decisions. As a result, case managers do not initially recommend collecting sputum unless the patient fails to respond to therapy, says Wheeler.
• Variation in the use of oxygen therapy was corrected.
Looking at practice pattern data, case managers detected wide variability in the use of oxygen therapy. "What we’re doing now is looking at what day you should begin to starting weaning the patient off oxygen," says Wheeler. "And looking at what level the oxygen sets should remain. That better guides the staff in terms of anticipating, responding, and communicating to the physicians, because they have some sense of measurable criteria against which to compare."
• Improvements were made in maintaining function.
Because the majority of pneumonia patients treated at CHI are older adults, case managers began looking at "more consistently aggressive ambulation, so that we have a sense of the patient’s functional status when they came in, and how we could maintain that, given their ability to tolerate progressive activity," says Wheeler.
Additionally, the team developed a home care pneumonia pathway in order to maintain appropriate continuity of care. The home care pathway guides the hospital-based home care service regarding the appropriateness of continuing with antibiotics, as well as the dissemination of patient education information.
Home care liaisons communicate directly with physicians and hospital staff regarding the care of individual patients, Wheeler notes. "We’ve also standardized our patient education message from one level to the other," she adds. "And the home care representative is also a member of the pathway writing team."
As a result of CHI’s efforts to revise its pneumonia critical pathway, cost per case has dropped by about $500 from March 1994 to September 1996. Over that same time span, length of stay has decreased from seven days to 5.3 days, Wheeler reports.
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