Critical Path Network-DVT/PE path: Specific, detailed, and effective
Duke University Medical Center in Durham, NC, developed its inpatient clinical path for the treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE) late last year. "It's been up and running almost a year," says Lori H. Postal, RNC, MS, the facilitator in the department of disease management at Duke. Like paths used at other facilities, Duke's DVT path is an outline that addresses patients' care each day of their stay, from preadmission through discharge and follow-up care. Like others, it streamlines and provides a coordinated approach to care. That's where the similarities end, though.
"What's different about our path," she says, "is that it is more specific than those used by other facilities. The dosages and frequency of treatment are very precise. Many of the other paths I've benchmarked with are not as specific as ours, especially relating to medication and antibiotics." The physician order set is a companion to Postal's work product, and contains orders exactly as they are written on the path. The doctor checks what he or she wants. "If it's checked," she says, "it's ordered. If not, it's not done." This allows individualization for each patient. Other parts of the clinical path include a patient version of the path, outcome and documentation forms, and an education record.
Hospital Case Management asked Postal if any physicians balked at her pathway due to a belief that it represented cookbook medicine. "Very few," she answers. "We've had good buy-in. The majority think this is good and go on to use it as a teaching tool for their house staff and residents.
"The care of 80% of patients is fairly routine, and physicians feel that they should be spending 80% of their time on the remaining 20% of patients that have complex needs," she explains. Formatting her path in template fashion allows physicians to check off the routine tasks, and "that saves them quite a bit of time," she says. "Then they can spend the majority of their time thinking about their complicated cases or aspects of their patients' care that is more complicated."
The average length of stay (LOS) at Duke for DVT/PE is running 2% under the disease management department's target of four to five days. "Considering that our path is brand new," says Postal, "we are pleased. On average, patients stay 4.9 days in the hospital now." Her department benchmarks internally against the population they had prior to the path being implemented as well as against other similar institutions with similar populations — large teaching institutions in metropolitan areas.
Before patients with suspected DVT undergo an ultrasound, their diagnosis considers:
• swelling;
• pain;
• risk factors — stasis, injury to vein, hypercoagulability;
• (if low risk for bleeding) baseline labs — prothrombin time (PT), partial prothrombin time (PTT), automated blood count (ABC), chemist ries (ChemCS).
A negative ultrasound is followed by a repeat ultrasound in five to seven days or an MRI or venogram if calf DVT is suspected or patient has persistent symptoms. If results are still negative, no treatment is given.
Then care is driven by an algorithm in conjunction with clinical judgment.
Before patients with suspected PE undergo a lung ventilation and perfusion (VQ) scan or spiral CT, their diagnosis considers:
• shortness of breath, hypoxemia, chest pain;
• risk factors — stasis, injury to vein, hypercoagulability;
• chest X-ray;
• (if low risk for bleeding) baseline labs — PT, PTT, ABC, ChemCS.
A VQ scan is preferred if there is a history of previous PE and a previous VQ scan was done or if creatinine is elevated. A spiral CT may be appropriate if a non-embolic cause of abnormality is suspected or if other underlying lung or pleural pathology is present or suspected.
Thrombolysis in any case is handled medically by enoxaparin, warfarin, and/or heparin, according to Duke's path. "Some patients may have a vena cava filter inserted," says Postal, "but the management is mostly medical."
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