Stroke path slashes LOS by three days
Development process gave staff sense of belonging’
Established in 1995, the Palo Alto, CA-based Stanford Stroke Center’s ischemic stroke pathway slashed length of stay (LOS) from a pre-pathway high of 7.8 days to a current low of 4.1 days. (See sample pathway, pp. 147-148.) Because of Palo Alto’s largely capitated reimbursement environment, earning physician support for the pathway was a cinch, and most staff members were also eager to contribute. But even with these advantages, the pathway was less than an unqualified success at first.
The nursing staff experienced difficulty in supporting the burden of increased documentation, says Nanette H. Hock, RN, MSN, CCRN, CNRN, nurse coordinator of the stroke program. "At first we thought it was just that they were getting used to using a new form. But it turned out that there was just so much data that was being asked of the staff."
Following a three-month pilot test of the pathway, it became clear that a number of adjustments had to be made. "Documentation was an evolving process," says Hock. "It wasn’t something that was written and set in stone right away. And I must say it took about six months to actually say, OK, this is how we’re going to document [the pathway], and it’s going to be part of the medical record."
Pathway includes nursing care plan
At the end of the pilot test, the development team reconvened to consider ways to pare down the scope of the pathway and make it more user-friendly for the nursing staff and other disciplines. For example, the pathway team convinced nurses there was no need to write a nursing care plan separate from the pathway. By incorporating the nursing care process into the pathway, the team was able to eliminate a major source of redundant documentation. The team also created pre-printed medication sheets. "Now, nurses are only required to check off the times that they administered certain drugs," says Hock.
The stroke pathway’s development process began with a steering group of four people: the neurology ward’s head nurse, a stroke neurologist, a case manager, and Hock. This initial group looked first at diagnosis-related group data to find out what had been the most common stroke diagnosis at the center.
"At that point, we just decided to start writing things down and begin visualizing what we wanted to do," says Hock. The group then discussed its ideas with the administration, which approved the formation of a larger and more formal development group. The development group consisted of representatives from all affected disciplines, including social work, case management, nursing, and rehabilitation.
As part of his or her participation in the group, each representative was put in charge of something, says Hock. "For example, speech therapy; we wanted more data about swallowing problems, and aspiration pneumonia and what tests are done. So we made the specific list of things we were interested in and encouraged them to bring information which we may not even have asked for."
Departments invested in process
This approach also facilitated staff participation by giving each department "a sense of belonging" during the development process, Hock adds. "Even if only one person is being represented from a department, that person actually obtains feedback from the whole department and reports to the department about the pathway. That’s been a very successful approach for us."
Stanford’s positive history with other clinical pathways also helped encourage staff cooperation. In particular, many staff members were familiar with the hospital’s successful coronary artery bypass graft pathway. "That path had an extremely good reputation, so we used it as an example of a success story," says Hock. "It’s local data that staff had been involved with."
Hock considers herself fortunate that she works in a capitated environment where physicians have a vested interest in streamlining the plan of care. "I’ve heard horror stories about physicians not cooperating or making changes [to the pathway] and all that," she says. "But that’s definitely not the case at Stanford. Not to be arrogant about it, but we probably tend to have a more progressive group of people working here."
Even so, Hock allows that some staff members, particularly nurses, continue to struggle with the pathway. "It’s not a system that’s easy to work with, no matter how refined it looks in writing," she says. "And I guess something about CQI really is true: Improvement is a continuous process."
[Editor’s note: For more information about the Stanford stroke pathway, contact:
Nanette H. Hock, RN, MSN, CCRN, CNRN, nurse coordinator, Stanford Stroke Center, 701 Welch Rd., Building B, Suite 325, Palo Alto, CA 94304-1705. Telephone: (415) 723-4448.]
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