MS pathway encourages physician buy-in
Path stresses PT screening, follow-up care
The critical pathway development team at Atlanta-based Shepherd Center’s multiple sclerosis clinic wanted to avoid the physician resistance that so many case managers encounter when designing pathways, so they chose not to take a best-practice approach to their path for inpatient IV therapy.
The decision wasn’t difficult, considering that the center had maintained a relatively low seven-day length of stay for MS patients receiving Solumedrol, an IV form of prednisone, even without a pathway in place.
With the intention of moving to best practice within two years of implementation, case managers at Shepherd embarked on formulating a current-practice pathway aimed at standardizing procedures and eliminating possible complications, says Donna Court, RN, MN, interdisciplinary pathway nurse at Shepherd. As a result, all nine of the patients placed on the pathway since its implementation in the fall of 1996 have been discharged within the target LOS of five to six days. (See sample pathway, p. 145.)
Patients on the pathway receive 1 gm of Solumedrol per day in the acute setting to control exacerbations related to a sudden weakening of their muscles or the appearance of other severe functional impairments. Solumedrol, a steroid, reduces inflammation of the nerves of people who have MS. On an outpatient basis, the drug is usually administered orally and in much smaller doses. "When [patients] lose functionality or can’t take care of themselves the way they normally do, that’s when you would go to the heavy-duty IV therapy," says Court.
Using your own data, not someone else’s
Court and her colleagues decided to base the Solumedrol pathway on current rather than best practice for a couple of reasons. "With current practice," Court says, "you take what your clinicians are currently doing, look at your best averages, best lengths of stay, and predicted outcomes in your facility. Although we went into it with the hope of moving toward best practice eventually, we thought this approach would be more easily accepted by physicians."
It was thought that physicians would feel less threatened if they were asked only to apply the best techniques already established at Shepherd, says Court. "You’re not telling them they have to use Rice University’s protocol, where they can get a patient in and out in three days," she says. "Or telling them to look at the Canadian Health System’s practice of doing this. They are looking at their own data from their own institution and being asked to standardize when the IV is started."
Another way Court helped win physician support for the pathway was to form an authorship team centered around a physician champion, Doug Stuart, MD, the primary admitting physician for MS patients undergoing IV therapy. The team also included a registered nurse, a case manager, and representatives from occupational therapy (OT) and physical therapy (PT). Court also chose a facilitator to look up initial data and perform chart reviews.
Staff at the MS clinic carefully track newly admitted patients to make sure IV therapy begins within two hours of admission, Court says. "They’re coming in for Solumedrol, and if that treatment is delayed, then we need to look into the reasons for that," she says. Also on day one, staff members discuss the treatment plan and realistic expectations of the therapy with patients and family members.
By day two, patients undergo thorough PT and OT screening to determine if they’ve experienced "secondary degeneration" in addition to the present exacerbation of the disease, an approach Court considers unique to Shepherd Center and its "holistic approach" to care. She admits that adding this screening component probably increases LOS: "If the patient has some identified rehab needs requiring hospitalization, they might have to then stay past the Solumedrol treatment. That wouldn’t necessarily give us what we want in terms of a short stay. But in terms of providing the thoroughness that the patient needs, it’s important to do it."
During the discharge planning phase of the inpatient stay, the patient’s information is entered into Lotus Notes and a follow-up visit is scheduled for one month later, says Cynthia Bishop, BSN, CRRN, staff nurse at the MS clinic at Shepherd Center. Patients who have been put on a monthly IV steroid regimen following their inpatient stay can receive treatment in Shepherd’s outpatient clinic, beginning at the time of their first follow-up. For patients who live farther away, case managers coordinate the treatment either through home health or a hospital in the patient’s area.
Bishop acknowledges that coordinating care and locating funding for patients who live in different states can be a difficult challenge. "A lot of it depends on their transportation and their level of disability, whether they can get out of the house and go someplace without difficulty," Bishop says. "If they’re getting home health for other reasons, that’s often set up at the time they’re discharged from the hospital." Follow-up care for Medicare patients usually is coordinated through a local hospital, Bishop adds, because Medicare won’t pay for IV steroids administered by home health.
[Editor’s note: For more information about Shepherd Center’s MS pathway for Solumedrol infusion, contact:
Cynthia Bishop, BSN, CRRN, staff nurse, Shepherd Center, 2020 Peachtree Rd. NW, Atlanta, GA 30309. Telephone: (404) 350-7394.
Donna Court, RN, MN, interdisciplinary pathway nurse at Shepherd Center, 2020 Peachtree Rd. NW, Atlanta, GA 30309. Telephone: (404) 350-7799.]
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