Path inventory facilitates benchmarking care paths
Philly hospital customizes peers’ best practices
Because DRG 98 is the top admitting diagnosis for pediatrics nationally, best practices incorporated into clinical pathways for asthma can help improve the cost-effectiveness of care, says Sharon Lau, consultant for Medical Management Planning (MMP), a consulting firm based in Bainbridge, WA. But how do quality improvement teams identify best practices and locate their peers who are using them?
As facilitator of the Benchmarking Effort for Networking Children’s Hospitals, which measures 150 performance indicators among 24 children’s hospitals, MMP also helps members create clinical pathways by identifying best practices and sharing the process of incorporating them in clinical pathways.
To facilitate that effort, MMP consultants created a matrix for a clinical pathway inventory. It was part of a white paper MPP wrote, Clinical Pathways: A Strategy for Development and Implementation. Each hospital was asked to list its pathways on the matrix outline and indicate their stage of development, Lau says.
The first stage of the matrix represents roll-out. "Here, the pathway was just being developed and/or rolled out to the organization," she says.
The second stage represents "internal process improvement." "This meant the pathway was being used on patients and was in process of being tested and improved upon."
The third and final stage represents a "best clinical practice." In this category, "the pathway had been used and fine-tuned to the point that the hospital using it is actually at a level of best practice as measured by indicators like length of stay, cost per case, patient satisfaction, etc.," she says.
The matrix also listed "outcome measurements used" and contact names and phone numbers for readers to contact with more detailed questions.
For a team at St. Christopher’s Hospital for Children in Philadelphia, the pathway inventory helped managers develop a successful asthma clinical pathway that cut length of stay (LOS) in half. Before the new pathway was developed, St. Christopher’s LOS for DRG 98 for the first quarter of 1996 was 3.94 days, compared with the best-ranking hospital in the benchmarking group, which had an LOS of 2.73 days.
A team of physicians and representatives from social work, discharge planning, quality management, and the emergency, respiratory, pulmonary, and allergy departments begin meeting in early summer last year.
"We began by asking the hospitals [listed in the matrix] to send us their pathways and to discuss with us the lessons learned," says Margaret Chaplin, CPHQ, CHE, administrative director for quality resources at St. Christopher’s.
Looking for details
After team members studied crucial components of other pathways, they were ready to begin identifying their own. For example, a study on steroid use in asthma conducted in 1995 by Jack Becker, MD, section chief of allergy at St. Christopher’s, showed that patients in the study had a LOS that was a day shorter than those not in the study.
"During the pathway development, we identified the fact that it was due to aggressive and frequent evaluation and weaning," Becker notes. The team modified the study protocol for the pathway, incorporating the following best practices:
• Frequent evaluations.
Everyone from the physician to the respiratory therapist evaluates patients more frequently and makes adjustments as needed in therapy. "Patients on continuous nebulizer treatments are evaluated by a physician at least every four hours, says Guy Caporiccio, BS, RRT, manager of diagnostic and respiratory care and support service.
Caporiccio also says the new clinical pathway created the position of respiratory coordinator therapists who monitor updated asthma scores hourly and relay them to other members of the care team.
Patients who aren’t on continuous therapy are evaluated three times a day by a physician instead of once a day, the standard before the pathway was implemented.
"For us, this gives us concrete guidelines a map for treating patient," he says. "Before, therapists were doing high-frequency therapy for an extended period of time, but there was no guide telling us how to respond to the patients’ needs."
An unexpected benefit of the pathways was that they reduced the tensions that arose among team members because no clear guidelines existed, he says.
"We wasted a lot of time trying to get the physicians to come and evaluate the patients so we could adjust their treatment, and it sometimes lead to resentment. Now we are released from any type of adversarial relationship because everybody on the team knows exactly what he or she needs to do to improve patient care and decrease LOS."
Another component of the pathway that has reduced LOS is the practice of beginning discharge planning on admission. "It reminds us to consider [patients’] discharge needs immediately and not wait until day two to make arrangement for home nebulizer or inhaled preventative therapy," Becker says.
Educate against readmissions
• Patient education.
The pathway calls for patient and family education, which is soon to be implemented. Becker says literature, instructional videos, and hands-on sessions will offer information on the following subjects:
- the role of medications and the adverse reactions associated with them;
- signs and symptoms of asthma;
- asthma triggers;
- operation of equipment;
- infection control;
- peak flow meters.
"It is our hope that a thorough patient education effort will prevent future admissions," Becker says.
[Editor’s note: For more information, contact Margaret Chaplin, St. Christopher’s Children’s Hospital, Administration, Erie Ave. at Front St., Philadelphia, PA 19134-1095. Telephone: (215) 427-5566.
Or contact Jack Becker, St. Christopher’s Children’s Hospital, Allergy Department Annex 2020, Erie Ave. at Front St., Philadelphia, PA 19134-1095. Telephone: (215) 427-8800.]
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