CMs fight for acceptance of premature infant path
Standardization a key selling point for staff buy-in
The idea seemed simple enough. Case managers at University Hospital-University of Colorado Health Sciences Center in Denver identified factors they believed were boosting length of stay among premature infants and decided to tackle the problem with a clinical pathway. They did their homework, convened a pathway team, and spent a year hammering out a finished draft.
The response? "Everyone was against it," says Ginger Okada, RN, a case manager at the hospital who championed the pathway. "The nurses didn’t think it was a good idea; the physicians didn’t think it was a good idea. We needed to win people over."
The idea to create the pathway originated with the hospital’s office of clinical practice, which saw that costs per case and length of stay were higher there than at similar facilities. One possible reason was Denver’s mile-high altitude, which might have made breathing more difficult for fragile infants. Because of the altitude, the hospital requires that babies be able to breathe freely without supplemental oxygen for 40 minutes before they’re eligible for discharge. "That way, we know that if the parents are asleep and the baby pulls the nasal cannula off in the middle of the night, it’s going to be safe for a while," Okada says. "I don’t think many other hospitals around the country require that." University Hospital also requires that infants be free of life-threatening apnea bradycardia (pauses in breathing combined with a slow heart rate) for five days before discharge.
But while the case managers and office of clinical practice viewed the proposed pathway as an opportunity to improve and standardize care, they encountered stiff resistance from physicians and staff nurses, who claimed it wasn’t necessary. Many cited the old bromide about pathways being "cookbook medicine." The challenge quickly became how to win sufficient support for the pathway to have a chance at success.
The main appeal to the nurses was that standardization would help simplify and add consistency to the care of premature infants. Nurses had long had problems with physicians writing different or incomplete orders upon admission. Those problems were complicated by the fact that the facility is a teaching hospital, with different attending physicians each month. "And of course the interns also go through very rapidly," Okada says. "Things would change from month to month, and we wouldn’t know what to expect. We used that to say, If we have the pathway [with its preprinted orders], then you’ll know what to expect when you’re getting an admission of this type." (See sample page from the pathway, p. 26.)
Okada used a similar argument regarding discharge: "Everybody gets frustrated when it’s the day of discharge and things haven’t been done that needed to be done. We used that as a selling point for the pathway," noting that the path broke down responsibilities by time period.
Okada and her colleagues also spent time listening to nurses’ questions and suggestions about the pathway. For example, the initial pathway, piloted a year ago, required nurses to initial and sign off in several places. Now the pathway will be charted by exception, which should speed up the documentation process.
Because of such efforts, the staff nurses have largely come around to support the pathway, Okada reports. Physicians, however, have been tougher to convince. Their initial opposition to the pathway stemmed from their contention that environmental factors — and not their own practice patterns — were to blame for the higher length of stay at University Hospital.
Okada and her colleagues are using nurse practitioners as their liaisons to the physicians. "I don’t know that we’ll ever quite win the attendings over," she says. "What we’re going to have to do is show them the benefits that we’ve seen from using [the pathway]." That means providing hard data on outcomes, which should be available within six months.
In the meantime, Okada’s trying to win converts by dispelling myths about pathways being mere "cookbook medicine." For example, one attending who had been particularly vocal in opposition to the pathway came to Okada recently to ask if there was any way to make sure all infants got head ultrasounds. "I used that as an opportunity to show him that head ultrasounds are on the pathway, and if infants were on the pathway, the ultrasounds wouldn’t get missed." Okada notes that, like the nurses, the physicians have generally responded well to the inclusion of preprinted orders on the pathway.
Another positive development was the creation of a family education pathway that is provided to parents. (See sample page from the family pathway, p. 27.) Okada wrote the family pathway herself, then ran it by a support person who adjusted it to the proper reading level and added graphic design elements. "We can tell them what to expect, but if it’s written down and we can show them, then they’re able to understand it better," Okada says.
Despite the success of the preprinted orders and family pathway, some elements of the clinical pathway itself still needed work following the pilot test in early 1998. One problem was that, initially, the pathway had to be documented only once per phase — with a phase lasting anywhere from eight hours to several weeks. As a result, some people would forget the pathway altogether.
"Our approach this time is to replace the Kardex documentation they already do with a notebook at the bedside that they need to chart on every shift," Okada says. If they did everything required for that shift, they only have to sign at the bottom of the form. If something was omitted, they circle it on the form, fill in a brief explanation, and reschedule if necessary. "So it serves as a kind of reminder sheet for them," Okada adds.
With a second trial due to start soon, Okada remains patient and optimistic that the pathway will take hold and achieve positive outcomes for premature infants and the facility. "When we started this process, I had done the research on clinical paths and their benefits, and I knew where I was coming from," she says. "But I had to be patient in dealing with the rest of the team. You can’t force people to do things just because you see the situation a certain way. You have to help them come around to seeing the benefits."
For more information, contact Ginger Okada, RN, University Hospital-University of Colorado Health Sciences Center, 4200 East Ninth Ave., Denver, CO 80262. Telephone: (303) 372-6470.
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