Critial Path Network
Initiative helps hospital improve quality indicators
CM in HR ensures Core Measures are followed
The percentage of patients with community-acquired pneumonia who received antibiotics within four hours of admission doubled in just three quarters after the staff at Saint Luke’s Health System in Kansas City, MO, instituted a process improvement initiative.
For the first quarter of the year, only 40% to 42% of patients admitted from a physician’s office were meeting the Centers for Medicare & Medicaid Services (CMS) Core Measure for antibiotic administration. By the fourth quarter, the figure rose to 86%.
The 582-bed tertiary care hospital recently revised and consolidated its 163 clinical pathways, resulting in 75 pathways with corresponding order sets. The pathways are outcomes oriented and are based on Milliman criteria for moving patients through the continuum.
The hospital’s case management department operates within a triad model in which case managers and social workers are assigned by unit and work directly with the RNs on the unit as a team.
The case managers all are RNs who conduct the medical review and assist with payer requirements for utilization review. The social workers are in charge of the psychosocial evaluations and the final discharge plan.
"The staff nurses and attending nurse are in constant communication with the case managers and social worker to ensure that the quality measures are being met and to focus on what the patient needs to move along the continuum of care," says Anita Messer, RN, MHSM, ACM, director of care integration.
One key in the improvement of antibiotic administration for pneumonia patients is a case manager whose duties include working with the admissions office to make sure the order set and clinical path are initiated when the patient is still in the admitting office of the hospital.
When a physician’s office calls the admissions office to announce that a patient with pneumonia is coming in, the case manager is alerted. He or she calls the physician’s office, initiates the order set for pneumonia, and takes the order for the antibiotics from the physician.
The case manager accompanies the patient to his or her room, notifies the nurse of how much time has elapsed, reminding the nurse that the patient needs the antibiotics within four hours of admission.
The case manager is part of the transfer team that screens patients who have been transferred from other facilities and is called into admissions to follow patients with pneumonia. The process has been so successful that the hospital plans to expand her role to include other diagnoses, such as congestive heart failure and chronic obstructive pulmonary disease (COPD).
A multidisciplinary team, working under the hospital’s Office of Clinical Practice Guidelines, a division of case management, began by examining the pathways and order sets for community-acquired pneumonia and looking for ways to ensure that the criteria are met.
"It was a huge collaborative effort. The case managers had been working with the pathways and order sets and were given the lead in the project. We included the nurses from the floor where the majority of pneumonia patients were admitted, hospitalists, laboratory representatives, and the pharmacy. We looked at how the process of ordering labs or antibiotics worked or didn’t work," says Melissa K. Thomas, RN, MSN, CPHQ, clinical project manager at the 582-bed tertiary care hospital.
The team began by identifying the units that have a high number of admissions with pneumonia and working with them to assure that the antibiotics are administered in a timely manner. The pharmacy has worked with the nursing staff on those units so that the most common drugs prescribed for pneumonia are stocked in the automated pharmacy distribution system so the nurses don’t have to order them from the pharmacy and wait for delivery.
"When you have just 120 minutes, you’ve got to have a turnkey operation to ensure that everything happens in a timely manner," Thomas says.
The team worked together to identify barriers and determine how the barriers could be improved. They monitored the processes that had been put into place to make sure they worked.
For instance, a stat sleeve was utilized to expedite obtaining the antibiotic from the pharmacy. The stat sleeve is a plastic sleeve in which the pneumonia order set is sent to the pharmacy. They checked to make sure the stat sleeve cued the pharmacist to unlock the antibiotic.
They also checked to make sure the case manager in admissions assured that the order set was implemented.
While the process improvement project was under way, a member of the PI team, usually Brent Beasley, MD, the physician leader, went to the floor as an observer and followed the process when the case manager was notified of a pneumonia admission.
"We followed the patient through the process and determined what the team did when the patient got to the floor, when the orders were faxed to the pharmacy, and if all the triggers we had in place were followed," Thomas says.
The process improvement team leaders acted strictly as observers and didn’t step in when something needed improvement.
"The whole goal was to verify what processes were in place and see where any breakdowns were in the process," she says.
When Beasley saw opportunities where his colleagues could improve what was being done, he made a note of it and talked with them later.
"He asked them how we could work around the barriers and brought back a lot of information on the process flow," she says.
The case management and nursing staff work together on all the units to achieve outcomes for the patients.
"The staff nurses are key in making sure the patients are on the pathway and in making sure that their day-to-day needs are met. They coordinate with the case managers to medically manage that patient and make sure everything is in place," Messer says.
The social workers work with the patients and families to make the final placement after discharge, helping the family do whatever is needed to achieve the best outcome.
Saint Luke’s has had clinical pathways since 1990. Three years ago, the Office of Clinical Practice Guidelines was started through the case management department and charged with reviewing the pathways to ensure that they were evidence-based, up-to-date, and that the clinical pathways and orders sets matched.
The pathway team includes the physician champion, a staff nurse champion, pharmacy, nutrition, laboratory representatives, and case managers. "These are frontline people who know the disease process and how to treat the patient effectively and move the patient along safely," Messer says.
All of the CMS Core Measure are included in the pathways.
The team revised the pathways to include the Milliman criteria and reformatted them to make them outcomes-oriented.
Instead of Day 1, Day 2, the pathways are divided into phases — Admissions Phase, Acute Phase, Stability Phase, and Discharge Phase, all following Milliman criteria. Instead of listing tests, procedures, consultations, and nursing tasks, the revised pathways are replaced by the body system — using neurology, cardiology, GI, and muscular skeletal divisions when each is appropriate.
"It’s more physiology based and in sync with how the nurses and physicians interact with patients," Messer says.
Each phase of care contains Milliman criteria and outcomes. For instance, the admission phase of care on the community-acquired pneumonia pathway includes blood cultures and administering anti-biotics within four hours of admission, along with the Milliman clinical stability indicators and qualifying criteria the patient must meet to move to the acute phase.
"We don’t have patients falling off the pathways any more. If they’re not responding or meeting outcomes, the nurses, case managers, and physicians can look to see if this patient is doing something different," Thomas says.
Since few patients come in with one disease process, the revised pathways allow staff to move patients from one pathway to another.
For instance, a patient with COPD was admitted with community acquired pneumonia and, before the Stability Stage was accomplished, the pneumonia had resolved. His fever was gone and his white blood count was normal, but the pneumonia had exacerbated his COPD.
"Rather than taking him off the clinical pathway altogether because he no longer met criteria and he had met the outcomes, the nurse switched him to the COPD pathway, and the care of this patient continued until he could be safely discharged," she says.
The office conducts random chart audits to see if the pathways for the most frequent diagnoses are being followed.
"We know that if we get good outcomes for the patient population on the pathway, this will convince the staff to follow the pathway," Thomas says.
The treatment team collaborates and shares accountability for ensuring that the patients are on the pathways. If the case manager sees that a patient has been admitted and the pathway hasn’t been started, he or she talks with the nursing staff and gets the pathway initiated.
If the nursing staff has a patient on the pathway who isn’t moving along, he or she contacts the case manager and asks for help moving the patient through.
"What has made a big difference in compliance has been our physician leaders who collaborate with their colleagues and encourage them to use the order sets with the matching clinical path. In the last several years, we’ve made great inroads in the right direction for patient care because of the physician leadership," Thomas says.
St. Luke’s commitment to quality and continuous improvement quality earned the prestigious Malcolm Baldridge National Quality Award in 2003. The hospital has adopted the Baldridge Criteria for Performance Excellence as its business model.
(Editor’s note: Melissa Thomas may be contacted at: [email protected]; Anita Messer may be contacted at: [email protected].)
The percentage of patients with community-acquired pneumonia who received antibiotics within four hours of admission doubled in just three quarters after the staff at Saint Lukes Health System in Kansas City, MO, instituted a process improvement initiative.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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