Clinical pathways program presents challenges

Software tends to be physician-driven

Advancing technology continues to reshape the way acute-care case management is practiced. One example of that is the growing trend toward automation. However, early experience shows that technology is no guarantee for physician buy-in at the front end, much less patient compliance at the back end.

Several large institutions such as New York University (NYU) Medical Center in New York City now are using automated systems. However, even for a large sophisticated system such as NYU, automation it is no easy task. It is not primarily the hospital information system that is the problem, according to Barbara Delmore, RN, a nurse case manager on the NYU surgery unit. She says the biggest challenge is getting certain physician groups to use it.

"Right now, there are only two surgical groups using it faithfully," she says. "The others prefer not to use the care plan that gets loaded each day." Instead, she says they tend to use the order sets, which also are components of the pathway.

NYU began automating in its surgery department using a system called CareMinder, which takes the user through a series of order sets. Based on the written pathways that the hospital had used for years, and set up with the help of nurse specialists working in information systems, the automated pathway takes physicians or case managers through patient care, step by step, using different screens on the computer.

When the patient comes out of surgery, physicians execute all the orders at once instead of on a daily basis, Delmore explains. The CareMinder version is put into suspense by the nurse who sends the patient to the operating room (OR), she says. Once the patient comes out of the OR, the resident starts to execute the orders for the OR day, which is referred to as Day Zero.

The process is very interactive, Delmore adds. One step triggers the next. There also is an option to go outside the pathway’s guidelines if someone deviates from the pathway.

Caregivers can order lab tests or antibiotics directly on the computer, she points out. "The clinical pathway is supposed to be looked at every single day. That is the whole purpose."

However, the system has some difficulties, Delmore says.

"Unfortunately, if someone goes into the OR and they were not put on the clinical pathway when they left and nobody put them on between the time the patient went to the OR and came to the recovery room, then you have lost the whole pathway," she says.

The software is all physician-driven, Delmore says. "Some groups use it and have no problem with it, and some do not." In short, it has become more of a practice issue than a technology issue. "The bottom line is that the clinical pathways are still there. They are still present, just in a different form," she says. NYU continues to push the system. Eventually, Delmore wants nurses to be able to chart the outcomes, she says. NYU also would like the system to be Windows-based, which it is not. "That, to me, would be cutting-edge."

Emory University Hospitals in Atlanta also has begun the automation of care pathways, says Rosalie Przykucki, RN, MSN, coordinator of clinical performance improvement. One benefit of the Emtek system, currently in place only on Emory’s intensive care units (ICUs), is that it has some graphing capabilities. "Some of the physicians want to see trends, [such as] What has his temperature been for the last 24 hours?’ and it actually builds a graph for you," she adds.

"I wish our systems were completely automated, but they are not," she adds. Instead, Emory has been structuring its paper pathways to be the same at both Emory University Hospital and Crawford Long Hospital — the result of the merger of the two Atlanta facilities. Currently, when a patient leaves the Emory ICU, all the pathway information is downloaded and printed onto a readable chart copy, which then follows the patient, Przykucki says.

Not just cookbook medicine’

The automatic aspect of the new technology gives physicians even more reason to call it "cookbook medicine." In fact, Przykucki argues the opposite is true. Having pathways on the computer makes it much easier to change and modify them to fit individual patients’ needs.

In addition, more physicians are buying into the pathway process through this technology. "I think as more and more physicians go through their medical training, they are going to find that this is a tool that really helps them," she explains.

Przykucki agrees with Delmore that the real state of the art will be when the automated pathways and order sets become electronically linked to outcomes. "Everybody would love that."

Emory still is committed to the pathways but does not have a traditional case management system, she says. "It is a hybrid program more than strict case management, and my role is an interface to clinical performance improvement."

Przykucki says she looks at the overall flow of various pathways in the system — how well patients are doing in terms of the lengths of stay and any complications. "I also work with the physicians in the pathway teams on implementing changes for any new technology and new protocols that have come along," she adds.

When a patient is ready to leave the hospital, caregivers know where the patient should be and what he or she can do at home, Przykucki says. "This will give the caregiver and patient an idea of what he should be able to do or what he may need help with," she explains. Patient pathways have been around for a long time, but there is now a lot more emphasis on the aspect of patient training, she explains.

For example, caregivers now can tell patients the kinds of procedures taking place for specific diagnoses such as diabetes or coronary artery disease, she says. "Then we move the patient through the hospital process to the point where he or she is ready to go home and we have given them patient education to take beyond the hospital walls."

Przykucki says that because a patient’s stay in a hospital typically is short, it often is difficult to cram everything into that short period of time. That is why it is important to give patients something to take home that is easy to read and that has a link to the Internet or a 24-hour hotline at the hospital or the physician’s office to help get their questions answered, she adds.

"Unfortunately, in the period of time in the hospital, their mind is not concentrating on everything," she explains. "It is racing ahead or thinking about what the doctor just said." The patient pathway can help translate the message into something the patients can take home.

Certain services such as surgical services also have clinical coordinators who call patients at regular intervals after discharge, Przykucki reports. "Our nurses routinely call the patients to follow their progress." Emory also has a 24-hour hotline in case there is an emergency and patients need to contact a physician, she says. A lot of this information is automated in the links that are available on the Internet sites. Some of the clinical programs for developing pathways and many of the major software companies now have programs that can be tailored to both clinical pathways for the hospital and the clinical pathway for patients based on evidence-based pathways.

"In general, any pathway that is worth its salt, needs to have a basis in evidence-based medicine," she says. "Basically, that is nothing more than looking at the body of clinical trials that are out there and trying to utilize them in a way that will bring about the best results for your patients."

[For more information, contact:

  • Barbara Delmore, RN, Nurse Case Manager, New York University Medical Center. Telephone: (212) 263-7946.
  • Rosalie Przykucki, RN, MSN, Coordinator of Clinical Performance Improvement, Emory University Hospitals, Atlanta. Telephone: (404) 712-4665.]