Pathways help involve patients and families in plan of care
Pathways help involve patients and families in plan of care
For certain populations, patient pathways assist in the educational process
Clinical pathways, multi-disciplinary plans of care for patients with a particular diagnosis, are not only for members of the medical team. Simple versions of these pathways, written in lay language, help to empower patients and their families, and also initiate involvement in the management of their care.
"The patient pathway presents information on what the patient can expect each day. The fear of the unknown can be scary for patients. The pathway is beneficial to patients because by teaching them what to expect, we can decrease that fear as well as get them involved in their care," says BJ Wingert, RN, BSN, MS, patient education specialist at OhioHealth in Columbus.
Patient pathways have a little information on the disease followed by details on what to expect as far as treatment and care. Also included are the discharge instructions.
The patient pathway helps patients in the hospital understand what they need to do each day to prepare for discharge.
"We could really replace a normal teaching sheet with a patient pathway, because basically it is the format that is different. The content is very similar; it is just how the information is put down in a sequence or a table to move the patient from day to day," explains Wingert.
OhioHealth has about 14 patient pathways, although it has created 40 clinical pathways. If there is little variance in day-to-day care or the length of hospital stay is too short, a patient pathway is not created. Regular teaching handouts are used to educate the patient and family members.
"As we create new clinical pathways, we look at whether a patient pathway would be effective for a patient population. We do not have any real set parameters to creating this type of education. If existing material covers the content we do not automatically create a pathway," says Wingert.
When clinical pathways were introduced in the 1990s many institutions began to use them to coordinate care. Children's National Medical Center in Washington, DC, began to create pathways in 1996. They were implemented for several reasons but primarily to reduce the variation in practice for high-volume diagnostic groups, vulnerable patient populations, and patient populations that were high consumers of resources, says Pat Johnson, PhD, practice facilitator in quality improvement at Children's.
Initially, three pathways were created. One was for asthma patients, who generate high volume at Children's. The second pathway was created for diabetes, because these patients are very vulnerable and usually admitted to the intensive care unit in ketoacidosis. They are also high consumers of resources, says Johnson. The third pathway was for the sickle cell anemia teen population, because they are high volume at Children's, vulnerable, and high consumers of resources.
Currently, Children's has 47 pathways. When they are implemented, the families receive a copy of the medical version; however, for most pathways they also are given a patient-friendly copy that is easier to understand, says Johnson.
In order for a pathway to be worthwhile, it should be appropriate for 80% of the diagnostic group.
For example, for a diabetes pathway to be created, about 80% of the diabetes patients should be able to be managed on that pathway. The other 20% would have too many co-morbidities or be too ill with ketoacidosis or other exclusions. If only 50% of patients can be managed by the pathway there is no advantage, says Johnson.
Get whole team involved
Once a patient pathway is determined to be beneficial, all disciplines involved in the care of a patient for that diagnosis should be involved. In addition, patient education coordinators must have input to guide the formatting, reading level and consistency of information, says Wingert.
At Children's, patients also provide input.
"We always start by trying to have patients be part of the group that does the patient pathway," says Johnson. However, it is often difficult to get participants. One solution has been to find families that have children in the hospital to act as a focus group in order to get all kinds of family input.
According to Johnson, the families most likely to participate in a committee live in the suburbs, so the use of the immediate focus group format ensures that urban families have input as well. Going from room to room to gather four or five parents often works best. Other ways of soliciting input include the use of e-mail communication and sometimes simply reading information to people on the phone. The diverse Patient and Family Advisory Council, which meets monthly, is used during the creation of patient pathways as well.
At Children's, the design of the clinical pathway is a standard chart format with a horizontal framework of time and vertical aspects of care. The patient pathway is a two-page document with information about treatment and care during the hospital stay on one side and care at home on the reverse.
Wingert said staff at OhioHealth looked at several pathways from other institutions before deciding on a format. Some had a multitude of columns and headings.
The horizontal row topic headings are selected for each specific patient population. The pathways are not all alike and some combine row headings, such as activity and comfort, if there is little content, explains Wingert. "For column headings we most often use Admission/Surgery Day, Day 2-?, and the Day of Discharge," she adds.
Of course, pathways no matter how well they are designed and written are only beneficial if the patient receives one. Typically, at OhioHealth a patient is given a pathway when admitted to the hospital with a certain diagnosis, and it is used to explain the treatments, care, and home care instructions, says Wingert.
The pathway is put on the patient's medical record upon admission to Children's, and then the nurse orients the family on the plan of care. "If the patient is old enough he or she is oriented to the pathway also. For all our big pathways we have an accompanying sheet at the family level," says Johnson.
Education is a key component of the clinical pathway, adds Johnson. One topic header for the column lists the patient education and support provided as part of the plan of care. For example, on the asthma clinical pathway it includes:
- Orient to setting.
- Give and explain patient/family pathway handout if not received in ED.
- Explain procedures and medications.
- Initiate assessment phase of the asthma teaching plan.
- RT to explain devices with RN support.
- Education on preventive techniques and acute management of asthma; document all teaching outcomes on Patient Education Form.
- Provide asthma handouts.
- Review path with patient/family; give copy to parent/family.
- Complete all education before discharge; document teaching outcomes on Patient Education Documentation Record.
Johnson says that although education is not perfect, certain things must be taught to the patient and family before discharge. To ensure it has been completed, the nurse has to sign the discharge instructions verifying the teaching, and the family also must sign to indicate they have learned what was taught.
Sources
For more information about implementing patient pathways to complement clinical pathways, contact:
- Pat Johnson, PhD, Practice Facilitator Quality Improvement, Children's National Medical Center, 111 Michigan Ave. NW, P-2 West Wing, Washington, DC 20010. Telephone: (202) 476-5327. E-mail: [email protected].
- BJ Wingert, RN, BSN, MS, Patient Education Specialist, OhioHealth, Patient Education Department, 3535 Olentangy River Road, Columbus, OH 43214. Telephone: (614) 566-5613. E-mail: [email protected].
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