Computer pathways manage care, not data

By Deborah M. Shelton, RN, MSN, CCRN

Critical Care Clinical Nurse Specialist and Care Manager

Baptist Hospital

Nashville, TN

Since the beginning of its pathway development process in July 1994, Baptist Hospital in Nashville, TN, has recognized the value of utilizing technology to the fullest extent possible.

Baptist Hospital has implemented 138 pathways — or CarePaths — encompassing such areas as general surgery, urology, neuroscience, oncology, cardiac care, OB/GYN, neonatal, and emergency. About 50% of patients at Baptist are on CarePaths.

One of the unique features of our CarePaths is the ability to chart variance data into the computer and have that information computer-generated rather than manually collected by the care manager. This computerization enables the care manager to oversee and manage clinical parameters of patient care, rather than collecting and managing data.

The deep vein thrombosis (DVT) CarePath represents the model used for all CarePath development at Baptist Hospital. A multidisciplinary team coordinated by physicians developed each pathway. The CarePaths include an interdisciplinary plan of care that is germane to the targeted patient population. All disciplines involved chart use within the confines of the CarePath document, with all variances documented in the computer. CarePath documentation has evolved from purely clinical assessment to outcome-focused interdisciplinary charting, including nursing, physical therapy, social services, nutrition services, respiratory therapy, and others.

The method of documentation used for the CarePaths is charting by exception. The first portion of the CarePath includes the interdisciplinary orders for the plan of care, including the physician orders as well as nursing interventions and others — for example, consult social service if meets criteria. The reassessment portion of the CarePath contains the clinical assessment parameters, as well as outcome questions. The third section contains the education topics to be discussed with the patient and/or significant other.

Originally, physician orders had charting lines. In reality, no one charts a "no" against a physician order — because it is a physician order. Reasons for a delay in performing an order might be related to labs not back, stat meds not sent from pharmacy, nurses overloaded with tasks, for example. These reasons are important to monitor, but the intent of the outcome question is not evident.

Ask the right questions

What we have learned is that the right question must be asked to receive the right answer. Therefore, if a significant outcome is expected by implementing the physician order and that order cannot be fulfilled as expected, this represents a significant variance that requires monitoring. The appropriate outcome question will now yield a meaningful, measurable response. This also improved documentation efficiency for staff.

Variance screens were developed by researching and polling staff for reasons items might not be accomplished. When the nurse initials "no" to a charting entry, the appropriate variance screen is accessed in the computer, and the variance is selected. Each answer is coded with a unique code number. Variances are monitored by the care manager on a daily basis, and interventions occur as needed in individual situations. The real benefit, however, is that reports are generated on a quarterly basis or can be manually retrieved at any point for data interpretation or performance improvement (PI) activities. For example, if in a three-month time frame, five out of 10 patients with DVT did not receive their Coumadin in a timely manner because the protime was not back from the lab (the protime must be within range to give the Coumadin dose ordered by the CarePath), then the issue is discussed with the lab and solutions proposed or PI monitors initiated.

The CarePaths are computer-generated when the CarePath is initiated by the physician. Therefore, CarePath revisions can be done on-line without the need to discard paper documents. Once a CarePath is ordered for a patient, the orders contained in that CarePath are automatically retrieved to the screen. Computerized order entry occurs when the unit clerk/nurse selects the pre-built orders. An enhancement of the system for the physician is a Physician Order Guide that prints with each CarePath to list succinctly the CarePath orders.

Educational materials for CarePath patients have been standardized by the team members to prevent repetitive or contradictory information and include mandated topics from the Joint Commission on Accreditation of Healthcare Organizations, such as food/drug interactions. Most educational material and documentation of education is computer-based and includes who was taught, information taught, readiness to learn, and understanding or demonstration.

The yo-yo effect

One significant outcome and improvement in patient care related to the DVT CarePath is that q6h PTTs are no longer performed with heparin changes. There is a yo-yo effect on the PTT with q6h lab draws without therapeutic levels being obtained. After the heparin bolus and drip are started, a PTT is drawn six hours later. PTTs are then drawn on a daily basis with therapeutic levels achieved within 24 hours and a steady state for the remainder of the Heparin therapy.

Length of stay and cost are not significantly different for CarePath vs. non-CarePath patients with DVTs. However, reducing lab draws and maintaining therapeutic anticoagulation levels have improved the quality of patient care. Also, one major system improvement — early morning lab results are now on the chart when the physician makes rounds (protime results for Coumadin orders) — is a direct result of the DVT CarePath.

The success of the CarePath Program at Baptist is related to several factors, including administrative support, inclusion of physicians from the inception, "tweaking and squeaking" our information system for maximum performance, and the capability to demonstrate that CarePaths do affect the hospital and patient outcomes. During our recent Joint Commission survey, the surveyors commended five programs at Baptist, including our successful CarePath Program.