Clinical path cuts LOS, boosts efficiency for skin flap patients

Multidisciplinary pathway standardizes treatment

Clinicians at the Shepherd Center in Atlanta have developed and introduced to the medical/surgical unit a clinical pathway for skin flap procedures to provide consistent interdisciplinary care and establish common discharge criteria. 

In the skin flap procedure, a section of skin and associated subcutaneous tissue is moved from one part of the body to another, while the vascular supply to the tissue is maintained. The procedure is for patients who have Stage III and IV pressure ulcers. 

Shepherd Center, a 100-bed specialty hospital, provides care for people with spinal cord injuries, acquired brain injuries, urological disorders, and neurological diseases such as multiple sclerosis. Patients with spinal cord injuries or neurologic disorders are at a higher than normal risk for developing pressure ulcers because of their decreased mobility and loss of sensation. 

Based on an internal chart review, a six-week length of stay (LOS) was considered adequate for the skin flap procedure, says Donna Court-Tillis, RN, MN, CCRN, an interdisciplinary pathway nurse at Shepherd. About 25 patients have been placed on the path since its inception in 1995, and most have been discharged within the six-week LOS window. Some patients have been sent home after only four weeks. 

Controlling LOS is one benefit of clinical pathways. Another is improved efficiency, such as eliminating the need for daily assessment sheets. A daily patient skin documentation form, for example, was no longer needed once the skin flap pathway was introduced, says Court-Tillis. The pathways are at the core of patient documentation and become a permanent part of the medical record. (A copy of the skin flap pathway is inserted in this issue.)

Specialized care needed

Neurologic patients recovering from surgery typically require more specialized care than other patients when going home or to an alternate care site, Court-Tillis says. A viable discharge plan is drafted during the patient’s preoperative period. The plan is then monitored throughout the patient’s hospital stay to address possible changes in follow-up care. 

Discharge plans are finalized in the fifth and sixth weeks of the path by the case manager, who may collaborate with a community resource coordinator to help with nursing home placement, home health referral, or preparing a ventilator-dependent patient for transfer. 

The criteria for discharge include the following: 

• Patient sits in a wheelchair five to eight hours per day. 

• Patient complies with skin care program. 

• Surgical wound has healed. 

• For nonhealed wounds, a definitive discharge plan including home health has been established. 

• Patient shows no sign of active infectious process.

Variances show up quickly

Variances from the pathway usually are determined quickly — in only hours or days, Court-Tillis reports. Variances determined in such short periods of time, however, are not as significant for rehabilitation patients as they are for neurological-surgical patients, she adds. For example, patients on the skin flap path can exhibit signs of a variance on the first day of week two but may improve by the fifth day of that week. 

At Shepherd, variances are documented only if they are present at the end of the week listed on the path. Patients should be well enough for removal of the Foley catheter by the end of the fourth week, for example. A bowel and bladder program supervised by an enterostomal nurse would begin on the fifth week. 

A revised data analysis system for variance tracking was introduced in the fall, Court-Tillis says. The case manager now documents variance information and gives it to a secretary for data entry. A long-range goal of the facility is to have case managers enter the data directly into the unit’s computer, with analysis supported by Lotus Notes software. 

"Pathway development is an interdisciplinary effort at Shepherd and involves departments that are responsible for providing care to a particular patient group," says Court-Tillis. The following departments were involved in developing the skin flap path: 

• nursing; 

• enterostomal therapy; 

• physical therapy; 

• medical/surgical staff. 

Each case manager at Shepherd works within a particular specialty and is responsible for ten to 14 patients. The case management department employs nine case managers, two community resource coordinators, and a family training specialist who is responsible for patient and family education.