Don’t let Kardex hold back pathway implementation

You may have to get rid of the old crutch

The Kardex — a nurse’s old friend, a security blanket. Perhaps, though, the Kardex is serving as a crutch at your hospital — a familiar one that’s too easy for nurses to clutch in a time of rapid change. That’s what was happening at Grays Harbor Community Hospital in Aberdeen, WA.

Nurses were so habituated to the Kardex, which had been used for decades, they continued using it to track patient care — even after the hospital implemented clinical pathways. They wrote notes and information about patients, including physician orders, on the cards and used them to give reports at shift change.

The result: Nurses weren’t using clinical pathways to their full potential. At times, they weren’t even aware of where on the pathway the patient was, or how long the expected length of stay was, explains Brenda Newell, RNC, charge nurse/modular leader of the telemetry unit and clinical pathway chairwoman.

The few nurses who were diligent enough to use the pathways were writing down the same information twice, once on the pathway and once on the Kardex, Newell says. Because the Kardex is not even a permanent part of the medical record, all information recorded there was lost after discharge.

Another problem: Nurses weren’t tracking pathway variances. Grays Harbor currently has 58 pathways. Tracking variances is the only way to improve them, and it must be done continuously. Clinical pathways usually are designed to aid in documentation and allow all caregivers to work from the same forms, eliminating duplication.

Kardex eliminated on every unit

The solution seemed drastic at the time — get rid of the Kardex on every unit. But, "with both records present at shift change, it was just easier to look at the more familiar Kardex and bypass the care path, ignoring the care planning and managed care aspects," Newell says.

First, the hospital’s pathway team redesigned the pathways to make them more user-friendly. They enlarged the category boxes for physician orders and provided space to individualize pre-printed problems and expected outcomes.

On the back of the pathways they printed a form on which nurses list each variance, the date and pathway day, the cause, the action taken, and the date resolved. At the bottom of the pathways, they added boxes where nurses from each shift initial that the plan of care was followed. The pathway team also added designated spaces to enable nurses to share the plan of care with their patients.

Education was key

Next, pathway team members arranged for in-depth inservices for all nurses. They taught nurses how to document on the pathway, the benefits of using the pathway as the sole documentation source, and how to select the proper one for each patient.

Only after all the pathways were reprinted and all the nurses trained did the team remove the Kardexes, Newell says.

Hospital leaders even made nurses’ use of the pathways and variance reporting part of their annual evaluations, Newell says. At shift report, the oncoming nurse is apprised of each patient’s status on the pathway. For example, "Mrs. Smith is on day three of a five-day expected length of stay" illustrates the patient’s location on the pathway in relationship to expected outcomes, Newell says. Also, the nurse learns the patients’ current conditions, any variance from the pathway, and the actions taken.

Conducted by the pathway team, retrospective variance analyses now are more meaningful, as nearly 100% of variances are reported, Newell says. Nurses are used to the new system, and although resistant at first, they are complying at nearly 100%, according to a recent audit, Newell adds.