Critical pathway is a combination of ideas

Other providers, surgeons, therapists had input

The joint replacement critical pathway being used by the rehab unit at DuBois (PA) Regional Medical Center is a combination of pathways from other providers, preferences of referring orthopedic surgeons, and input from the staff.

The effort was spearheaded by Martin Schaeffer, MD, medical director for the department of physical medicine and rehabilitation. Before he started development of a critical pathway for hip and knee replacement patients, Schaeffer collected as many orthopedic pathways as he could from other hospitals. He also used materials provided by HealthSouth Corp. Managed Services, a division of HealthSouth Corp., based in Birmingham, AL, which manages acute inpatient rehabilitation units. "I took the best from each one and was able to draw up a pathway that incorporates the individuality of our orthopedic surgeons," he says.

Most of the pathways Schaeffer studied were longer than the one he came up with, and most providers had separate pathways for hip replacement and knee replacement patients.

Schaeffer started his work creating the pathway by meeting separately with each orthopedic surgeon and finding out their preferences for treating their patients in the rehab unit. Among the questions he asked were:

• what settings they preferred for the continuous passive motion device following knee surgery;

• what their deep venus thrombosis precautions were for hip surgery patients;

• what kind of dressing their patients needed;

• when they could take showers;

• whether they wanted their patients to use compression stockings.

Schaeffer took the areas in which there was common ground and put them into the pathway for all knee or hip replacement patients. Other areas of the pathway are check-off boxes where individual physiatrists can indicate the protocols they want used with their patients.

An advisory team of staff from the rehab unit was set up to assist in drafting the pathway. Representatives of all disciplines reviewed the document and suggested changes. Instead of starting with a critical pathway in the early months of the rehab unit’s existence, Schaeffer waited until the staff became more familiar with the inpatient rehab process.

"Since inpatient rehab was unknown to many on the staff, and nursing and therapists had never worked together, we had to educate the staff first," he says.

Schaeffer began discussion with the staff during the second year the rehab unit was open and developed the pathway over several months.