Perioperative pathway ensures consistent care

"It’s too confusing."
"There’s too much paperwork."
"Each time I learn how to do it this way, it gets changed."

Change is difficult enough in a health care setting, but if you think you’ve had a tough time developing pathways, imagine developing five perioperative pathways for use in a same-day surgery program, condensing the five pathways to three, then reducing the three to one perioperative pathway that is used not only in day surgery, but also in endoscopy and inpatient surgery.

Those were the challenges for the day surgery staff at North Colorado Medical Center in Greeley. Pathways have been used at the hospital since 1992, but in 1994, all units were expected to use pathways to chart patient care, explains Becky S. Winter, RN, BSN, surgical services resource nurse and outcomes coordinator at the center.

"We based our original five pathways on the type of anesthesia used for the patient’s procedure," she says. The program received an award for the first five pathways in the "Pick a Path" contest conducted by Hospital Case Management newsletter, published by American Health Consultants, publisher of Same-Day Surgery. The first five pathways were:

- monitored anesthesia care for eye patients;
- adult general monitored anesthesia care;
- pediatric monitored anesthesia care;
- intravenous conscious sedation;
- local anesthesia.

After four years, the staff reduced the number of pathways to three to address adult, pediatric, and IV conscious sedation.

"Five pathways was cumbersome, and they all looked the same on the first pages," says Winter. "We had many cases of nurses who began charting on a pathway, only to discover halfway through it that it was the wrong pathway form."

In January 1999, the staff developed one pathway that can be used for day surgery, endoscopy, and inpatient surgery. Winter formed a pathway implementation team composed of all nursing units that might use the form. Physician input came from a representative of the anesthesia department and a review of the pathway by all members of the department. (See related story, p. 36.)

The multidisciplinary team ensured that everyone supported the form from the beginning, says Thelma M. Taylor, RN, BSN, staff nurse in the ambulatory care department and a member of the team. "We were asking some department staff members, such as endoscopy, to completely change the way they had been charting," she says. "We knew it wouldn’t be an easy process, so we wanted them involved at the beginning."

The biggest change was the move to charting by exception, says Taylor.

"In nursing school, we are taught that if we wrote it in the chart, we did it," she explains. "The most often asked question when switching to pathways on which we only write something when the patient’s recovery doesn’t follow the pathway is Is it legal?’"

Inservice education conducted by Winter and the education department alleviated nurses’ fears and explained the use of the forms. Posters showed the old and new forms. Highlighted areas showed the location of similar information and areas that contained new information such as vital sign parameters.

During the pathway development process, the team found some inconsistencies among units. "Our research to develop our pathways showed that vital signs should be monitored [intraoperatively] every five to 15 minutes or based on medication titration, but we discovered that endoscopy patients were not monitored at this frequency," says Winter.

Visiting policies for the postanesthesia care units (PACU) were different in inpatient and outpatient surgery. "This was confusing to families who had experience with both units," she adds. "Our day surgery program did not have written policies, but we routinely allowed the families of pediatric patients to come back to the PACU and we did not limit the number of visitors."

The inpatient surgery PACU did limit the number of family members to one at a time for pediatric patients. "We now have written policy regarding number of visits that applies to both units," Winter says.

Pre-op phone calls to endoscopy patients were improved as a result of pathway implementation. Prior to use of the pathway, staff members making the calls told patients what time to arrive, what dietary restrictions should be followed, and to plan for a driver, says Winter. "If the patient asked questions about the procedure, he or she was referred to the physician," she says.

Now, the pathway enables the endoscopy staff to answer questions and review a care plan because the prompts are in the pathway, she says.

The pathway development process also caused the rewrite of the protocol for IV conscious sedation. "The standard time in the recovery room used to be one hour, but some IV conscious sedation patients are ready to leave sooner," she explains. Recovery room nurses now base the decision to release the patient on specific criteria.

You can make the pathway development process smoother and less time-consuming by gathering as much up-to-date information related to the care that the pathway addresses.

Do your research upfront, says Winter. She reviewed standards from accrediting organizations and professional organizations, current medical and nursing textbooks, and the policies and procedures of her own organization.

"Make sure you reference everything you put into your pathway," she adds. "For example, on your vital signs parameters, footnote exactly which source was used for the parameters." This note will save you time and effort if the parameter is questioned, she explains.