Critical Path Network-Practice teams boost pathway effort

Results show improvement in quality, cost

By Nan Meyers, MSN, RN, CNRN

Clinical nurse specialist, Neuro/Ortho/Rehab/Trauma Care Center

Borgess Health Alliance, Kalamazoo, MI

Borgess Medical Center, a 426-bed tertiary care Level 1 Trauma Center in Kalamazoo, MI, has had a stroke clinical pathway since 1993. The first pathways developed at Borgess were for surgical diagnosis-related groups (DRGs); stroke was one of the first medical DRGs to be implemented.

Clinical pathways have provided a means for outlining the standard of care in its most basic form. They are patient-population-specific, providing a day-by-day map of the standard of care, and they should be reviewed annually.

After the opening of an inpatient rehabilitation unit in 1992, both the acute inpatient rehab and the acute care hospital staff observed that several patients returned from the rehab unit to the acute hospital for treatment of deep vein thrombosis (DVT) or aspiration pneumonia. An extensive manual chart audit confirmed that those patients had not had DVT prophylaxis treatment or speech therapy swallow evaluation studies during their stroke acute hospital stay.

The decision to develop a stroke clinical pathway was made based on our clinical path selection criteria, which were developed to provide a logical way of determining which disease or DRG would best fit the clinical pathway process. The selection criteria included:

• high patient volume;

• high cost and resource utilization;

• opportunity for system improvement related to customer satisfaction;

• support by the hospital's Centers of Excellence;

• significant variance in national or regional comparisons;

• significant internal variance in practice patterns;

• request by service line or physician to develop a pathway;

• participation by a physician champion for the clinical pathway and specialty physicians.

The interdisciplinary stroke clinical path committee was empaneled, and a neurologist physician champion was chosen. Clinical pathway outcome data were obtained by manual chart audits and from the hospital's informatic systems (Atlas and Trendpath).

After implementing the pathway, a six-month evaluation revealed the following advantages for patients on the pathway vs. patients not on the pathway:

• three to four fewer days in lengths of stay (LOS);

• a 10% to 49% increase in use of DVT prophylaxis measures;

• a 31% to 35% increase in swallowing screenings by speech therapy;

• a 38% increase in discharge planning interventions.

Since the development of the pathway, its use by physicians has ranged from a low of 12% for the second quarter of fiscal year 1996 to a high of 48% for the fourth quarter of fiscal year 1998.

The clinical path committee noted that 1998 outcomes for mortality, morbidity, LOS, complications, and direct cost were deviating from the desired range. The committee attributed the worsening outcomes to the following:

• reviewing the pathway only once a year;

• inadequate communication of outcomes to physicians and staff nurses;

• lack of consistent use of the pathway by physicians on all admitted stroke patients.

For certain patient populations, something more than pathways may be needed to obtain desired outcomes, in which case a collaborative practice team (CPT) may be of use. A CPT is defined as a multidisciplinary group that uses research as a basis for analyzing patient outcomes and implementing ongoing process improvements, with the goal of improving care across the continuum for chronic high-risk patient populations.

The decision was made to move the stroke clinical path committee to a CPT, based on the following selection criteria:

• high-risk or problem-prone;

• chronic illness and/or a population that requires more frequent monitoring;

• existence of significant clinical improvement opportunities;

• high resource utilization;

• existence of opportunities for improved self-management.

At the first stroke CPT meeting in January 1999, the clinical nurse specialist presented the team concept and detailed its objectives, its target population selection, its process flow, and evidence-based research and prioritization of data. The CPT members agreed to meet monthly in order to review stroke outcome data, evaluate current quality indicators, and develop new indicators. They also agreed to devise action plans addressing quality initiatives, including research question development, consistent methods of communicating stroke outcome data, and implementation of community and professional stroke education programs.

Tool updates staff on stroke outcomes

A communication tool developed by clinical nurse and quality specialists is now used to disseminate the clinical pathway, protocols, and CPT information. The tool is used by the CPT clinical nurse specialist co-facilitator, and it ensures that appropriate physician and nursing staff are updated on stroke outcome data and initiatives in a consistent and timely manner.

While members of the stroke collaborative team were in planning and implementing mode, stroke outcome data from the third quarter of 1999 continued to show worsening outcomes in mortality, morbidity, complications, LOS, and direct cost. The CPT co-facilitators — a neurologist and a clinical nurse specialist — presented the 1999-trended stroke outcome data to the hospital's physician medical executive committee. Members of the committee voted that all patients who were admitted to the hospital must have the appropriate clinical pathway ordered and implemented.

The CPT plans to investigate a quality initiative in the emergency department (ED) regarding stroke time anchors and how they affect outcomes. Stroke time anchors indicate how quickly a patient should move through the ED, from presentation through diagnosis and treatment and on to acute hospital admission.

An ad hoc group of the CPT is devising a way to concurrently track the ED time anchors using the hospital's informatics systems. Once the tracking mechanism is in place, data will be collected and a statistical analysis will be completed. This study is expected to provide an opportunity to evaluate the effect of the ED time anchors on stroke outcomes.

Physician use of pathway has increased

Even though results of the CPT initiatives are limited, first quarter 2000 stroke data reveal significant improvements in mortality, morbidity, complications, LOS, and direct cost outcomes. Clinical pathway use by physicians has increased. There are continuing efforts to provide stroke education on an ongoing basis for physician practice groups, nursing staff, emergency medical service personnel, and the community.

The CPT has played a pivotal role in bringing patient outcomes for the stroke population into the acceptable range. Stroke continues as a chronic illness that forever changes the patient and his or her family. The consistent vigilance of the CPT clearly lends itself well to the management of this population.