Clinical practice guidelines improve patient care at Connecticut hospital 

Five tools guide treatment from admission through discharge

Through an integrated five-pronged approach, Danbury (CT) Hospital has been able to improve patient care for patients with any of 13 diagnoses.

The Clinical Practice Guidelines (CPGs) include five tools: clinical pathway, standardized physician orders, patient education materials, specific discharge instructions, and critical indicators for success. Each tool is linked to the others.

Since the implementation of the congestive heart failure clinical practice guidelines, patient compliance with discharge instructions has increased from 25% in 2002 to 70.8% by January 2004. Hospital readmission rates for congestive heart failure patients have dropped from 5.8% in fiscal 2001 to 3.8% in fiscal 2003.

Danbury Hospital has one of the lowest lengths of stay in the state of Connecticut, says Doris Imperati, RN, BSN, MHSA, CCM, director of clinical resource management.

Before the new system was implemented, the hospital used a traditional clinical pathway, initiated by nursing, to trigger interventions on a daily basis. The practitioners practiced in silos, with variable clinical outcomes. All quality review and variance analysis was conducted on a retrospective basis.

"The pathway wasn’t being effectively used and did not address quality measures or needs of the patient throughout the continuum and did not include external benchmarking," Imperati says.

The hospital has completed CPGs for 13 diagnoses, including pneumonia, chronic obstructive pulmonary disease, congestive heart failure, stroke, caesarean, and other surgical procedures. The CPGs consist of five tools that interrelate with each other and help coordinate the patient’s care from admission through discharge. Here are the components of the system and how they work:

  • Standardized physician orders.

If a patient comes into the emergency department (ED) with congestive heart failure and is to be admitted to a medical unit, the resident on duty will use the appropriate order set to admit the patient.

"The order set includes all the best practices and expertise of how a patient with congestive heart failure should be treated — laboratory tests, medical procedures, and the most up-to-date medications," says Elizabeth Adler, BSN, MHA, clinical quality manager.

  • Clinical pathway.

When the patient is admitted to the unit, the nurses and clinicians on the floor use the clinical pathway to determine the expectations and clinical practices on a daily basis. For instance, on Day 1, they know to weigh the patient, check the laboratory report for the BUN level, and determine if the patient needs an ACE inhibitor or diuretic. The case manager monitors the process to ensure the tools are being used and the patient is getting the best possible care. If the order set wasn’t used or something is missing, he or she intervenes.

  • Patient education booklet.

Early in the stay, staff give the patient a full-color booklet about congestive heart failure and how to manage it on a day-to-day basis. The practice guidelines team collaborated with nursing and case management to develop the booklet.

"We told the people writing the booklets to pretend they were the patient and include what they would want to know. They are written so patients can understand what to expect during their hospital stay, their role in their care and discharge management, and what they can expect from their treatment team," Adler says.

• Discharge instructions.

The standardized discharge instructions prompt the physician through everything that is considered a best practice and includes specific information for the patient. For instance, it tells congestive heart failure patients to weigh themselves every day and what they should do if they gain weight.

  • Critical indicators for success.

Each CPT has critical indicators that are developed by the CPT team.

The case managers concurrently review all the diagnoses and their critical indicators. The information goes to Adler, who enters it into a spreadsheet program and runs reports. The reports are given to each physician and nurse champion to take to their peers for feedback.

"When we analyze the data, if we have not met the goal, we get together with the treatment team to review the problem and come up with solutions," she notes.

"We are very conscientious about being on the cutting edge for the best practices in medical, surgical, and obstetrical interventions. When we started, our tools were not as complete or thorough as we would have liked. They did not assist with concurrent review or any reviews that we anticipate coming from JCAHO [the Joint Commission on Accreditation of Healthcare Organizations] in the future," Adler points out.

Many of the hospital’s patients have several primary and many secondary diagnoses and may have multiple providers of care. The clinical practice guideline is the tool that keeps everyone on the same page, she adds.

A committee with representatives from all departments in the hospital did research to come up with what other facilities were doing and came up with a plan for developing the clinical practice guidelines.

"We didn’t develop these guidelines in a silo. Everybody has a role in creating a CPG," Adler says.

The committee did an internal study of the hospital’s patients to come up with the diagnoses for which CPGs were in order.

Volume was one indicator

"Like many other community hospitals, we have an aging population, and our choices for some of the CPGs were influenced by volume. These include congestive heart failure, chronic obstructive pulmonary disease, and pneumonia," she says.

The committee examined the hospital’s surgical procedures to see what procedures could be improved to benefit the patient and avoid excessive costs if the resources aren’t controlled. For instance, the hospital does a lot of gastric bypass surgery for patients with morbid obesity, a procedure that is very expensive.

"We wanted to make sure all practitioners are treating the patients the same way, according to best practices," Adler notes.

The state’s professional review organization has been looking at quality issues and standards of care.

"Whatever they’re looking at, we want to look at," she says. "We want to use the best practices and keep our treatment patient-focused, but we also recognize that we are affected by external regulatory agencies."

The CPG for each diagnosis was developed by a multidisciplinary team with at least one physician member. For instance, because of the complexity of treatment for aspiration pneumonia, the CPG development team included a pulmonologist, a hospitalist, and an infectious disease specialist who worked together.

Each team has a physician champion who is an expert in that field, a nurse champion, a case manager representing the clinical resource management department, a medical director, and a pharmacist.

Other hospital personnel join the team if their input is needed for that particular diagnosis. For instance, the team creating the CPG for total hip replacement included an occupational therapist and a physical therapist.

As the manager of the team, Adler coordinates the activities, making sure the team stays on track and on schedule. There is an ad hoc member who checks over the order sets and laboratory tests to make sure they use the most current abbreviations.

"In the past, we referred to cardiac enzymes [as] CPK.’ Now they’re called CK.’ We want to be current by calling the tests by the right abbreviation even though the laboratory may understand what we mean if we use the old terms." A single clinical practice guideline takes about two months to develop from the first committee meeting through implementation, Adler says.

"At the initial meeting, I think it’s important to stress that each team member has specific responsibilities with the team," she adds.

As portions of the guidelines are developed, the physician champion shares them with his or her peers and gets input.

"Those are the people who will be using it, and if they have conflicts with the guidelines, we want to address it," she says.

The nurse champion educates the nursing staff about the CPGs and what role nursing plays to make the project a success. She makes sure that all the supplies needed for compliance with the CPGs are available on the unit so the physician can have access.

The clinical resource management champion works with the nurse champion to share information and data with the staff and educates the case managers about the guidelines.

"We want to make sure that everybody who is involved in using these guidelines gets the big picture. Communicating to the nursing staff and the physicians is very important. Outcomes are shared to show areas of improvement and where we need to improve," she says.

For instance, the hospital standard calls for any patient with a diagnosis of pneumonia to be on antibiotics within 240 minutes of arrival to the hospital.

Analysis of the initial data from the CPG for pneumonia showed that some patients were not getting antibiotics within 240 minutes of arrival. Most pneumonia patients come through the ED, where they may stay more than four hours.

The committee met with the ED chief and arranged for the antibiotics to be administered in the ED. Now the average for administering antibiotics is within 170 minutes of admission.

Adler compiles graphs and spreadsheets for the leadership of the hospital, showing how each CPG is working.

The team continually reviews the CPGs, making changes as necessary. For instance, when there are changes in the hospital’s formulary, the order sets are changed to include the latest recommended medications.

"We owe the success of this program to having the attitude that no one operates in a silo. Everyone affects outcomes, results, and potential improvements in the system, and everyone is held accountable," Adler says.

The hospital uses a paper system and is moving to a computerized system. Each piece of paper in each clinical practice guideline is numbered and entered into the computer system so if a unit runs low, the nurse can easily order replacements.

Adler is working with the hospital’s programmers to create a computerized physician order-entry system. The computerized order-entry system was begun last July in the intensive care unit, then introduced to the medical and surgical floors and is scheduled to be implemented in cardiology next. "Because we have to keep a paper backup, I work with the programmers to make sure that what goes on the computer is identical to what is on paper," she says.