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Marilyn Hanchett, RN, MA, CPHQ
Coordinator, Clinical Pathways
Jean O’Neal, RN
Manager, Registration Services
Columbia (MO) Regional Hospital
Clinical pathways were introduced in 1995 at Columbia Regional Hospital, a 100-bed community hospital, which is now affiliated with University of Missouri Health Care, also in Columbia. At that time, project manager Jean O’Neal, RN, developed an innovative tool for educating and involving patients in their care.
The patient pathway corresponds to the clinical pathway but is a separate document. It is a day-to-day compilation of what the patient can expect to happen and describes the patient’s responsibilities for those activities. The patient pathway uses simple terminology and is based on a seventh-grade Flesch-Kincaid reading level. Unlike the clinical pathway, which is part of the medical record, the patient pathway is given to the client. He or she is encouraged to refer to it regularly and use it as a resource throughout the hospital stay.
Depending on the reason for admission, the patient may be introduced to the pathway at a variety of entry points. For example, a female client who is discussing a hysterectomy with the surgeon may receive the patient pathway in the doctor’s office prior to the actual surgery date. A patient who arrives for preoperative evaluation prior to joint replacement surgery will receive the pathway in the outpatient department. "In both examples," O’Neal points out, "the patient has an opportunity to ask questions before being admitted."
Since their introduction in 1995, patient pathways have become an integral part of the hospital’s Preoperative Education and Testing (POET) Program. Sheila Corey, RN, who coordinates the POET Program in conjunction with the hospital’s Institute for Outpatient Surgery, has seen the immediate impact of the tool during her daily teaching sessions. "Many times patients are more than just anxious; they are afraid. By going over the patient pathway with them and their family members, they know what to expect. They have a better understanding of what will happen and if they forget, they can refer back to the pathway." In fact, Corey says that the pathways have been a critical component in maintaining the consistently high customer satisfaction scores achieved by the POET Program.
It is important to remember that the patient pathway does not preclude the use of other types of patient education materials. However, unlike disease, procedure, or treatment-specific teaching aids, the patient pathway helps explain the hospital experience. The case manager is the champion for the clinical pathway. In this role, he or she also is responsible for ensuring the patient pathways are current, relevant, and available to the various users throughout the hospital system. Case managers work closely with physicians and their assistants to assure the accuracy of all pathway materials. In many cases, the case manager supplies physician offices with copies of all pathway information.
Case managers, as well as all other members of the health care team, struggle to balance the need for thorough patient education with the demand for cost-effective resource utilization. Preadmission education, especially for surgical cases, has been identified as an effective measure in reducing anxiety, improving postoperative pain management, and enhancing patient satisfaction.1,2 When given the choice, patients prefer to receive instruction prior to admission/day of surgery.3,4 However, the impact of preadmission teaching on other patient outcomes has not been fully investigated, nor has it been consistently correlated with reliable indices of recovery.
It is clear that more study is needed. Case managers can be important facilitators in this process. Through the design, use, and evaluation of tools such as the patient pathway, case managers have an opportunity to demonstrate the value of client education/involvement, including the impact on resource utilization and length of hospital stay. This next level of analysis is currently in progress at Columbia Regional Hospital.
Marty Hausman, RN, CCM, who facilitated the revision of Columbia Regional’s Abdominal/ Vaginal Hysterectomy Pathway, states, "By combining the traditional clinical pathway with tools such as the patient pathway, our case management staff are better able to not only manage tangible resources, but also intangibles such as goals and expectations." (For a sample of the pathway in PDF format, please click here.)
1. Beddows J. Alleviating pre-operative anxiety in patients: A study. Nursing Standard 1997; 11(37):35-38.
2. Williams OA. Patient knowledge of operative care. Journal of Research in Social Medicine 1993; 86(6):328-331.
3. Brumfield VC, Kee CC, Johnson JY. Preoperative patient teaching in ambulatory surgery settings. Journal of AORN 1996; 64(6):941-946, 948, 951-952.
4. Schoessler M. Perceptions of pre-operative education in patients admitted the morning of surgery. Patient Education Counseling 1989; 14(2):127-136.