Using clinical pathways, monitoring for variances

Choosing the pathway, choosing the patient What is the working diagnosis? Do we have a pathway for this diagnosis? Is the patient eligible to be in this pathway?

Activating the pathway AP/RIC signs at the bottom NIC acknowledges What do these signatures signify? Pathways are activated one time interval at a time. Pathways are subdivided into either time intervals (day 1, day 2, etc) or units of care (e.g., NSD pathway)

Filling out patient information Who fills these out?

Indicate date for interval or phase Who fills this out?

Fill out SOAP Who fills out the SOAP?

With the pathway soap filled out, is a Patient Database Form still needed? Not anymore Optional Only when there’s additional information to supplement the pathway SOAP Always

Reviewing orders Who reviews the orders? Mandatory orders need to be carried out once the pathway is activated. How would you indicate that you want Protime to be carried out? Put X on the bullet Encircle the bullet Do nothing Underline the order Remember: bulleted orders are carried out automatically once the pathway is activated.

Reviewing orders Mandatory orders need to be done 100% of the time. True or false? False. They may be deferred. How? Putting X on the bullet Crossing out the order and signing Writing the word “defer” beside the order smv

Optional orders that are checked will be carried out automatically. How would you indicate that you want 12-L ECG to be done? Show how on your pathway form. Shade the box Write “X” on the box Check the box Optional orders that are checked will be carried out automatically.

Unwanted optional orders are left blank. 9. If pain reliever is not ordered, how would it be indicated? Show how on your pathway form. Cross out the order Write “X” on the box Do nothing Write “Defer” beside the order Unwanted optional orders are left blank.

Order has been crossed out and signed 10. If you have carried out an order, how would you indicate it? Show how on your pathway form. Order has been crossed out and signed The word “OK” is written and signed The word “Done” is written and signed Signed and timed in Sign column PRV 10:35am PRV 11:20am

Summary so far… What pathways are How to use pathways Activating Reviewing orders Mandatory & optional orders Deferring mandatory orders Signifying that the order has been carried out

Variances

What are variances Any mandatory or checked optional intervention that was not done An abnormal finding An unmet outcome within the time frame An outcome met earlier than expected

TMC variance codes A. Patient/family 1. Patient’s medical condition 2. Patient/family decision 3. Patient/family availability 4. No funds 5. Other reasons B. Physician 1. Medical order 2. Provider(s) decision 3. Provider(s) response time 4. Other reasons C. TMC System 1. Results/Data availability 2. Supplies/Equipment related 3. Appointment Availability 4. Weekend/Holiday D. Outside TMC 1. Transportation availability 2. Home Care availability 3. Other reasons

Documenting variances Who Any member of the health care team who noted them Where Variance code is written on the pathway’s Var column How Variance notes may be written on progress or nursing notes Documented in the Variance Monitoring Form

Patient refused the test. Is this a variance? Yes No Surgical floor JEO 6:05pm Dr. Goellegue 4 hrs A2 PRV 10:35am Is 12-L ECG ordered? Yes No Patient refused the test. Is this a variance? Yes No What is the variance code? Where is the variance code written? Show it on your pathway form. The single sheet of the pathway shows The orders The orders that were carried out The order that were not done The reason/s why the order was not done A2

Arterial blood gas was requested Arterial blood gas was requested. It wasn’t done because the procedure is not covered by the HMO. Is this a variance? What is the variance code? Show on your pathway form how this will be documented.

Reviewing outcomes

Outcomes The measurable outcomes that a patient is expected to experience is specified in the pathway for every time interval (e.g., daily, per shift). Pre-determined by the pathway developers Listed in discharge planning section If not met, should signal calling the attention of the AP so that interventions can be modified, added, discontinued in a timely way.

Reviewing outcomes: MD’s role All care team members must review the problem list, variances and outcomes daily. Pathways ensure that the members of the care team are looking at the same plan of care. AP and all referred MDs are accountable for reviewing the patient’s progress against intermediate and discharge outcomes on a daily basis. And for revising the plan of care based on the review of patient’s outcomes.

Reviewing outcomes: nurse-in-charge’s role Reviews patient’s progress daily against intermediate and discharge outcomes Review variances daily and report them to the AP and the rest of the care team. Ensures that all variances result in re-evaluation of plan of care by appropriate disciplines.

Patient outcomes, day 1 Day 1 Can the next time interval (Day 2) be activated for this patient? Why? Why not?

Patient outcomes, Day 1 Can the next time interval (Day 2) be activated for this patient? Why? Why not? Is this a variance? Document.

Are all patient outcomes met? Yes No Is patient for discharge? Yes No PRV 10:35am Day 4 outcomes Are all patient outcomes met? Yes No Is patient for discharge? Yes No Document the disposition on your pathway form. Is this a variance? Document. Patient’s length of stay exceeded that of the pathway. This is a variance.

Discontinuing the pathway

Discontinuing the pathway The pathway will be discontinued whenever: The patient’s primary diagnosis changes The patient’s condition significantly worsens The patient fails to meet clinical outcomes for 24-48 hours To discontinue the pathway, a progress note (SOAP) is written by the MD outlining the patient’s new plan of care and new orders. A new nursing plan of care is also written. The pathway is then filed in the patient record.

Think about this: Why should pathway be discontinued if the primary diagnosis changed? Why should pathway be discontinued if the patient’s condition significantly worsens? Why should pathway be discontinued if outcomes are not met within the time frame?

Summary What pathways are How to use pathways Identifying variances Activating & acknowledging Mandatory & optional orders Deferring mandatory orders Signifying that the order has been carried out Identifying variances Reviewing outcomes Discontinuing the pathway