1. Using clinical pathways, monitoring for variances

2. 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?

3. 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)

4. Filling out patient information
Who fills these out?

5. Indicate date for interval or phase
Who fills this out?

6. Fill out SOAP
Who fills out the SOAP?

7. 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

9. 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.

10. 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

11. 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.

12. 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.

13. 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

14. 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

15. Variances

16. 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

17. 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 Medical order
2. Provider(s) decision
3. Provider(s) response time
4. Other reasons
C. TMC System Results/Data availability
2. Supplies/Equipment related
3. Appointment Availability
4. Weekend/Holiday
D. Outside TMC Transportation availability
2. Home Care availability
3. Other reasons

18. 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

19. 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

20. 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.

21. Reviewing outcomes

22. 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.

23. 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.

24. 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.

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

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

27. 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.

28. Discontinuing the pathway

29. 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 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.

30. 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?

31. 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