Presentation on theme: "Using clinical pathways, monitoring for variances"— Presentation transcript:
1Using clinical pathways, monitoring for variances
2Choosing 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?
3Activating the pathway AP/RIC signs at the bottomNIC acknowledgesWhat 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)
4Filling out patient information Who fills these out?
5Indicate date for interval or phase Who fills this out?
9Reviewing 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 bulletEncircle the bulletDo nothingUnderline the orderRemember: bulleted orders are carried out automatically once the pathway is activated.
10Reviewing ordersMandatory orders need to be done 100% of the time. True or false?False. They may be deferred. How?Putting X on the bulletCrossing out the order and signingWriting the word “defer” beside the ordersmv
11Optional 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 boxWrite “X” on the boxCheck the boxOptional orders that are checked will be carried out automatically.
12Unwanted 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 orderWrite “X” on the boxDo nothingWrite “Defer” beside the orderUnwanted optional orders are left blank.
13Order 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 signedThe word “OK” is written and signedThe word “Done” is written and signedSigned and timed in Sign columnPRV10:35amPRV11:20am
14Summary so far… What pathways are How to use pathways Activating Reviewing ordersMandatory & optional ordersDeferring mandatory ordersSignifying that the order has been carried out
16What are variancesAny mandatory or checked optional intervention that was not doneAn abnormal findingAn unmet outcome within the time frameAn outcome met earlier than expected
17TMC variance codes A. Patient/family 1. Patient’s medical condition 2. Patient/family decision3. Patient/family availability4. No funds5. Other reasonsB. Physician Medical order2. Provider(s) decision3. Provider(s) response time4. Other reasonsC. TMC System Results/Data availability2. Supplies/Equipment related3. Appointment Availability4. Weekend/HolidayD. Outside TMC Transportation availability2. Home Care availability3. Other reasons
18Documenting variances WhoAny member of the health care team who noted themWhereVariance code is written on the pathway’s Var columnHowVariance notes may be written on progress or nursing notesDocumented in the Variance Monitoring Form
19Patient refused the test. Is this a variance? Yes No Surgical floorJEO6:05pmDr. Goellegue4 hrsA2PRV10:35amIs 12-L ECG ordered? Yes NoPatient refused the test. Is this a variance? Yes NoWhat is the variance code?Where is the variance code written? Show it on your pathway form.The single sheet of the pathway showsThe ordersThe orders that were carried outThe order that were not doneThe reason/s why the order was not doneA2
20Arterial 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.
22OutcomesThe 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 developersListed in discharge planning sectionIf not met, should signal calling the attention of the AP so that interventions can be modified, added, discontinued in a timely way.
23Reviewing 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.
24Reviewing outcomes: nurse-in-charge’s role Reviews patient’s progress daily against intermediate and discharge outcomesReview 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.
25Patient outcomes, day 1Day 1Can the next time interval (Day 2) be activated for this patient?Why? Why not?
26Patient outcomes, Day 1Can the next time interval (Day 2) be activated for this patient?Why? Why not?Is this a variance? Document.
27Are all patient outcomes met? Yes No Is patient for discharge? Yes No PRV10:35amDay 4 outcomesAre all patient outcomes met? Yes NoIs patient for discharge? Yes NoDocument 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.
29Discontinuing the pathway The pathway will be discontinued whenever:The patient’s primary diagnosis changesThe patient’s condition significantly worsensThe patient fails to meet clinical outcomes for hoursTo 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.
30Think 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?
31Summary What pathways are How to use pathways Identifying variances Activating & acknowledgingMandatory & optional ordersDeferring mandatory ordersSignifying that the order has been carried outIdentifying variancesReviewing outcomesDiscontinuing the pathway