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138 unit 2 | Working Within the Organization CikguOnline
myocardial infarction (MI), a proposed course of problems within the system that extend the length
events leading to a successful patient outcome of stay or drive up costs because of overutilization
within the 4-day DRG-defined time frame or repetition of services. For example:
might be as follows (Doenges, Moorhouse, &
Mr. J. was admitted to the telemetry unit with a
Geissler, 1997): (1) Patient states that chest pain
diagnosis of MI. He had no previous history of heart
is relieved; (2) ST- and T-wave changes resolve
disease and no other complicating factors such as
and pulse oximeter reading is greater than
diabetes, hypertension, or elevated cholesterol levels.
90%; patient has clear breath sounds; (3) Patient
His DRG-prescribed length of stay was 4 days. He
ambulates in hall without experiencing extreme
had an uneventful hospitalization for the first
fatigue or chest pain; (4) Patient verbalizes
2 days. On the third day, he complained of pain in
feelings about having an MI and future fears;
the left calf. The calf was slightly reddened and
(5) Patient identifies effective coping strategies;
warm to the touch. This condition was diagnosed as
(6) Ventricular dysfunction, dysrhythmia, or
thrombophlebitis, which increased his length of hos-
crackles resolved
pitalization. The case manager’s review of the
SCMs may be used alone or together. A patient events leading up to the complaints of calf pain
who is admitted for an MI may have care planned indicated that, although the physician had ordered
using a critical pathway for an acute MI, a heparin compression stockings for Mr. J., the stockings never
protocol, and a dysrhythmia algorithm. In addition, arrived, and no one followed through on the order.
the nurses may refer to the standards of care in The variances related to his proposed length of stay
developing a traditional nursing care plan. were discussed with the team providing care, and
SCMs can improve physiological, psychological, measures were instituted to make sure that this
and financial outcomes. Services and interventions oversight would not occur again.
are sequenced to provide safe and effective out- Critical pathways provide a framework for com-
comes in a designated time and with most effective munication and documentation of care. They are
use of resources.They also give an interdisciplinary also excellent teaching tools for staff members
perspective that is not found in the traditional from various disciplines. Institutions can use criti-
nursing care plan. Computer programs allow cal pathways to evaluate the cost of care for differ-
health-care personnel to track variances (differ- ent patient populations (Capuano, 1995; Crummer
ences from the identified standard) and use these & Carter, 1993; Flarey, 1995; Lynam, 1994).
variances in planning QI activities. Most institutions have adopted a chronological,
The use of SCMs does not take the place of the diagrammatic format for presenting a critical pathway.
expert nursing judgment. The fundamental pur- Time frames may range from daily (day 1,
pose of the SCM is to assist health-care providers day 2, day 3) to hourly, depending on patient needs.
in implementing practices identified with good Key elements of the critical pathway include discharge
clinical judgment, research-based interventions, planning, patient education, consultations, activities,
and improved patient outcomes. Data from SCMs nutrition, medications, diagnostic tests, and treat-
allow comparisons of outcomes, development of ment (Crummer & Carter, 1993). Table 10-2
research-based decisions, identification of high- is an example of a critical pathway. Although orig-
risk patients, and identification of issues and prob- inally developed for use in acute care institutions,
lems before they escalate into disasters. Do not be critical pathways can be developed for home care
afraid to learn and understand the different SCMs. and long-term care. The patient’s nurse is usually
responsible for monitoring and recording any devi-
Critical Pathways ations from the critical pathway. When deviations
Critical pathways are clinical protocols involving all occur, the reasons are discussed with all members
disciplines. They are designed for tracking a of the health-care team, and the appropriate
planned clinical course for patients based on aver- changes in care are made. The nurse must identify
age and expected lengths of stay. Financial out- general trends in patient outcomes and develop
comes can be evaluated from critical pathways by plans to improve the quality of care to reduce the
assessing any variances from the proposed length of number of deviations.Through this close monitor-
stay. The health-care agency can then focus on ing, the health-care team can avoid last-minute