CVA pathway cuts across seven hospital units
CVA pathway cuts across seven hospital units
Path focuses on five key outcomes
In October 1996, St. Luke’s Medical Center in Milwaukee launched its ambitious cerebrovascular accident (CVA) pathway, its first to span several units across the facility. By bringing together professionals from different disciplines under a standard plan of care, St. Luke’s managed to cut its length of stay for CVA by 1.6 days, dropping it below the national average for the first time while maintaining a patient satisfaction rating of 94%.
The five-day pathway applies to patients who have suffered either an ischemic or a hemorrhagic stroke. It was tapped to be St. Luke’s first cross-unit pathway after an investigation of the facility’s stroke population revealed that stroke patients were receiving care on 18 different units in the hospital, says Lee Jeske, RN, BSN, a nurse clinician at St. Luke’s. "We felt that we would do the patients a much better service by getting them focused more on two or three units, if that was possible," she says. Currently the pathway spans seven units three intensive care units and four separate floors.
In addition to consolidating care for CVA patients, administrators and case managers wanted to decrease variances while maintaining or improving quality of care. To that end, the pathway team identified five key outcomes considered essential to accomplishing its goals:
• Someone from speech therapy should see the patient within 12 to 16 hours of admission to the unit.
"We feel that this is very important, because aspiration is one of the complications stroke patients have," Jeske says. "We felt that if we could get speech therapy in there quickly, we would be able to avoid that complication."
• A nurse should assess the patient’s severity according to the Bethesda, MD-based National Institutes of Health’s (NIH) stroke scale.
Social services and nursing then use the results of the severity assessment to help patients and their families better plan for the discharge process.
• Patients should know the details of the discharge disposition plan.
"So they’ll know right up front that, based on the NIH scale, they’ll either be able to go home, or they might need some time in a rehab setting or long-term setting, depending on the severity of the stroke," Jeske says.
• The patient should have a physiatry referral on the second day of the pathway.
• Patients should be properly educated about the extent of their condition.
"They should be able to say that they had a stroke and the residual of that stroke is, for instance, a weakness or a speech problem," Jeske says. "And then they can verbalize what it is we are going to do about it."
To educate patients about the nature and extent of their strokes, St. Luke’s developed a standard educational package featuring a picture-based patient recovery plan that details what they can expect in terms of treatment and therapy. The package also includes five pamphlets that discuss the recovery process, and how someone adapts to having had a stroke.
"After giving the patient the package, the nurse checks off on the pathway that they gave the package, and then checks off the patient’s response to receiving the information," Jeske says. "And there are some other specific things on the pathway that address the teaching of the patient, from all disciplines involved, including nursing and pharmacy."
To document how well it was achieving its five key outcomes for CVA patients, St. Luke’s developed a scannable variance tracking tool and a database for outcomes management using Teleform, a software system produced by Cardiff Software in Carlsbad, CA.
The variance sheet is attached to the pathway, and nurses fill out both at the same time, Jeske says. Then, when the patient’s discharged, the information is sent down to clinical information services. They compile the information and send it back to one of the team leaders either Jeske or Paula O’Hearn, CNS, another clinical nurse specialist. "Then we take that information and make decisions based on what we get from it," Jeske says.
Data recorded on the forms can be used for daily patient variance analysis and fed back to clinicians quickly. They can also be scanned, verified, and aggregated for the pathway team to use in further process and outcome improvement efforts.
Jeske concedes that because the pathway crossed so many units, nurses took some time getting used to it. "There was a lot of education involved," she says. "But it’s been a positive thing, and I’m very satisfied with the outcomes we’ve achieved. I feel that now we can impact more outcomes and make things better for our stroke population in general."
For more information about the CVA pathway, contact Lee Jeske, RN, BSN, nurse clinician, St. Luke’s Medical Center, 2900 W. Oklahoma Ave,. Milwaukee, WI 53201-2901. Telephone: (414) 649-7934.
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