J Integr Care Pathw 2008;12:45-55
doi:10.1258/jicp.2008.008007
© 2008 Royal Society of Medicine Press
An academic medical centre's programme to develop clinical pathways to manage health care: focus on acute decompensated heart failure
Dawn Lombardo *,
Tania V Bridgeman 
,
Nathalie De Michelis and
Molly Nunez *
* Department of Medicine, Division of Cardiology;
Department of Case Management, University of California Irvine Medical Center, CA, USA
Correspondence to: TVB Email: tbridgeman{at}uci.edu
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ABSTRACT
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Heart failure (HF) is a major public health issue and acute
decompensated heart failure (ADHF) is a leading cause of hospitalization
in the USA. The United States health care delivery system is
bound by regulatory agencies requiring strict compliance to
key clinical indicators, which are publicly reported. Clinical
pathway development is a systematic approach to managing health
care that involves a high degree of collaboration between patients,
physicians, nurses and various health-care team professionals.
The University of California, Irvine Medical Center (UCIMC)
developed an evidence-based multidisciplinary pathway for patients
with ADHF. This clinical pathway incorporates universally proven
assessment and treatment measures in ADHF. Adjunctive to this
process are patient and nursing guides to the ADHF pathway.
Utilization of this pathway has been shown to significantly
impact clinical performance by early identification of potential
negative clinical outcomes. Clinical pathways, such as the ADHF
pathway, promote clinical excellence in caring for acute and
chronic diseases states.
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INTRODUCTION
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In 1989, the USA witnessed a crisis in health care resulting
in intense competition and major changes in the health-care
delivery system. Health-care costs have continued to rise. The
increases in costs have been attributed primarily to technology,
an ageing population and an increased cost of chronic illness.
Shortened length of stays in hospital and rising costs have
caused a shift from inpatient care to outpatient care with a
focus on chronic illness. It has been predicted that nearly
60% of health-care services now offered inside the hospital
will be offered outside the hospital.
The University of California Irvine Medical Center (UCIMC) comprises a 449-bed facility with 400 specialty and primary care physicians, a level I Trauma Center and a level III Neonatal Intensive Care Unit. In an effort to have better control of costs and effectively compete in a changing health-care system, UCIMC is restructuring and developing new management models. These new models present a new paradigm utilizing a ‘continuum of care’ concept. In the traditional health-care environment, patients are cared for in a ‘fragmented’ manner, which can result in the duplication of services and inappropriate care (when one provider's treatment interferes with another). The ‘continuum of care’ concept coordinates patient care services, for a specific disease entity across the continuum of health care. The benefits to the health-care system utilizing the continuum concept lie in the increase in the quality of health care provided, increased productivity of the provider system and lower costs associated with this practice. Clinical pathways addressing prehospital care, acute care and personal care following discharge have been found to promote clinical excellence. They define key elements that are expected to happen at predictable time periods.
Clinical pathways are a strategy of managing care that emphasizes early assessment of a patient's condition and comprehensive care planning inclusive of service systems. Clinical pathways have proven to be a powerful tool both in maintaining clinical excellence and controlling costs. Since 2000, UCIMC has developed over 20 clinical pathways with a focus on the integration of care, following the ‘continuum of care’ concept. The following inpatient pathways have been developed at UCIMC under the auspices of our Clinical Pathway Coordinating Council composed of four physicians, three nurses, three pharmacists and one representative from information systems:
- Total knee replacement;
- Total hip replacement;
- Community acquired pneumonia;
- Lumbar decompression;
- Anterior cervical;
- Lumbar decompression/fusion/revision;
- Acute decompensated heart failure (ADHF);
- Ischemic stroke;
- Intraparenchymal haemorrhage;
- Subarachnoid haemorrhage;
- Colorectal surgery open and closed;
- Bariatric surgery;
- Head and neck surgery with malignancy with tracheostomy;
- Head and neck surgery without tracheostomy;
- Management of patients with devastating brain injuries;
- Transient ischemic attack;
- Kidney pancreas transplant;
- Rhabomyolysis protocol;
- Neutropenic sepsis.
The following intraoperative pathways have been developed
and are implemented:
- Bariatric surgery;
- Cardiac anaesthesia for coronary bypass and valve replacements.
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CLINICAL PATHWAY APPROVAL AND VARIANCE TRACKING
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Imperative to the success of this continuum of care model is
the ability of each discipline, in the multidisciplinary process,
to review and approve the clinical pathway prior to implementation.
Following multidisciplinary approval, administrative approval
is then required including: pharmacy and therapeutics, risk
management, medical executive committee and the governing body
of the university medical centre. The rigid approval process
is then followed by quarterly variance reporting. Variance,
reporting shows deviations from the clinical pathway in association
with the ‘driver’ of variance, which could be: the
patient (refusal of a medication impacting his or her clinical
outcome), the care-giver (incorrect timing of a digoxin level),
an internal service issue (not able to perform a dobutamine
stress test when ordered) or an external service issue (no bed
availability in a skilled nursing facility causing an increased
length of stay).
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MEDICAL PATHWAY DEVELOPMENT
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The Clinical Pathway Coordinating Council quickly noted that
the development of medical pathways was very complex in nature,
especially when compared with the development of surgical pathways.
In particular, those medical pathways addressing chronic diseases,
such as ADHF, pneumonia and COPD, proved more difficult to develop.
Since ADHF is being followed closely by the regulatory bodies
in the USA, and there exists a desire from hospitals to improve
clinical outcomes and reduce ADHF re-admissions, the ADHF pathway
has been chosen to be profiled in the article (Figure
1).
A brief overview of the background of this disease confirmed
the team's commitment to developing the HF clinical pathway.
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BACKGROUND
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HF is a serious public health problem in USA. In Europe, approximately
5% of acute and medical admissions are related to HF. About
five million Americans carry the diagnosis of HF with more than
550,000 new cases of HF diagnosed every year. Each year, a quarter
of the million people die from HF and the disease accounts for
about 3.5 million hospitalizations per year. It is also responsible
for over 11 million physician office visits per year and is
the leading cause of hospitalization among elderly patients.
The national annual financial burden amounts to $25–$50
billion spent in the care of HF patients.
1 The HF pandemic and
its enormous cost to the health-care system is the reason the
Center for Medicare and Medicaid Services and The Joint Commission
(TJC) launched the hospital quality initiative (HQI) in 2001
to track evidence-based hospital quality measures.
2 HQI aims
to improve the care provided by the nation's hospitals and to
provide quality information to consumers and the public.
3
The Acute Decompensated Heart Failure National Registry (ADHERE), a large, national, multicentre registry, revealed that the hospital treatment of HF frequently does not follow published guidelines, nor does it conform to TJC hospital quality measures, potentially contributing to the high morbidity, mortality and economic cost of this disorder. ADHERE findings also suggested that the wide variations in conformity may reflect differences in training, guideline familiarity and implementation of tools and systems to ensure that the recommended care is provided and documented.4,5
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HEART FAILURE CLINICAL PATHWAY PLANNING AND DEVELOPMENT
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A multidisciplinary team was set-up with health-care professionals
who are involved in planning or in delivering care for this
patient population. The team included: three cardiologists,
a hospitalist, nurses from the telemetry monitoring unit and
cardiac care unit, a cardiology nurse practitioner, a programme
manager, a dietitian, a pharmacist, a laboratory representative,
a case manager, a performance improvement (PI) representative,
a radiology department representative and an information services
representative. (The selection of a physician champion to lead
the team was an important key to the success of this project.)
The clinical pathway development team investigated the following areas of evidence in the pathway development phase:
- Conducted a literature search;
- Consulted pharmaceutical guidelines for cardiac medications;
- Reviewed protocols;
- Assessed clinical pathway programmes in other institutions;
- Referenced the American College of Cardiology and American Heart Association (ACC/AHA) 2005 guideline for the diagnosis and management of HF patient;6
- Referenced the Heart Failure Society of an America (HFSA) 2006 comprehensive HF practice guideline;7
- Worked hand-in-hand with internal expert practitioners (cardiologists) to evaluate evidence-based practice in the management of HF at the university and nationwide;
- Conducted discussions with clinical staff involved in the care of HF patients for practical, clinical input.
Based on the information obtained from these resources,
the team drafted a clinical pathway with a timeline for categories
of specific care activities, interventions and expected outcomes
when delivering care to this population during their hospitalization.
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CLINICAL INDICATORS FOR HEART FAILURE
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A vital part of pathway development is the attention to disease-specific
clinical indicators. The following were selected as pertinent
indicators directly producing the desired clinical outcome on
discharge.
Brain natriuretic peptide (BNP) drawn on day one of the hospital stay
In a recent survey, emergency room physicians admitted uncertainty in their diagnosis of HF in 40% of the patients. BNP is a significant marker, especially useful in helping physicians distinguish dyspnoea due to HF from dyspnoea due to other causes, thus allowing more rapid initiation of appropriate medical therapies.8
Chest X-ray on day one of the hospital stay
A basic chest X-ray remains a standard tool in helping diagnose ADHF. It can show the size and outline of the heart and the presence of vascular congestion, infiltrates and effusions.
Left ventricular ejection fraction assessment
Patients with HF should be considered for an imaging study (echocardiogram, radionuclide scan) if one was not performed within one year of admission. Two-dimensional and Doppler echocardiography can determine systolic and diastolic left ventricular (LV) performance, cardiac output [ejection fraction (EF)], pulmonary artery and ventricular filling pressures. Echocardiography can also identify clinically significant valvular disease.9,10
Beta-blocker prescribed during hospitalization
Beta-blockers are recommended for all stable patients with current or prior symptoms of HF and reduced LVEF unless contraindicated (Level of Evidence: A).5
Angiotensin-converting enzyme/angiotensin-receptor blocker (ACE-I/ARB) for LVEF < 40%
ACE-I is recommended for all patients with current or prior symptoms of HF and reduced LVEF, unless contraindicated (Level of Evidence: A). ARBs are approved for the treatment of HF and are recommended in patients with current or prior symptoms of HF and reduced LVEF who are ACE-I intolerant. (Level of Evidence: A).5
Use of diuretics on day one of the hospital stay
A patient with HF who has volume overload should receive a loop diuretic, preferably intravenously.9,10. Administration of a diuretic within the first 24 hours is a significant indicator associated with decreased hospital length of stay and an improved clinical outcome.
Patient discharge education
Patient non-compliance with dietary guidelines and medications is a primary reason for clinical deterioration. Educating patients on HF and about their condition and plan of care will help to promote patient compliance with the treatment plan and reduce the chances of re-hospitalization. Health-care professionals should ensure that patients and their families understand their dietary restrictions, activity recommendations, prescribed medication regimen and the signs and symptoms of worsening HF. National guidelines strongly support the role of patient education.11
Smoking cessation counselling
HF patients with a history of smoking are counselled to abstrain from smoking during hospitalization. Smoking cessation classes are offered free of charge. Studies show that smokers are more likely to quit smoking if a doctor advises them to stop. One year after quitting smoking, a person's risk of heart disease decreases by 50%. National guidelines strongly recommend smoking cessation counselling for HF patients who smoke.12 A smoker is categorized as someone who has smoked cigarettes anytime during the year prior to hospitalization.4
Once all the clinical indicators were integrated into the HF pathway, it was ready for the implementation process.
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IMPLEMENTATION
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The UCIMC has a clinical documentation system into which all
clinical pathways are entered. Once the order set is accessed,
the patient is registered against the clinical pathway plan
of care. All care-givers have access to the clinical path site
on the UCIMC intranet and all users were educated in using this
system. The electronic HF order set was crucial in many ways:
assisting data collection, tracking variances in care and providing
a tool for communication within the multidisciplinary team indicating
the patient's progress against the clinical path.
The order set associated with the clinical pathway ensured the following:
- Appropriate documentation on nursing flow sheet;
- HF team notification of patient admission;
- Nutrition services notification, which triggered a dietary consult and a dietary order that would place the patient on a cardiac diet with sodium and fluid restriction;
- A process that would track measures and data elements;
- A process that would monitor and ensure reduction in variance in care;
- A philosophy that promotes awareness of evidence-based practice in the care of HF.
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BARRIERS
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Four primary barriers for the implementation of the pathway
were identified and resolved:
- One barrier identified early was the need to address the patient at the entry point into the health system. At this point, the emergency department (ED) physicians collaborated with the team to develop a clinical algorithm. This was done to expedite triage and treatment modalities (Figure 2). The ED algorithm title had to be changed in order to more accurately reflect early medical decision-making. HF diagnosis is sometimes not readily identified at triage. The ‘ADHF’ algorithm was revised and re-labelled ‘Acute Shortness of breath- Suspect Heart Failure’
- Initially, there was physician resistance to utilization of the electronic physician order set. This was overcome through education and reinforcement of the underlying goal of achieving clinical excellence in the care of these ED patients.
- Nursing found it difficult to follow this complex pathway. By assessing its usage and through discussion with nurses, it was discovered that the pathway would be more specific for nursing care and easier to follow if a short-hand version of the pathway was designed for them. A nursing guide was created that was specific to the practice of nursing and the hospital care of a HF patient from admission to discharge (Figure 3).
- HF patients did not understand the complexity of care provided to them and did not know what to expect during their hospitalization. To increase patients understanding of their condition and their care plan, the HF team developed an inpatient guide, similar in appearance to a clinical path, for the patient to follow their day-to-day care while in the hospital with ADHF (Figure 4). The patient's guide increases their satisfaction and empowers them, by increasing the patient's understanding of their condition, what they can expect each day and by making them aware of what they can do to improve their condition.
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EDUCATION AND TRAINING
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Once the new pathway was approved, a series of educational sessions
were given to:
- Physicians/hospitalists;
- Nurses;
- Cardiologists;
- Residents and fellows;
- Ancillary services;
- Medical grand rounds;
- Pharmacists.
It should be noted that continuous
education with all disciplines is necessary, especially with
new residents and interns beginning every July.
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IMPACT OF THE CLINICAL PATHWAY AND RESULTS
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The HF pathway allows us to track the following clinical and
administrative data:
- Length of stay;
- Average cost;
- Discharge by nursing wards;
- Percentage of order set use by admitting services;
- Admitting services;
- BNP;
- Diuretic and chest X-ray on day one of the hospital admission;
- Re-admission rate;
- Case mix by payer;
- Inpatient mortality;
- LVEF assessed;
- Beta blocker and ACE/ARB for LVEF < 40% prescribed at time of discharge;
- Complete discharge instructions given;
- Smoking cessation counselling;
- Outliers (significantly outside the expected length of stay and/or cost per discharge due to treatments of co-morbid conditions).
All the data gathered are reviewed,
analysed and evaluated by our HF PI committee. Once issues are
identified, the team makes recommendations and actions for improvement
are implemented.
The following graphs are reflective of monitoring variances in accordance with the HF clinical pathway:
- Compliance with the discharge instruction measure initially was found to be 40%. After implementation of HF discharge education in-services, the measure improved to 80% (Figure 5). The HF PI team worked diligently, and continues today, to improve this measure. The success of this measure is attributed to increased physician and staff awareness of the HF syndrome, its management and expected quality of discharge care delivered to UCIMC patients. This has been accomplished through staff attendance at required in-services and classes developed by the HF PI team. The HF PI team also ensures that every HF chart contains a standardized HF programme form, which reinforces the required discharge elements and patient care instructions. The Division of Cardiology and the Hospitalist Programme developed a memorandum of agreement which also addressed HF discharge care.
- Two important clinical indicators important in the treatment of ADHF are tracked from day one: the BNP and usage of diuretics (Figure 6). The increased usage of the ED algorithm and electronic physician order set assists in improving both these measures.
- HF has a high hospital re-admission rate, which is directly correlated with quality of care, therefore, it was important to measure the UCIMC hospital re-admission rate at seven days and 30 days, respectively (Figure 7). Hospital re-admissions highly correlate with patients': lack of compliance, lack of access to outpatient medical services, insufficient knowledge about diet, medication and management of HF symptoms. Hospital re-admission rate is also an indicator of possible premature patient discharge, discharge without appropriate treatments or discharge instructions. The HF PI team is working diligently to decrease hospital re-admission rates and improve quality of hospital care.
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Figure 7 Clinical indicator: heart failure re-admission rate at seven days and 30 days post-hospitalization
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DISCUSSION
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Clinical pathways are becoming the expectation of the health-care
industry, especially in organizations seeking Certifications
or Centers of Excellence. Evidence-based practices are necessary
to remain abreast of clinical decision-making and are the result
of quality research, randomized controlled trials and improvements
in the technology in diagnosing diseases resulting in earlier
treatment. The implementation of the HF clinical pathway at
UCIMC was a key element in strengthening its HF programme and
in obtaining The Joint Commission Heart Failure Disease Specific
Certification, a symbol of high quality of care. The ED algorithm,
the Acute Decompensated Heart Failure Clinical Pathway, The
Nursing Guide to the HF Clinical Pathway and the Patient Guide
HF Hospital Care contribute to the reduction in the variation
of care leading to improved clinical outcomes and perception
of care.
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CONCLUSION
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UCIMC clinical pathways have promoted a collaborative, quality-driven
plan of care between nurses, physicians and other necessary
professional health-care providers when treating an ADHF patient.
A notable inclusion, in the development of the ADHF pathway,
was the broadened scope of collaboration to include patient's
input and participation in the plan of care. By including the
patient, we envision that all future pathway development will
have the patient as an integral part of the care process since
this significantly empowers them and allows them a more thorough
understanding of their disease process and its treatment. We
are now in an environment where patients can electronically
access an institution's disease-specific data and we can anticipate
that patients will choose their medical care accordingly. Naturally,
it behooves a health-care organization to utilize this powerful
strategy to help assure high quality of care through utilization
of the best evidence-based medicine to assure improved clinical
outcomes for patients with ADHF.
Note: The Clinical Pathway and Emergency Department Clinical Algorithm are authorized for use only at the University of California Irvine Medical Center.
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Footnotes
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Dawn Lombardo DO, Assistant Professor of Medicine; Tania V Bridgeman PhD RN, Director of Clinical Path Development; Nathalie De Michelis BSN RN, Cardiovascular Program Manager; Molly Nunez MSN NP RN, Cardiovascular Nurse Practitioner, University of California Irvine Medical Center, 101 The City Drive South, Orange, CA 92868, USA.
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References
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- American Heart Association American Stroke association. Hearth Disease and Stroke Statistics. http://www.americanheart.org/downloadable/heart/1200082005246HS_Stats%202008.final.pdf (last accessed 5 August 2008)
- The Center for Medicare and Medicaid Services. http://www.cms.hhs.gov/ (last accessed 2 August 2008)
- The Joint Commission. http://www.jointcommission.org/ (last accessed 7 August 2008)
- Adams KFJr, Fonarow GC, Emerman CL, et al.; ADHERE Scientific Advisory Committee and Investigators. Characteristics and outcomes of patients hospitalized for heart failure in the United States: rationale, design, and preliminary observations from the first 100,000 cases in the Acute Decompensated Heart Failure National Registry (ADHERE). Am Heart J 2005;149:209–16 (doi: 10.1016/j.ahj.2004.08.005)[Medline]
- Yancy CW, Lopatin M, Stevenson LW, De Marco T, Fonarow GC, ADHERE Scientific Advisory Committee and Investigators: Clinical presentation, management, and in-hospital outcomes of patients admitted with acute decompensated heart failure with preserved systolic function: a report from the Acute Decompensated Heart Failure National Registry (ADHERE) Database. J Am Coll Cardiol 2006;47:76–84 (Erratum in: J Am Coll Cardiol 2006;47:1502)[Abstract/Free Full Text]
- American College of Cardiology/American Heart Association task force. ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in adult. Circulation 2005;112:1825–52[Free Full Text]
- Heart Failure Society of America. HFSA 2006 Comprehensive Heart Failure Practice Guideline. J Cardiac Failure 2006;12:e1–122[Medline]
- McCullough PA, Nowak RM, McCord J, et al. B-type natriuretic peptide and clinical judgment in emergency diagnosis of heart failure: analysis from Breathing Not Properly (BNP) Multinational Study. Circulation 2002;106:416–22[Abstract/Free Full Text]
- The National Clearing House. http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=3303 (last accessed 17 August 2008)
- American Medical Directors Association (AMDA). Heart failure. Columbia (MD): American Medical Directors Association (AMDA), 2002:18p (31 references)
- Centers for Medicare & Medicaid Services (CMS). Specifications Manual for National Hospital Quality Measures, Version 2.3b. The Joint Commission, 2007 (various pages)
- Bonow RO, Bennett S, Casey DEJr, et al. ACC/AHA clinical performance measures for adults with chronic heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures (Writing Committee to Develop Heart Failure Clinical Performance Measures). J Am Coll Cardiol 2005;46(6):1144–78[Free Full Text]
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ABSTRACT
INTRODUCTION
