O.C. Hospital Leads Industry’s Turn to ‘Clinical Pathways’ : Health: Saddleback Memorial’s use of detailed plans for patients’ recovery is helping change standards for medical care.
Ignoring a terrific view of the Aliso Hills outside her window at Saddleback Memorial Medical Center, Anne Welsh kept a wary eye on the metal contraption flexing her bandaged knee.
It was her fourth day in the Laguna Hills hospital, where the 84-year-old Lake Forest resident had knee replacement surgery that was necessary because, as she quipped, “I just got old.”
It was also her last day at the hospital.
Welsh’s orthopedic surgeon, Dr. Michael Farrell, was telling her that she would be transferred to Beverly Manor, a nearby skilled nursing center, to complete her recuperation.
A quick recovery? Not necessarily. But patients such as Welsh are being discharged from hospitals after shorter stays because of a new philosophy in health care. Using a system alternatively called clinical pathways or practice patterns, hospitals such as Saddleback are changing the standards for patient care.
The result, hospital administrators and health care experts say, is that hospitals are decreasing the length of time that patients receive costly hospital care while at the same time improving the quality of care overall.
Such a concept is especially relevant today, when the federal government and insurance carriers are screaming for cost reductions and hospitals are forced to rethink standard procedures.
“Ten years ago, there just weren’t the incentives to do this sort of thing,” said Marjorie J. Ingram, vice president of support services at Saddleback Hospital. “But that has all changed.”
In the past, doctors managed their patients’ care as they saw fit. Often, treatments varied from doctor to doctor, even within a single hospital setting. Now, most hospitals in Orange County and beyond are looking at clinical pathways--a method pioneered several years ago by the New England Medical Center in Boston--as one possibility.
The system works this way: Hospital administrators provide clinical “maps” that tell patients and their families what to expect from day to day--and in some cases minute to minute--during a hospital stay. The maps also give medical staffs specific blueprints for care, shortening hospital stays because doctors are able to focus quickly on each patient’s treatment.
Clinical pathways “are used quite widely now,” said Dr. Daniel Lang, medical director of Valley Presbyterian Hospital in Van Nuys and medical director of the Hospital Council of Southern California. “This is one of the most exciting tools to come down the line for community hospitals.”
The clinical maps also give a hospital’s doctors a concise, timely way to see what treatments each patient is expected to undergo, even if the doctors on call are not the attending physicians.
“They all had, in the past, their ways of practicing,” Ingram said of Saddleback’s 550 doctors. “Now this becomes a collaborative group practice.”
Saddleback appears to be ahead of the pack in Orange County in developing a comprehensive clinical pathways system.
The hospital’s clinical maps, still in the testing phase in areas such as cardiology and orthopedics, are expected to be refined further and introduced as a full-scale system in November. By then, 70% of all procedures conducted at the hospital will be standardized, Ingram said.
The Saddleback system was developed by doctors and nursing staff members working together to draft several possibilities for each procedure until they agreed on the best and safest treatment. The result was a series of menu-like charts that are hung on the walls outside patients’ rooms.
For patients such as Welsh, hospital stays are reduced by as much as 50%, partly because there are fewer delays in ordering postoperative treatments: Charts stating what time of day certain procedures are expected are posted for all hospital and medical staff to peruse.
The orthopedic clinical map, for instance, shows from Day One what consultations, tests, treatments, medication and nutrition the patient should undergo.
By the end of the fifth day, the patient is either discharged according to a set of so-called discharge outcome criteria; sent to skilled nursing centers; or given home health-care services.
But clinical pathways take other forms.
Valley Presbyterian’s Lang said that one hospital uses chalkboards set up in patients’ rooms: Doctors write in the prescribed treatments and the days they are to be performed.
Sharon Silow-Carroll, a health care policy analyst with the Economic and Social Research Institute in Washington, said that virtually every hospital in the United States is at least considering clinical pathways.
She joined other experts, however, in warning that clinical pathways may be a fad and that there is no hard evidence yet that patients receive better care or that clinical pathways are truly cost-effective.
“I think in some ways they are being oversold,” Silow-Carroll said of the new systems. “We have to be careful. If the goal is just to cut costs, there can be real concerns” about patients receiving adequate care.
Rick Hicks, assistant administrator at Fountain Valley Regional Hospital and Medical Center, agreed that there can be drawbacks to clinical pathways. Though his hospital is also using them to some extent, Hicks said, not all procedures are best handled that way.
In some areas, medicine is still an art as much as a science, Hicks said, and doctors of some specialties need the leeway to offer customized treatments if they think those would be best for patients, especially those with complications.
“That is the central issue of this theme,” Hicks said. “You can get carried away with the process.”
That said, however, he supports clinical pathways in some areas, such as orthopedic and open-heart surgeries: “There are enough commonalities in some patients that one can establish fairly tight treatment protocols.”
“Basically, if you replace a hip or a knee, as long as you don’t have (other) substantial health problems, people will react the same way,” Hicks said.
Welsh was just such a candidate for Saddleback Hospital’s clinical map system, Dr. Farrell said.
Checking Welsh’s chart on the wall outside her room, Farrell noted that all her vital signs corresponded with the discharge outcome criteria on her clinical map. “She’s done real well,” he said.
Inside his patient’s room, Farrell spoke softly to her, asking how she felt and explaining that she would be transferred to the skilled nursing center within a day.
Welsh smiled, allowing her humor to overshadow her obvious discomfort.
“Well, that’s good,” she said. “Maybe I’ll get there in time for the line dance.”
Clinical ‘Maps’ Improve Efficiency
By mapping out patient care from start to finish, Saddleback Memorial Medical Center’s orthopedic surgical unit is able to keep patients informed and shorten hospital stays. How a clinical map for a total hip replacement surgery is used: Planning group meets: Care manager, physicians, physical therapists, dietitians and nurses meet to discuss procedures for a typical total hip replacement surgery, including patient education and postoperative care.
Itinerary drawn up: Outlines each day’s tests, exercises and medications. Seminar before surgery: Patients are given a copy of their clinical map translated into layman’s terms. Information is gathered from each patient on what type of equipment, training or special services are required after discharge. For example, a patient who lives in a two-story house will need physical therapy training on how to go up and down steps before they go home.
After surgery: Patients consult clinical map to know when catheters or oxygen will be removed, dressings changed and when physical therapy will begin. Patients who participate actively in their own care tend to progress faster and leave the hospital better prepared. Source: Saddleback Memorial Medical Center; Researched by JANICE L. JONES / Los Angeles Times
