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