THE VIRGINIAN-PILOT
Copyright (c) 1996, Landmark Communications, Inc.
DATE: Monday, October 7, 1996 TAG: 9610070040
SECTION: FRONT PAGE: A1 EDITION: FINAL
SOURCE: BY DEBRA GORDON, STAFF WRITER
LENGTH: 139 lines
When Sentara Health System examined how stroke victims were treated in its four hospitals, it learned a disturbing fact: Patients' treatment and outcome - even among cases of the same severity - depended on which doctor admitted them. And 144 doctors were admitting stroke patients.
Some patients spent weeks in the hospital. Others just a few days. Some developed complications like pneumonia or ulcers. Others none. But there was no way to share information on what worked best, to answer the question: ``What is the optimum way to treat a stroke?''
So two years ago, Sentara asked a team of people - every person who interacted with a hospitalized stroke victim, from the doctor to the respiratory therapist - to find the answer.
The team reviewed medical records, talked to doctors and combed the scientific literature to learn what worked best when treating strokes.
They took this information and created a kind of ``recipe'' detailing the most effective way to treat a stroke. This outline, called a ``clinical pathway,'' covers every aspect of a stroke patient's care from the emergency room through discharge and beyond. For instance, it recommends:
When doctors should consult with a brain surgeon instead of a neurologist.
What tests to order and when to order them.
When and what kind of medications to give.
It provides standing orders for such things as therapy consultations and routine tests, so nurses don't have to wait for the doctor to order them.
It even reminds the medical staff to explain everything to the patient and family, to contact the chaplain and to discuss spiritual needs.
``Clinical pathways can find out what the best care is and how to give it to everyone, not just one patient,'' said Dr. Armistead D. Williams, a Norfolk neurologist who helped design the stroke pathway. ``It's a systematic way to find problems and fix them.''
Throughout the country, health-care systems are using clinical pathways to improve the way their doctors and other medical staff perform procedures and treat illnesses - everything from heart transplants to delivering babies.
The trend is driven not only by a desire for quality, but by increasing competition as insurance companies and employers search for the best health care buy.
That emphasis on cost frightens some medical professionals.
``Just cutting costs can be detrimental to quality,'' said Lou Hochheiser, vice president of medical management at Tidewater Health Care, parent company of Virginia Beach General Hospital.
``We thought we needed a process, not just reducing the dollars spent.''
So, like most hospitals in the region, three years ago Virginia Beach began examining its high-volume diagnoses, comparing the results it got in such areas as respiratory diseases and orthopedic surgery to those of other national institutions.
Today, it has more than 12 pathways addressing not only hospital care, but also ways to prevent hospitalization in the first place.
One benefit of pathways, said Hochheiser, is that they make it possible to objectively measure care and track improvement.
Using a clinical pathway, Virginia Beach General Hospital shortened hospital stays for asthma patients by 9.3 percent, while decreasing the cost per discharge by more than 8 percent.
In June, six months after Sentara began using its stroke pathway as part of a separate stroke unit staffed with specially trained nurses, data showed that patients on the unit suffered fewer complications, left the hospital sooner and were functioning better upon discharge than stroke victims treated elsewhere in the hospital.
And Children's Hospital of The King's Daughters reduced hospital stays 32 percent for ventricular septal defect surgery - repairing the hole between the two chambers of the heart - using a clinical pathway.
For penny-pinching employers and health plans, reduced lengths of stay translates into lower costs. But for patients, reduced lengths of stay translate into lower risks of contracting hospital-borne infections, and faster recoveries.
Clinical pathways bring another advantage to the patient - more information.
``It's making sure (patients) understand what's going on, that they're part of the process and invested in their own care,'' Williams said. ``That makes people feel better; they're more likely to commit to things they know.''
Clinical pathways revolve around information, both for the patient and the doctor. Using sophisticated data collection and analysis, hospitals and other health-care agencies compare the way doctors treat patients with the same diagnoses.
Such reports, for instance, might show that one doctor orders five X-rays for pneumonia patients, while another orders only two. Yet the second doctor's patients do just as well or better than the first.
The clinical pathway, then, might recommend only two X-rays.
The challenge, however, is convincing doctors that this is not ``cookbook medicine.''
``Physicians were trained to be absolutely self-reliant, independent practitioners, and whatever you think is right, is right,'' said Dr. Stuart Baker, vice president and chief medical officer for Sentara Health System. This training, he said, gave the concept of standardization a bad image.
But pathways' proponents stress that the protocols are only tools.
With the stroke pathway, for instance, it is still the doctor who decides whether to treat the patient with blood thinners. Once the decision to use blood thinners is made, then a specific pathway is available detailing how to use them and what complications to watch for.
Even resistant doctors are converting, Hochheiser said. ``Doctors know they have to change. Most physicians like to see themselves held up as high-quality.''
Dr. David Blais is one convert. The Norfolk internist was skeptical three years ago when Sentara asked him to design one of its first clinical pathways. ``I thought, `What if we spend all this time on it and at the end, we look at the data and can't see any difference?' ''
But after three years of study and a year of use, the pneumonia pathway he helped develop is showing results. Deaths from the disease have dropped from 12 percent to 9 percent at the three Sentara hospitals using the pathway.
``We did a better job with sicker patients,'' Blais said. ``Which is like a dream come true.''
The pneumonia pathway team realized that many doctors were still treating pneumonia with penicillin, even though most pneumonia bacteria are resistant to the drug. The longer it took to find the right drug, the more entrenched the infection became, with some patients winding up on ventilators.
The pathway recommends using broad-spectrum antibiotics immediately to treat most pneumonias. It also avoided antibiotics known to cause kidney damage, eliminating kidney problems among pneumonia patients on the pathway, Blais said.
Pathways are not limited to the hospital setting.
Sentara Medical Group, composed of 126 doctors, implemented a pathway for urinary tract infections a year ago, which has made Chesapeake resident Betty L. Stevenson's life much easier.
Stevenson, 48, develops these painful infections two or three times a year. Each time, she would have to take off work, see a doctor, get her urine tested and take antibiotics for seven to 10 days, often ending up with a vaginal yeast infection as a result of the medication.
But under the pathway, implemented a year ago, she just calls her doctor's office and, over the phone, answers a list of questions from the nurse, who then gets the doctor to call in a prescription for three days of antibiotics.
``I love it,'' Stevenson said. ``In three days (the infection) was completely gone.'' And, because she was on antibiotics for less time, she didn't get a yeast infection.
The measurable results are also impressive: Of 908 patients treated for urinary tract infections using the new pathway, the cost of treatment dropped from $90 an episode to $20 an episode, Baker said, while the number of patients who needed to be retreated dropped from 12 percent to 2 percent. ILLUSTRATION: [Color Photo]
VICKI CRONIS
The Virginian-Pilot
Dr. Armistead D. Williams helped design a pathway detailing the most
effective way to treat a stroke. by CNB