Clinical pathways are tools of coordinated care that use a team approach to move patients toward goals by optimizing resources. Heart failure is a condition that follows a predictable clinical course when given recommended care. Better outcomes are thought to arise from sequencing best practices over shorter hospital stays and incorporating communication and decision making that includes team members, patients and families. Documentation, monitoring, and evaluation of variances and outcomes are guided by checklists or fill-ins.
Expected Outcomes
The initial goals at admission to the hospital for heart failure include increased urinary output and decreased fluid in the lungs. As excess fluid leaves the body, lung fields will clear and the patient gradually requires less oxygen and respiratory support. With relief of fluid retention, the patient's weight drops and swelling in lower extremities goes down. Such improvements, along with daily dietary sodium allowance and other relevant nutritional information, are documented on the clinical pathway.
Tests and Treatments
A heart failure clinical pathway lists expected procedures with dates and the results of each. The pathway asks for verification of indwelling urinary catheter and guides the decision to discontinue. If the patient is on digitalis, blood thinners or is diabetic, the pathway reminds doctors to order appropriate labwork. Heart failure patients typically have chest X-rays and electrocardiograms such as echocardiograms, which measure how well the heart is pumping. Normal results of an echocardiogram are near 60 percent, and heart failure patients can expect to test at or below 40 percent, according to the Heart Failure Society of America.
Medications
Clinical pathways for heart failure serve to modify physician practices, when necessary. For example, according to a study conducted at Massachusetts General Hospital in Boston, some doctors do not routinely use angiotensin-converting enzyme (ACE) inhibitor drugs to treat heart failure, despite evidence that these medications reduce symptoms and prolong survival. A checklist of appropriate medicines, including commonly prescribed diuretics, potassium and digoxin, prompt physicians to consider other therapies such as ACE inhibitors, and to document any reasons for not using them. The pathway also requires specialists to communicate with the patient's family physician regarding medications.
Activity, Assessment and Education
The pathway provides space to record the patient's allowed activity, vital signs and nursing assessments. Patient and family education begin on admission, if possible, and become an increasingly important task as discharge nears. The patient's readiness to learn is assessed and needs are documented, such as smoking cessation, physical therapy, occupational therapy, dietary restrictions, proper use of medications, home monitoring--including daily weights--and when to call the doctor. Discharge planning may involve a social worker and include the scheduling of follow-up appointments, arranging transportation, home health supplies like oxygen and necessary referrals. The team members performing these functions are prompted to put records in the patient's chart and to forward appropriate paperwork.
References
- American Heart Association: Heart Failure Clinical Pathway
- Heart Failure Society of America: Quick Facts and Questions About Heart Failure
- "Archives of Internal Medicine": National patterns of angiotensin-converting enzyme inhibitor use in congestive heart failure
- "Annals of Internal Medicine": Critical Pathways as a Strategy
- National Guidelines Clearinghouse: Assessing Heart Failure in Long Term Care Facilities
