Critical pathway of care,concept mapping by Velveena M

Critical pathways of care (CPCs): used as the tools for provision of care in a case management system.
It brings together all the professional groups involved in patient care
to arrive at a consensus about standards of care and expected outcomes for selected patient groups.

1. Critical pathway of care Prsesnted by m.Velveena Msc nursing 1 st year con/, aiims,bbsr

2. INTRODUCTION Critical pathways of care (CPCs): used as the tools for provision of care in a case management system. It brings together all the professional groups involved in patient care to arrive at a consensus about standards of care and expected outcomes for selected patient groups.

3. Contd.. It is anticipated care placed in an appropriate time frame , written and agreed by a multi-disciplinary team -Welsh National Leadership and Innovation Agency for Health care(2005) A bbreviated plan of care that provides outcome-based guidelines for goal achievement within a designated length of stay.

4. CP Concept:

5. Goals of critical pathway

6. Goals of critical pathway

7. Critical pathway development Select a topic Topic selection in general should concentrate on high volume, high cost diagnosis and procedures.

8. Select a CPC Team

9. CPC Team The team decides what categories of care are to be performed, by what date, and by whom. Each member of the team is then expected to carry out his or her functions according to the time line designated on the CPC. The nurse, as case manager, is ultimately responsible for ensuring that each of the assignments is carried out. If variations occur at any time in any of the categories of care, rationale must be documented in the progress notes.

10. CPC Team Each member of the team stays in contact with the nurse case manager regarding individual assignments. Ideally, team meetings are held daily or every other day to review progress and modify the plan as required. CPCs can be standardized, as they are intended to be used with uncomplicated cases. A CPC can be viewed as protocol for various clients with problems for which a designated outcome can be predicted.

11. Contd.. Evaluate the current process of care In this step, data, rather than anecdotal records are key to understand current variation. For systems with electronic medical records, this process may be more automated. For other systems, a careful review of medical records is necessary to identify outcomes. Evaluate medical evidence and external practices After key rate-limiting steps have been identified, the critical pathway team must evaluate the literature to identify evidence of best practices. For most rate-limiting steps, there are few data available to define optimal processes of care. Determining the critical pathways format

12. HOW CPC IS CARRIED OUT The nurse contacts psychiatrists to inform him or her of the admission

13. HOW CPC IS CARRIED OUT The psychiatrist performs additional assessments to determine if other consultations are required Within 24 hours, the interdisciplinary team meets to decide on other categories of care Completion of the CPC, and make individual care assignments from the CPC Each member of the team stays in contact with the nurse case manager regarding individual assignments. Ideally team meetings are held daily or every other day

14. CHARACTERISTICS OF CPC

15. VARIANCES: A variance is defined as an unexpected client response that “falls off” the pathway, requiring separate documentation and further investigation by the interdisciplinary team. When there is a discrepancy between expected and actual events on a CP this is known as variance from the pathway. This is the only care documentation that should be carried out with a consequent substantial saving in time . The time thus freed up from writing down routine material for every patient can then be devoted to dealing with individual problems or variances .

16. CAUSES OF PATHWAY VARIANCE • Client or family • Caregivers • Hospital • Community •Payer(including insurance companies, health maintenance organizations, or managed care organizations) A simple procedure is to underline or circle the relevant piece of the CP and mark it ‘V1’ ‘V2’, etc. . while maintaining a record on a separate sheet of what happened in each case.

17. Contd.. Document and analyze variance Variances are patient outcomes or staff actions that do not meet the expectation of the pathway. In general, variance in clinical pathways is a result of the omission of an action or the performance of an action at an inappropriate (often, a late) time period. Because the critical pathway is a series of time-associated actions, this analysis of variance can be overwhelmed by multiple data points.

18. BASELINE FOR A WRITING A CRITICAL PATHWAY AREA OF CARE DAY 1 DAY 2 DAY3 Assessments and consultations       Tests       Treatments       Medications       Diet       Activity       Teaching       Discharge plans      

19. Care is plotted in terms of: X Axis- Time Y Axis: Various areas of care The multidisciplinary team agrees in advance what should be happening for each area of care at each day on the pathway. 1. Process: What should be done and when 2. Outcomes: What the patient should achieve at set times A key step in writing a pathway is to decide the length of the pathway first and then work backwards in time from the end-point .

20. BASIC QUESTIONS: 1.What does each discipline require in terms of patient outcomes 2. What is the best way of achieving these outcomes 3. Who should be accountable for seeing that the outcomes are achieved 4. How does care need to be restructured to meet the requirements of the first three questions The CP forms a guide to care delivery and expected outcomes

21. COMPONENTS OF A CRITICAL PATHWAY: Variance record

22. TECHNIQUES OF CRITICAL PATHWAY

23. CRITICAL PATHWAY OF CARE FOR CLIENT IN ALCOHOL WITHDRAWAL ESTIMATED LENGTH OF STAY : 7Days NURSING DIAGNOSIS : Risk of Injury related to CNS agitation OUTCOME : Client shows no evidence of injury obtained during alcohol withdrawal.

24.   DAY 1 DAY 2 DAY 3 DAY 4 DAY 5 DAY 6 DAY 7 Referrals Psychiatrist Assess need for : Neurologist Cardiologist Internist           Discharge with follow up appointments required Diagnostic studies Blood alcohol level Drug screen(urine and blood) Chemistry profile Urinalysis Chest X-Ray ECG     Repeat of selected diagnostic studies as necessary      

25. Additional assessments Vital signs q4h I&O Restraints p.r.n. for client safety Assess withdrawal symptoms : Tremors , nausea/vomiting/tachycardia, sweating ,high blood pressure , seizures, insomnia, hallucinations. Vital signs q8h if stable I&O Restraints p.r.n. for client safety Assess withdrawal symptoms : Tremors , nausea/vomiting/tachycardia, sweating ,high blood pressure , seizures, insomnia, hallucinations.   Vital signs q8h if stable I&O Restraints p.r.n. for client safety Assess withdrawal symptoms : Tremors , nausea/vomiting/tachycardia, sweating ,high blood pressure , seizures, insomnia, hallucinations.   I&O VS bid;remain stable Restraints p.r.n. for client safety Assess withdrawal symptoms : Tremors , nausea/vomiting/tachycardia, sweating ,high blood pressure , seizures, insomnia, hallucinations Marked decrease in objective withdrawal symptoms. I&O VS bid;remain stable Restraints p.r.n. for client safety Assess withdrawal symptoms : Tremors , nausea/vomiting/tachycardia, sweating ,high blood pressure , seizures, insomnia, hallucinations DC I&O VS bid;remain stable Restraints p.r.n. for client safety Assess withdrawal symptoms : Tremors , nausea/vomiting/tachycardia, sweating ,high blood pressure , seizures, insomnia, hallucinations. VS bid;remain stable Restraints p.r.n. for client safety Assess withdrawal symptoms : Tremors , nausea/vomiting/tachycardia, sweating ,high blood pressure , seizures, insomnia, hallucinations Discharge ; absence of objective withdrawal symptoms.   DAY 1 DAY 2 DAY 3 DAY 4 DAY 5 DAY 6 DAY 7

26. Medications Librium * 200mg in divided doses Librium p.r.n. Maalox pc&hs *Note : Some physicians may elect use Serax or Tegretol in the detoxification process. Librium p.r.n. Maalox pc&hs Librium 160mg in divided doses. Librium p.r.n. Maalox pc&hs Librium 120mg in divided doses. Librium p.r.n. Maalox pc&hs Librium * 80mg in divided doses.. Librium p.r.n. Maalox pc&hs Librium 40mg Librium p.r.n. Maalox pc&hs Discontinue Librium Maalox pc&hs Discharge; no withdrawal symptoms. Client Education     Discuss goals of AA and need for outpatient therapy Discharge with information regarding AA attendance or outpatient treatment                   DAY 1 DAY 2 DAY 3 DAY 4 DAY 5 DAY 6 DAY 7

27. PROBLEMS OF CPC:

28. STEPS IN INTRODUCING A CP: 1. Identify a group of patients with a common health problem or to undergo a specific medical intervention. There should be reasonably predictable series of events for majority of patients in the group. 2. Convene a multidisciplinary team meeting to secure the agreement of all parties. 3. Set the time line be agreeing the length of the CP and work backwards from the agreed end- point.

29. STEPS IN INTRODUCING A CP: 4. Write the necessary interventions and desired outcomes for each hour/ day/ week of the CP. 5. Decide how variances will be monitored, recorded and actioned together with who will have accountability for the management of variances. 6.Make changes to care and amend the CP as needed.

30. BENEFITS OF CPC • Support the introduction of evidence-based medicine and use of clinical guidelines • Support clinical effectiveness, risk management and clinical audit • Improve multidisciplinary communication, team work and care planning • Can support continuity and co-ordination of care • Provide explicit and well-defined standards of care

31. Contd.. • Help to improve clinical outcomes • Ensure quality of care and provide a means of continuous quality improvement • Help to improve communication between different care sectors • Disseminate accepted standards of care • Provide baseline for future initiative • Reduce costs by shortening hospital stays

32. DEMERITS OF CPC • Adaptability-on complicated case CPC becomes large and detailed, cumbersome and ineffective • Crash action-changes from scheduled plan in a timeline, crash action involving reprioritizing each step • Resource allocation-when resource don’t match CPC map, CPC begins to unravel

33. DISADVANTAGES Differences between unique patients. Overburdened with administrative cost. Problems of introduction of new technology. Require commitment from staff and establishment of an adequate organizational structure. May take time to be accepted in the workplace. Need to ensure variance and outcomes are properly recorded, audited and acted upon.

34. ROLE AS NURSE MANAGER Assess quality improvement. Effective planning. Evaluate quality. Interdepartmental Communication . Educating the staff of other departments about the pathway role and responsibilities. Provides patient care. Follow critical pathway and note any deviation in care.

35. Concept mapping

36. introduction Concept mapping is a diagrammatic teaching and learning strategy that allows students and faculty to visualize interrelationships between medical diagnoses, nursing diagnoses, assessment data, and treatments. The concept map care plan is an innovative approach to planning and organizing nursing care. Basically, it is a diagram of client problems and interventions. Compared to the commonly used column format care plans, concept map care plans are more succinct. 37 presentation title

37. Contd.. They are practical, realistic, and time saving, and they serve to enhance critical-thinking skills and clinical reasoning ability The nursing process is foundational to developing and using the concept map care plan, just as it is with all types of nursing care plans. Client data are collected and analyzed , nursing diagnoses are formulated, outcome criteria are identified, nursing actions are planned and implemented, and the success of the interventions in meeting the outcome criteria is evaluated. 38 presentation title

38. Contd.. The concept map care plan may be presented in its entirety on one page, or the assessment data and nursing diagnoses may appear in diagram format on one page, with outcomes, interventions, and evaluation written on a second page. In addition, the diagram may appear in circular format, with nursing diagnoses and interventions branching off the “client” in the center of the diagram. Or, it may begin with the “client” at the top of the diagram, with branches emanating in a linear fashion downward. 39 presentation title

39. contd ,.. A line between the nursing diagnoses should be drawn to show the relationship. Concept map care plans allow for a great deal of creativity on the part of the user, and permit viewing the “whole picture” without generating a great deal of paperwork. Because they reflect the steps of the nursing process, concept map care plans also are valuable guides for documentation of client care. 40 presentation title

40. 41 presentation title

41. Conclusion Critical care in psychiatric nursing refers to providing specialized nursing care to individuals with severe mental illness who require immediate medical attention due to life-threatening conditions such as suicidal ideation, self-harm, or substance abuse. The nursing process in critical care involves rapid assessment, diagnosis, and treatment to prevent deterioration and promote recovery. 42 presentation title

42. JOURNAL REFERENCE The use of critical pathways in caring for schizophrenic patients in a mental hospital Abstract To provide quality health care and at the same time, to control cost, literature suggests that using critical pathways as a tool can enhance resource management, increase collaborative practice, and benefit patient care. This study describes the processes of developing a critical pathway in caring for schizophrenic patients in a mental hospital in Hong Kong. The perceived benefits and difficulties in using the critical pathway are discussed from a nursing perspective . Nurses believed that the use of critical pathways could improve the coordination and effectiveness of care. Also, nurses' autonomy and professional status improved. However, inadequate knowledge and resistance from other disciplines were barriers to the implementation. Recommendations are given to overcome the barriers. 43 presentation title

43. References Townsend M. C., Morgan K. I. (2020), Psychiatric Mental Health Nursing Concepts of Care in Evidence-Based Practice (Ninth Indian Edition), Jaypee Brothers Medical Publishers (P) Ltd, Page no: 147-54. Sreevani R. (2016), A Guide to Mental Health & Psychiatric Nursing (4th Edition), Jaypee: The Health Sciences Publisher, New Delhi, Page no: 104-106. https://www.scribd.com. 44 presentation title