Pathway for patients admitted witii gastroenteritis to a miiitary iiospitai

Keriy McFadden-Newman, Tony Fenby, jenny Myers Abstract

As part of the Clinical EflFectiveness Programme, a care pathway was developed for use within the isolation facility in a military hospital in Iraq. The development of the care pathway was necessary to provide direction and to standardize the care provided. A care pathway using a structured and planned approach was developed, critically appraised and amended to ensure evidence-based and patient-focused care. This article provides an amended methodology for the development of further pathways suitahle for use within military nursing hased on the standard pathway produced hy De Lue (2002). The production of the pathway and supporting guideline will ensure standardized care for patients admitted vdth gastroenteritis. Key words: Military Nursing n Gastroenteritis Care pathways 7he British Military Hospital based in Southern Iraq provides a range of secondary care facilities. These include medical and surgical inpatient care and physiotherapy for a British military and at times multinational population of 20000 with the most frequent admission type being patients suffering with viral gastroenteritis. As part of ongoing developments to improve processes of clinical governance (CG), a generic care pathway front sheet had been developed with specialist inserts for the three main wards: medical, isolation and surgery. Wright and Hill (2003) state that care pathways are health plans that describe the process of care from admission through to discharge for a particular condition. They also suggest that the process of developing care pathw^ays is just as important as guidelines for care pathway completion. This article describes the development of a care pathway for gastroenteritis and can be used as a template for the future review of other pathways. the development of patient pathways provides a useful tool to integrate the patient's perspective. Serving on operations is a unique environment with a high turnover of medical and nursing staff. This in itself may result in minimal corporate memory and, thus, has the potential to create an unstable care environment, the consequence being that protocols can get lost in the continuity gap and lessons must be relearned. Therefore, the development of pathways in this unique environment can help to ensure the standardization of care. Bryan et al (2002) state that the formation of a care pathway requires the involvement of the multidisciphnary team (MDT). This includes all providers of care (nurses, doctors and allied health professionals) involved in the treatment of the patient group. De Lue (2002) describes an integrated care pathway as locally agreed, multidisciplinary practice, based on guidelines and evidence where available, for a specific patient user group. It forms all or part of the clinical record, documents the care given, and facilitates the evaluation of outcomes for continuous quality improvement. An integrated care pathway would be the first choice, but given a 6-weekly turnover of doctors on deployment it was difficult to gain and lnaintain a consensus within the clinical team. Clinical guidelines are currently being rewritten for use on operations that ^vill ensure a standard treatment plan and, therefore, an integrated care pathway will then be feasible. In the interim it was agreed to develop a nursing care pathway only. A team of three personnel completed the development of the pathw^ay for gastroenteritis with additional staff coopted as required (pathology, pharmacy and Senior House Officer). The additional staff provided advice prior to the first draft of the care pathway and feedback following initial use. Following an extensive review of the literature, the approach taken by De Lue (2002) was adopted although it was modified to suit the environment using a step-by-step
approach {Table 1).

Pathway development
Care pathways are seen by many as a key to developing and integrating CG into every aspect of care through the implementation of protocols into clinical practice (Riley, 1998). Riley demonstrates that pathway development and use is rising within the UK and this is supported by further work demonstrating improved patient outcomes (Johnson et al, 2000). Furthermore, Nemeth et al (1998) also argue that
Captain Kerry McFadden-Newman, Major Tony Fenby and Lieutenant Jenny Myers are Nursing Officers with Queen Alexandra's Royal Army Nursing Corps
Accepted for publication: July 2006

In most areas the initial pathway was unchanged. However, the literature review identified the importance of a protocol to guide the use of the pathway, variance audit, patient focus and use of outcomes to structure the pathway. Therefore, by using the approach in Table 1 the authors were able to revise the pathway and ensure that a protocol to guide the use of the pathway was initiated.

Information gathering
Patient focus was reviewed by analysing patient comments and from discussion with five inpatients prior to discharge.

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The pathway was reviewed individually with each patient explaining what care should be given. Patients were given an opportunity to suggest additions or deletions but they were content with planned care and no notable suggestions for change were made. However, in comparison with other pathways, such as the Acute Gastroenteritis Care Pathway introduced by Airedale NHS Trust (Fisher, 1998) or the Pancreatitis Pathway in use by Brigham and Women's Hospital in Boston (Goldszer et al, 2004), the absence of patient outcomes was noted and the general structure appeared task orientated and unrelated to the patient perspective. The structure of the pathway was then altered to allow for intervention recording and also the directions for care were structured to meet patient outcomes. A hospital-wide review of significant event analyses (SEA) over a 6-month period was undertaken to ensure any lessons learned were incorporated into the pathway. Significantly, there were 23 SEAs reported relating to administration, notably poor completion of patient records, and prolonged patient stay due to discharge planning. These areas are included within the pathway and it is envisaged that the development of the guidance for completion would move towards improving the standard of completion of the documentation. A review of admission criteria and treatment guidelines compiled by the Clinical Director during the deployment to Iraq, gave positive assurance that care planned through the pathway was congruent with both the treatment guidelines and also criteria for clinical investigations. A variances audit of 15 selected pathways demonstrated that there was confusion over the completion of assessment areas with some staff noting values of observations and others noting actions taken following recording. This was useful to identify standards of completion but also areas of repetition and clarity on discharge criteria and processes. Amendments to the pathway were made providing a standard template for these areas thereby creating a more reliable and robust document.

Table 1. Development of a care pathway

Pianning group and information gathering: - Pathway structure and content compared with simiiar pathways avaiiabie through National Electronic Library for Health - Pathway reviewed with patient group - Pathway reviewed against Significant Event Analysis (SEA). SEA or audit has been defined by Pringle et ai (1995) as occurring when individual cases in which there has been a significant occurrence (not necessarily invoiving an undesirable outcome for the patient) are analysed in a systematic and detailed way to ascertain what can be learned about overall quality of care and to indicate changes that might lead to future Improvements. - Pathway reviewed against complaints and protocols/guidelines - Variances audited. Pathway reviewed against Nursing and Midwifery Council (NMC) (Guidelines for Records and Record Keeping) standards for record keeping Review by the MDT Initial process of development was reviewed against guidance and the patient's journey through care (process map) Production of pathway and guideline for use. Source: De Lue (2002) shown in Table 2, thus creating a more organized document while taking into consideration every aspect of patient care including the patient's perspective.

Process mapping
The purpose of process mapping is to critically appraise the process of care/treatment as currently provided by the organization and identify areas for change (De Lue, 2002). It usually involves drawing two process maps. The first process map reflects what actually happens now and the second identifies the changes to be implemented. It is the second process map that will form the framework for the care pathway documentation. The patient journey through the military healthcare system is a simple process of referral via the primary health care or emergency departments, admission to ward, discharge to the patient's employing unit or returned to their home base in the UK. The initial pathway served as the first process map; this was critically reviewed by the MDT, patients and users with discussion of the points raised forming the basis for the final process map, identifying the changes required.

Guidance for the completion of the Care Pathway for patients admitted to Field Hospital with Gastroenteritis AU patients admitted to the Role 3 facility with gastroenteritis will have been assessed by a CMT/MO using the 'criteria for admission document' in use at the Primary Healthcare and Accident and Emergency departments. Once the patient has been brought from the referring department to the Isolation ward, the staff nurse responsible for the care of the patient will initiate and complete the care pathway. This care pathway is a restricted medical document that will be kept in the patient notes. Currendy, due to lack of space and confidentiality the patient notes are kept by the nurses station, however, it is important to remember that the patient should have access to this care pathway at any time should they wish to see it. Completion of document (see Table 3) Patient details - This area should be completed as accurately as possible paying particular attention to the section titled 'Unit (in theatre)'.This should be the unit that the individual is currently serving with while in theatre;

Table 2. Changes to the care pathway for gastroenteritis

Guidance written for completion of the pathway Admission and discharge checklists amended to become specific for patient group Admission assessment changed to specifically request vital sign values and assessment focused on patient group Structure amended to become patient outcome focused Discharge criteria integrated throughout pathway Variance in care section remained, with prompt to include date, time and nurse's initials following each entry Date of development, version number and review date amended to header and footer.

Gastroenteritis care pathway

Following the processes outlined above, changes shown in Table 2 were made to the pathway. By using information gathering and process mapping the pathway was amended as

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we use this information when giving discharge details to the Hospital Management Cell (HMC).The 'Unit location' section should read the location in theatre of the unit they are currently serving with, e.g. Camp 4, SLB; Murphy Lines, SLB;OSB, Basrah. All sections under patient details should be completed and if no information is obtained then please annotate as such (N/A, NR) Signature chart - This section is self explanatory and must be completed by any individual using the care pathway. User initials are requested on the signature chart as initials are used to indicate any entries you may make as a user. Position should read RN (A), HCA, etc.You, as the user, may wish to add your mihtary status also, i.e. NOIC, 2IC. Admission checklist - This is a failsafe checklist and your should complete it correctly, i.e. only tick the box next to the task when actually completed you should not miss any areas of admission. You must initial at the bottom of the checklist when all areas are complete. Admission assessment This assessment contains all areas of clinical management and nursing care/medical care given on admission. The box to the right of the table titled 'Value/comment' is such that you have a choice of what you wish to insert. Should an area under assessment not take place or is not required then this should be annotated as such under comments. Do not leave a box empty, this simply suggests that you did not complete the admission assessment fully. The notes section at the bottom should be used for any variance to care and not to repeat any of the assessment and care given above. An admitting nurse initial is required at the bottom of this box. Discharge checklist - Again, a failsafe checklist and you should complete it correctly, i.e. only tick the box next to the task when actually completed, you should not miss any areas of discharge. You must initial at the bottom of the checklist when all areas are complete. Each new page of the care pathway, i.e. each 24-hour period should have patient details completed at the top under the headings given. Each 24 hours has been segmented into AM, PM and Night for reporting purposes. Care should be reported on at various times of the day and even when on a long day system the nurse providing care for the patient should be assessing care at regular intervals. Clinical assessment - this area aims to give specific prompts to the user to ensure that all clinical care pertinent to the gastroenteritis patient is assessed and the note section is then available for comment on this assessment. All prompts require annotation beside each and if not required then this is what needs to be stated by the prompt. The 'charts commenced' section has fluid balance and stool chart preprinted as these are the two charts each gastroenteritis patient should have on admission. Other charts to be included in this section are vomit, diet, peak flow and BM chart. Outcomes -This section aims to take the user through all patient outcomes within a 24 hour period looking at: Adequate fluid balance and outcomes under this section. Patient tolerating diet and outcomes under this section.

Relief of symptoms such as abdominal cramps, nausea and expected outcomes. Personal needs met including personal hygiene and sleep pattern. Infection control outcomes Discharge criteria. The discharge criteria for a gastroenteritis patient is: Apyrexial Tolerating diet and fluids Formed stool (type 5 or less) passing less than or equal to three times daily. Therefore, all of the above wiH be answered in the care pathway prior to the discharge section. Once the discharge checklist has been fuUy completed the user can then annotate that 'yes' the discharge criteria has been met. This deletes the need for the user to write the discharge summary, i.e. 'patient RTU with 2 days of Hght duties' in the variance of care section. The user will then initial all entries made at the end of the column pertaining to the time of day. The variance in care section should only be used to make entries for any care given beyond that stated in the care pathway and should not duplicate any entries in the care pathway. If any entries are made the user should initial and enter Date,Time and Group after the entry. The care pathway should be easy to use and provide all necessary clinical assessment and outcomes for a gastroenteritis patient.

Summary
The development of the care pathway was necessary to provide direction and standardize care provided within the isolation facility at the British Military Hospital. Using a structured and planned approach the pathway was developed, critically appraised and amended to ensure patient focus was maintained, a high standard of patient care provided, and that the pathway was easily auditable. The methodology utilized for the review was evidence based and provided a rigorous structure that included aU elements of the delivery of care while removing some of the complexity of pathway design. The production of the pathway and supporting guideline for use will ensure standardized care for patients admitted with gastroenteritis. liSfii

Bryan S, Holmes S, Postlethwaite D, Carty N (2002) The role of integrated care pathways in improving the patient experience. Prof Nurse 18(2): 779 De Lue K (2002) The ten-step guide to developing a care pathway. Nurse 2 Nurse. 2(10): 10-2 Fisher A (1998) Care Pathway: Acute Gastroenteritis. National Electronic Library for Health: Protocols and Care Pathways. Available: www.nelh.nhs. uk. Accessed 25 April 2005 Goldszer R C , Rutherford A, Banks P (2004) Implementing cbnica] pathways for patients admitted to a medical service: lessons learned. Critical Pathways in Cardiology 3(1): 3 5 ^ 1 Johnson S, Dracass M, Summers S, Eddington J (2000) Setting standards using integrated care pathways. Prof Nurse 15: 6403 Nenieth L, Hendricks H, Salaway T, Garcia C (1998) Integrating the patient's perspective: patient pathway development across the enterprise. Top Health inf Manage 19(2): 79-87 Nursing and Midwifery Council (2002) Cuidelines for Records and Record Keeping. N M C , London Pringle M, Bradley CP, Carmichael CM et al (1995) Significant Event Auditing. A Study of the Feasibility and Potential of Case-Based Auditing in Primary Medical Care. Occas Pap R Coll Gen Pract (70): i-viii, 1-71 Riley K (1998) Care pathways. Paving the way. Health ServJ 108(5597): 30-1 Wright J, HiU P (2003) Chnical Guidelines in Clinical Governance. Churchill Livingstone, Edinburgh

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Table 3. PATIENT DETAILS SURNAME: RANK: SERVICE NO: DATE OF ADMISSION: PROVISIONAL DIAGNOSIS: SIGNATURE CHART NAME RANK

FORENAME: DOB: M/F: HOSPITAL NO: UNIT (In Theatre) ALLERGIES/SENSITIVITIES RELEVANT MEDICAL HISTORY:

UNIT LOCATION:

NUMBER

SIGNATURE

INITIALS

POSITION

ADMISSION CHECKLIST TASK YES NO All patient details and diagnosis correct, checked with patient Wrist and allergies bands FMED 830, yellow copy to HMC FMED 10 correctly completed Location of weapon/ammo, contact HMC if neccesary Knives/Gerbers handed into ward staff Morphine autojet handed into staff- 1033 given to patient FMED 965 8. ID Tags with patient CBA/Helmet/Respirator/Personal Kit with patient. If not HMC informed of requirements. Patient's own medications accounted for

COMMENT

Welfare facilities explained

Emergency &. Fire procedures/Actions on explained Admissions book completed Ward Bed state/Fire Board completed Inform EHT if food handler or admission significant Hospital standing orders read and signed by patient Gastroenteritis audit completed by patient FMED 85 initiated Admitting Nurse Initials ADMISSION ASSESSMENT Value/Comment Handover adequate Clerked By Dr Temp C BP mmHg Pulse Bpm Resps Rpm SpO2 on Air % Met Score Pain Score (Wessex 0-3) Tolerating oral fluids or IVl in progress Cannula in situ Care discussed with patient (Obtaining specimen. Fluid intake. Charts) Infection control issues discussed - Hand wcishing, Clinical Waste Disposal Full orientation to ward - Ablutions shown INVESTIGATIONS Urinalysis Bloods X Ray ECG Stool checked - Colour, Type, Blood/Mucous present Admitting Nurse Initials DISCHARGE CHECKLIST TASK

If food handler send sample

YES

NO

COMMENT

FMED 11 Correctly completed

FMED 830 - Pink copy to HMC HMC Discharge information FMED 14 and FMED 965 completed Morphine autojet returned to patient - 1033 disposed off Light duties proforma - 2 Days Weapon/Ammo organised for collection through HMC Discharge advice information given to patient TTOs given and explained (If applicable) Discharge book completed All patient documentation and FMED 830 (Green) completed sent to HMC Discharge Nurse Initials

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Table 3. continued. Name Rank Clinical Assessment TPR 8v BP - BD minimum Additional assessment MET/BM/Peak Flow/Pain Clinical Investigations

No A M - NOTES PM - NOTES NIGHT - NOTES

ECG/Bloods/Samples Charts commenced FMED too - Negative/Positive balance Stool chart - Review sample. Note type and Trends Other OUTCOMES Adequate fluid balance maintained Patient passing urine Y/N Rehydration discussed Oral fluids tolerated Y/N If not - cannula inserted Y/N -Date inserted Site checked Y/N IV Fluids commenced Y/N, Rate Patient tolerating diet Tolerating diet - advice given Relief of symptoms Abdominal cramps Anti-spasmodic given Y/N Nausea - anti emetic given Y/N Pyrexia Y/N consider anti pyretic, fan therapy. Personal Needs Met Hygiene needs met (Independent, assisted wash) Visited by welfare officer/padre/unit rep Promote environment conducive to sleep Treatment plan discussed Y/N Infection Control - Reiterate and confirm: Hand hygiene Clinical waste disposal How to take stool and urine samples Discharge criteria Is patient for discharge Y/N Discharge criteria met Y/N Initiais Variance in care - DTG and Initial following each entry

KEY POINTS
I Pathway development is useful to improve clinical effectiveness and consequently patient outcome. I Frequent changeover of clinical staff leads to unstable care environment, which is stabilized through the use of a standardized nursing pathway. IA methodological review of care, with the input from patients was useful in developing a structured pathway. I Process mapping was a useful tool in ensuring the holistic development of the nursing care pathway. Guidance for completion of nursing pathways is essential for audit and standardization.

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