HOW TO USE THE CLINICAL PATHWAY

Transcription

1 Grey Bruce Health Network TOTAL HIP REPLACEMENT CLINICAL PATHWAY SITE: GBHS - Owen Sound PATIENT ID. 2. INCLUSION CRITERIA: All patients admitted for an ELECTIVE total hip replacement procedure. HOW TO USE THE CLINICAL PATHWAY This is a proactive tool to avoid delays in treatment and discharge. These are not orders, only a guide to usual orders. Place the Clinical Pathway in the nurses clinical area of the chart. All health care professionals should fill in the master signature sheet at the front of the Pathway. Addressograph/sticker each page of the Pathway, except for the Variance Record PHYSICIANS: Add or delete tasks according to individual patient complexity, and initial all changes. HEALTH CARE PROFESSIONALS: Initial tasks as completed. Place N/A and initial any box where the task is not applicable to the patient. Additional tasks due to patient individuality can be added to the pathway in OTHER boxes and/or Progress Notes. 5. Please indicate any variances to Indicators on the Variance Record. POSITION NAME (Please Print) INITIAL SIGNATURE NURSING CLINICAL NUTRITION OT PT DISCHARGE PLANNING CCAC OTHER (SPECIFY)

2 POSITION NAME (Please Print) INITIAL SIGNATURE NURSING CLINICAL NUTRITION OT PT DISCHARGE PLANNING CCAC OTHER (SPECIFY) All rights reserved. No part of this document may be reproduced or transmitted, in any form or by any means, without the prior permission of the copyright owner. 2

3 Grey Bruce Health Network TOTAL HIP REPLACEMENT CLINICAL PATHWAY SITE: GBHS - Owen Sound COMORBID CONDITIONS: PATIENT ID PROCESS PRE-ADMISSION PERFORMANCE INDICATOR PHYSIO VISIT Record as "Met" or "Not Met" on Variance Record VITAL SIGNS WITH O 2 SATS: BP ASSESSMENT (OBSERVATIONS/ MEASUREMENTS/ ELIMINATION) HEIGHT AND WEIGHT REVIEW PRE-ANAESTHETIC QUESTIONNAIRE COMPLETE NURSING HISTORY CONSENT SIGNED BY PATIENT START PRE-OP CHECKLIST INTERNAL MEDICINE CONSULTS ANESTHESIOLOGIST PHYSIO CLINIC CCAC IF REQUIRED (SEE BLAYLOCK DISCHARGE PLANNING RISK ASSESSMENT SCREEN) ECG DIAGNOSTICS/ LABORATORY CBC, Na, Cl, K, CROSSMATCH G&S, URINE C&S CHEST X-RAY REVIEW PCA VIDEO AND PAMPHLET MEDICATIONS INSTRUCT PATIENT TO REVIEW MED NEEDS WITH PHYSICIAN PATIENT ON ANTI-COAGULANT THERAPY 3

4 PROCESS PRE-ADMISSION TREATMENTS/ INTERVENTIONS NUTRITION MOBILITY/ACTIVITY PSYCHOSOCIAL SUPPORT/ EDUCATION DISCHARGE PLANNING REVIEW CLOTHING REQUIREMENTS REVIEW USE OF BEDPAN, URINAL, CATHETER SPECIFIC INSTRUCTIONS BY SURGEON OR INTERNIST REVIEW PRE-OP INSTRUCTIONS RE: DIET, NPO ATTEND PHYSIO CLASS ATTEND OT CLASS REVIEW TOTAL HIP REPLACEMENT INFORMATION PACKAGE COMPLETE LOWER EXTREMITY FUNCTIONAL SCALE (LEFS) AND PUT SCORE ON VARIANCE RECORD DISCHARGE SUMMARY SHOWER PRIOR TO COMING TO HOSPITAL REVIEW SURGICAL INFORMATION BOOKLET AND VIDEO: DEEP BREATHING AND COUGHING, CALF PUMPING, ETC. REVIEW HOME SUPPORT HOSPITAL POLICY RE: DISCHARGE TIME DISCHARGE PLANS DISCUSSED WITH PATIENT COMPLETE BLAYLOCK DISCHARGE PLANNING RISK ASSESSMENT SCREEN 4

5 Grey Bruce Health Network TOTAL HIP REPLACEMENT CLINICAL PATHWAY Lower Extremity Functional Scale SITE: GBHS - Owen Sound Today, do you, or would you have any difficulty at all with: Extreme Difficulty/ Unable to Perform Activity Quite a bit of Difficulty PATIENT ID We are interested in knowing whether you are having any difficulty at all with the activities listed below because of your lower limb problem for which you are currently seeking attention. Please provide an answer for EACH activity. (Circle one number on each line) Moderate Difficulty A little bit of Difficulty No Difficulty Activities Any of your usual work, housework or school activities Your usual hobbies, recreational or sporting activities Getting into or out of the bath Walking between rooms Putting on your shoes or socks Squatting Lifting an object, like a bag of groceries from the floor Performing light activities around your home Performing heavy activities around your home Getting into or out of a car Walking 2 blocks Walking a mile Going up or down 0 stairs (about 3 flight of stairs) Standing for hour Sitting for hour Running on even ground Running on uneven ground Making sharp turns while running 8 fast Hopping Rolling over in bed Column Totals Total Score /80 Goal - score of 50 by discharge from services 5

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7 Grey Bruce Health Network TOTAL HIP REPLACEMENT CLINICAL PATHWAY Blaylock Discharge Planning Risk Assessment Screen SITE: GBHS - Owen Sound PATIENT ID Circle all that apply and total. Refer to scoring index for recommendations regarding discharge planning. Age Living Situation/Social Support Number of Previous Admissions/ Emergency Room Visits Number of Active Medical Problems 55 years or less Independent in activities of daily living and 0 0 instrumental activities of daily living years Dependent in: years 2 Eating/Feeding 80+ years 3 Bathing/Grooming Lives only with spouse Lives with family Lives alone with family support Lives alone with friend's support Lives alone with no support Nursing home/residential care 0 Toileting Transferring 2 Functional Status Incontinent of bowel function 3 Incontinent of bladder function 4 Meal Preparation 5 Responsible for own medication administration None in the last 3 months 0 Handling own finances One in the last 3 months Grocery Shopping Two in the last 3 months 2 Transportation More than two in the last 3 months 3 Appropriate 0 Up to three medical problems 0 Wandering Three to five medical problems Behaviour Pattern Agitated More than five medical problems 2 Confused Fewer than three drugs 0 Other Number of Drugs Three to five drugs Ambulatory 0 Cognition More than five drugs Oriented Disoriented to some spheres (person, place, self, time) some of the time Disoriented to some spheres (person, place, self, time) all of the time Disoriented to all spheres (person, place, self, time) and some of the time Disoriented to all spheres (person, place, self, time) all of the time Comatose 2 Ambulatory with mechanical assistance 0 Mobility Ambulatory with human assistance 2 Nonambulatory 3 None 2 0 Sensory Deficits Visual or hearing deficits 3 4 Visual and hearing deficits 2 5 Total Score: Signature: Date: Scoring Index >20 Probable outpatient physiotherapy or occupational therapy follow up, refer to Discharge Planner May require CCAC services, refer to Case Manager May require alternative level of care, refer to Discharge Planner 7

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9 Grey Bruce Health Network TOTAL HIP REPLACEMENT CLINICAL PATHWAY SITE: GBHS - Owen Sound PATIENT ID PROCESS PRE-OP ADMISSION/DAY OF SURGERY CERNER ORDER ASSESSMENT (OBSERVATIONS/ MEASUREMENTS/ ELIMINATION) CONSULTS DIAGNOSTICS/ LABORATORY MEDICATIONS TREATMENTS/ INTERVENTIONS NUTRITION MOBILITY/ACTIVITY PSYCHOSOCIAL SUPPORT/ EDUCATION DISCHARGE PLANNING TOTAL HIP REPLACEMENT PATHWAY VITAL SIGNS WITH O 2 SATS: TPR & BP COMPLETE PRE-OP ORDERS (I.E. SCRUBS, SHAVES) MEASURE FOR TED STOCKINGS AND SEND TO PACU REVIEW CHART FOR LAB WORK, ECG & X-RAY ORDERS COMPLETE PRE-OP CHECKLIST COMPLETE ANY PRE-OP BLOOD WORK OR TESTS ORDERED (I.E. FBS) REVIEW MEDS TAKEN USING NURSING HISTORY PRE-OP MEDS MRSA & VRE SWAB (NARES AND RECTUM) NPO AS ORDERED CLEAR FLUIDS UNTIL 0800 (IF SURGERY IN PM) TO OR: WALK STRETCHER MONITOR ANXIETY LEVEL FAMILY INSTRUCTED RE: SURGICAL WAITING AREA PLANS FOR DISCHARGE DISCUSSED WITH FAMILY 9

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11 Grey Bruce Health Network TOTAL HIP REPLACEMENT CLINICAL PATHWAY SITE: GBHS - Owen Sound PATIENT ID PROCESS POST-OP DAY OF SURGERY ASSESSMENT (OBSERVATIONS/ MEASUREMENTS/ ELIMINATION) CONSULTS DIAGNOSTICS/ LABORATORY VITAL SIGNS WITH O 2 SATS: Q4H ASSESS DRESSING MONITOR INTAKE / OUTPUT FOLEY CATHETER PRN INTERNAL MEDICINE IF REQUIRED PHYSIO BLOOD WORK AS ORDERED PCA AS ORDERED MEDICATIONS ANCEF GIVEN IN OR SEE MAR SHEET IV AS ORDERED SUPPLEMENTARY O 2 AS PER PROTOCOL EMPTY DRAIN Q SHIFT AND PRN TREATMENTS/ INTERVENTIONS CIRCULATION / SENSATION / MOTION Q4H APPLY TED STOCKINGS IN PACU BED BATH NUTRITION MOBILITY/ACTIVITY SIPS - REGULAR DIET SIPS - SPECIAL DIET: BED REST POSITIONING Q2-4H WITH PILLOW BETWEEN LEGS OVERHEAD TRAPEZE

12 PROCESS POST-OP DAY OF SURGERY REVIEW PCA PSYCHOSOCIAL SUPPORT/ EDUCATION ORIENTATION TO UNIT COMPLETE NURSING HISTORY WITH BRADEN RISK ASSESSMENT TOOL IF NECESSARY POST-OP NEEDS DEEP BREATHING & COUGHING, CALF PUMPING REVIEW HIP PRECAUTIONS DISCHARGE PLANNING ESTIMATED OF DISCHARGE AND DESTINATION KNOWN AND DOCUMENTED ON PROGRESS NOTES 2

13 Grey Bruce Health Network TOTAL HIP REPLACEMENT CLINICAL PATHWAY Braden Risk Assessment SITE: GBHS - Owen Sound PATIENT ID SCORING (Key on Reverse) RISK FACTOR SCORE Sensory Perception: Ability to respond meaningfully to pressure related discomfort Completely Limited Very Limited Slightly Limited No Impairment Moisture: Degree to which skin is exposed to moisture Constantly Moist Often Moist Occasionally Moist Rarely Moist Activity: Degree of Physical Activity Bedfast Chair Fast Walks Occasionally Walks Frequently Mobility: Ability to change and control body position Completely Immobile Very Limited Slightly Limited No Limitations Nutrition: Usual food intake pattern Friction and Sheer Very Poor Problem Probably Inadequate Potential Problem Adequate Excellent No Apparent Problem TOTAL SCORE NURSE S INITIALS Nursing Intervention: Once you have assessed the patient and identified a risk category (high, moderate, or low), carry out the following interventions for the patient's risk category. LOW RISK (SCORE > 5) MODERATE RISK (SCORE 3-4) HIGH RISK (SCORE < 2) Ongoing assessment for change in status related to any of the six risk areas Initiate and document plan of care on Kardex and Unit specific Progress Notes including: Includes Moderate Risk Intervention plus requested referral to: Document reassessment weekly on Kardex -Activity level (i.e. turning, positioning) -Continence management -Monitoring of pressure point areas -Monitor nutritional status -Skin care tools used: prevention mattresses or treatment (i.e. air mattresses), creams, bed hoop, trapeze, dressings -Patient education re: prevention -Physiotherapy -Occupational Therapy -Dietitian 3

14 RISK FACTOR Sensory Perception Ability to respond meaningfully to pressure related discomfort. Completely Limited Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level or consciousness or sedation. OR Limited ability to feel pain over most of body surface. 2. Very Limited Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness. OR Has a sensory impairment, which limits the ability to feel pain or discomfort over /2 of body. SCORE/DESCRIPTION 3. Slightly Limited Responds to verbal commands but cannot always communicate discomfort or need to be turned. OR Has some sensory Impairment, which limits ability to feel pain or discomfort in or 2 extremities. 4. No Impairment Responds to verbal commands. Has no sensory deficit, which would limit ability to feel or voice pain or discomfort. Moisture Degree to which skin is exposed to moisture Activity Degree of physical activity. Constantly Moist 2. Often Moist Skin is kept moist almost Skin is often, but not constantly by perspiration, always moist. Linen must be urine, etc. Dampness is changed at least once a shift. detected every time patient is moved or turned.. Bedfast Confined to a bed. 2. Chair Fast Ability to walk severely limited or nonexistent. Cannot bear own weight and/or must be assisted into chair or wheelchair. 3. Occasionally Moist Skin is occasionally moist, requiring an extra linen change approximately once a day. 3. Walks Occasionally Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair. 4. Rarely Moist Skin is usually dry, linen only requires changing at routine intervals. 4. Walks Frequently Walks outside the room at least twice a day and inside room at least once every two hours during waking hours. Mobility Ability to change and control body position. Completely Immobile Does not make even slight changes in body or extremity position without assistance. 2. Very Limited Makes occasional slight changes in body or extremity position, but unable to make frequent or significant changes independently. 3. Slightly Limited Makes frequent, though slight changes in body or extremity position independently. 4. No Limitations Makes major and frequent changes in position without assistance. Nutrition. Very Poor Never eats a complete meal. Rarely eats more than /3 of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement. OR Is on NPO and/or maintained on clear fluids or IV for more than 5 days. 2. Probably Inadequate Rarely eats a complete meal and generally eats only about /2 of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement. OR Receives less than optimum amount of liquid diet or tube feeding. 3. Adequate 4. Excellent Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products) each day. Occasionally, will refuse a meal, but will usually take a supplement if offered. OR Is on a tube feeding or TPN (Total Parenteral Nutrition) regimen, which probably meets most of nutritional needs. Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation. Friction and Shear. Problem 2. Potential Problem Requires moderate to Moves feebly or requires maximum assistance in minimum assistance. moving. Complete lifting During a move, skin without sliding against sheets probably slides to some is impossible. extent against sheets, chair, Frequently slides down in bed restraints or other devices. or chair, requiring Maintains relatively good frequent repositioning with position in chair or bed most maximum assistance. of the time, but occasionally Spasticity, contractures or slides down. agitation leads to almost constant friction. 3. No Apparent Problem Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair at all times. 4

15 Grey Bruce Health Network TOTAL HIP REPLACEMENT CLINICAL PATHWAY SITE: GBHS - Owen Sound PATIENT ID PROCESS POST-OP DAY PERFORMANCE INDICATORS 2 ANTIBIOTIC DISCONTINUED 24 HOURS POST SURGERY Record as "Met" or "Not Met" on Variance Record VITAL SIGNS WITH O 2 SATS: Q4H ASSESSMENT (OBSERVATIONS/ MEASUREMENTS/ ELIMINATION) CHEST ASSESSMENT CIRCULATION / SENSATION / MOTION Q4H ASSESS DRESSING MONITOR INTAKE / OUTPUT CATHETER CONSULTS DIAGNOSTICS/ LABORATORY CBC & LYTES HIP X-RAY MEDICATIONS SEE MAR SHEET IV AS ORDERED EMPTY DRAIN Q SHIFT AND PRN REMOVE DRAIN ORDERED TREATMENTS/ INTERVENTIONS REMOVE CATHETER (24 HOURS POST-OP) BED BATH WITH ASSIST TED STOCKINGS REMOVED FOR SKIN CARE NUTRITION SIPS - REGULAR DIET SIPS - SPECIAL DIET: 5

16 PROCESS POST-OP DAY UP IN CHAIR UP WITH WALKER IN ROOM WEIGHT BEARING STATUS ORDERED MOBILITY/ACTIVITY POSITIONING IN BED WITH PILLOW BETWEEN LEGS LIE TO SIT WITH USE OF RAIL FOOT AND ANKLE EXERCISES ISOMETRIC QUADS AND GLUTS PHYSIO DATABASE INITIATED PSYCHOSOCIAL SUPPORT/ EDUCATION DISCHARGE PLANNING POST-OP NEEDS DEEP BREATHING & COUGHING, CALF PUMPING ROUTINE POST-OP TEACHING REVIEW PATIENT PATHWAY REVIEW HIP PRECAUTIONS PLANS FOR DISCHARGE DISCUSSED WITH PATIENT/FAMILY AND DOCUMENTED ON PROGRESS NOTES ESTIMATED OF DISCHARGE DISCUSSED WITH PATIENT/FAMILY ASSESS DISCHARGE CRITERIA DAILY 6

17 Grey Bruce Health Network TOTAL HIP REPLACEMENT CLINICAL PATHWAY PROCESS SITE: GBHS - Owen Sound POST-OP DAY 2 PATIENT ID VITAL SIGNS WITH O 2 SATS: QID ASSESSMENT (OBSERVATIONS/ MEASUREMENTS/ ELIMINATION) CHEST ASSESSMENT CIRCULATION / SENSATION / MOTION Q4H MONITOR INTAKE / OUTPUT MONITOR BOWEL MOVEMENT CONSULTS DIAGNOSTICS/ LABORATORY MEDICATIONS CCAC IF NECESSARY OT - DRESSING IN STREET CLOTHES CBC & LYTES SEE MAR SHEET DISCONTINUE IV FLUID AND ASSESS NEED FOR INTERMITTENT SET ASSESS DRESSING TREATMENTS/ INTERVENTIONS REDUCE DRESSING TO ISLAND DRESSING TED STOCKINGS REMOVED FOR SKIN CARE NUTRITION REGULAR DIET SPECIAL DIET: AMBULATE 3 METRES WITH WALKER AND ASSISTANCE MOBILITY/ACTIVITY ACTIVE ASSISTED HIP ROM EXERCISES PHYSIO DATABASE COMPLETED TRANSFER TECHNIQUE REVIEWED WITH PATIENT 7

18 PROCESS POST-OP DAY 2 PSYCHOSOCIAL SUPPORT/ EDUCATION REVIEW PATIENT PATHWAY REVIEW HIP PRECAUTIONS VERBALIZES UNDERSTANDING OF PLAN OF CARE PATIENT TAUGHT USE OF MOLECULAR WEIGHT HEPARIN POST DISCHARGE IF APPLICABLE DISCHARGE NEEDS ASSESSED BY PHYSIO REVIEW WITH SURGEON, NOTIFY APPROPRIATE RECEIVING HOSPITAL OR UNIT OF POTENTIAL TRANSFER IF APPLICABLE DISCHARGE PLANNING BLAYLOCK DISCHARGE PLANNING RISK ASSESSMENT SCREEN REVIEWED, INFORM CCAC OF CHANGES IF APPLICABLE PLANS FOR DISCHARGE DISCUSSED WITH PATIENT/FAMILY AND DOCUMENTED ON PROGRESS NOTES ASSESS DISCHARGE CRITERIA DAILY 8

19 Grey Bruce Health Network TOTAL HIP REPLACEMENT CLINICAL PATHWAY PROCESS SITE: GBHS - Owen Sound POST-OP DAY 3 PATIENT ID VITAL SIGNS WITH O 2 SATS: TID ASSESSMENT (OBSERVATIONS/ MEASUREMENTS/ ELIMINATION) CHEST ASSESSMENT CIRCULATION / SENSATION / MOTION Q4H MONITOR INTAKE / OUTPUT MONITOR BOWEL MOVEMENT VOIDING QS CONSULTS DIAGNOSTICS/ LABORATORY MEDICATIONS OT - IF PATIENT GOING HOME AND DESIRE FOR TUB BATH OT - TEDS DRESSING TRAINING IF APPROPRIATE CBC & LYTES SEE MAR SHEET ASSESS DRESSING DRESSING CHANGE TREATMENTS/ INTERVENTIONS IV DISCONTINUED AS PER ORDERS TED STOCKINGS REMOVED FOR SKIN CARE NUTRITION REGULAR DIET SPECIAL DIET: 9

20 PROCESS POST-OP DAY 3 MOBILITY/ACTIVITY PSYCHOSOCIAL SUPPORT/ EDUCATION DISCHARGE PLANNING UP WITH WALKER IN HALL INDEPENDENTLY PHYSIO FOLLOW UP ARRANGED TAUGHT LIE TO SIT UNDER HOME CONDITIONS ASSISTED WITH EXERCISES TRAINING TO DRESS IN STREET CLOTHES DRESSED IN STREET CLOTHES REVIEW TRANSFER TECHNIQUE WITH PATIENT EQUIPMENT FOR HOME ARRANGED IF NECESSARY REVIEW TOTAL HIP REPLACEMENT TEACHING BOOKLET REVIEW PATIENT PATHWAY REVIEW HIP PRECAUTIONS PATIENT TAUGHT USE OF MOLECULAR WEIGHT HEPARIN POST DISCHARGE IF APPLICABLE REHAB ASSESSMENT COMPLETED AS NEEDED DISCHARGE NEEDS ASSESSED DESTINATION AND FOR DISCHARGE KNOWN Destination: Date: DISCHARGE DISCUSSED WITH PATIENT/FAMILY PATIENT PREPARED FOR DISCHARGE (E.G. CLOTHING) ASSESS DISCHARGE CRITERIA DAILY 20

21 Grey Bruce Health Network TOTAL HIP REPLACEMENT CLINICAL PATHWAY SITE: GBHS - Owen Sound PROCESS POST-OP DAY 4 VITAL SIGNS WITH O 2 SATS: BID ASSESSMENT (OBSERVATIONS/ MEASUREMENTS/ ELIMINATION) CHEST ASSESSMENT CIRCULATION / SENSATION / MOTION Q4H ASSESS DURATION OF DVT PROPHYLAXIS ACCORDING TO RISK FACTORS MONITOR INTAKE / OUTPUT MONITOR BOWEL MOVEMENT CONSULTS DIAGNOSTICS/ LABORATORY MEDICATIONS DISCHARGE PLANNING REFERRAL FOR ALC IF REQUIRED SEE MAR SHEET ASSESS DRESSING DRESSING CHANGE TREATMENTS/ INTERVENTIONS ASSIST WITH AM CARE TED STOCKINGS REMOVED FOR SKIN CARE NUTRITION REGULAR DIET SPECIAL DIET: INDEPENDENT LIE TO SIT UNDER HOME CONDITIONS INDEPENDENT EXERCISES PROGRESS TO CRUTCHES IF REQUIRED MOBILITY/ACTIVITY TEDS DRESSING TRAINING IF APPLICABLE TUB TRANSFER TRAINING IF APPLICABLE INDEPENDENT TRANSFERS IN AND OUT OF BED ASSESS STAIRS IF REQUIRED 2

22 PROCESS POST-OP DAY 4 PSYCHOSOCIAL SUPPORT/ EDUCATION DISCHARGE PLANNING REVIEW PATIENT PATHWAY REVIEW HIP PRECAUTIONS VERBALIZES UNDERSTANDING OF PLAN OF CARE PATIENT TAUGHT USE OF MOLECULAR WEIGHT HEPARIN POST DISCHARGE IF APPLICABLE ONE OF: DISCHARGE HOME TRANSFER TO REHAB TRANSFER TO HOME HOSPITAL ASSESS DISCHARGE CRITERIA DAILY 22

23 Grey Bruce Health Network TOTAL HIP REPLACEMENT CLINICAL PATHWAY SITE: GBHS - Owen Sound PATIENT ID PROCESS ONGOING POST-OP CARE SKIN ASSESSMENT VITAL SIGNS WITH O 2 SATS: Q SHIFT ASSESSMENT (OBSERVATIONS/ MEASUREMENTS/ ELIMINATION) CIRCULATION / SENSATION / MOTION CALF PUMPING SIGNS/SYMPTOMS OF THROMBUS/PHLEBITIS VOIDING QS MONITOR BOWEL MOVEMENT CCAC AND/OR OUTPATIENT PHYSIO CONSULTS DISCHARGE PLANNING IF REQUIRED FOLLOW UP APPOINTMENT ARRANGED: DIAGNOSTICS/ LABORATORY SEE MAR SHEET MEDICATIONS SELF-MED PROGRAM IF APPROPRIATE ASSESS DRESSING / CHANGE PRN ASSESS WOUND PRN REMOVE DRESSING IF WOUND CLEAN & DRY TREATMENTS/ INTERVENTIONS REMOVAL OF SUTURES / STAPLES: : TEDS REMOVED FOR SKIN CARE ASSIST/TEACH DRESSING IN STREET CLOTHES NUTRITION REGULAR DIET SPECIAL DIET 23

24 PROCESS ONGOING POST-OP CARE MOBILITY/ACTIVITY TRANSFERS: AMBULATION: STAIRS: EXERCISES: BED MOBILITY AWARE OF PRECAUTIONS INDEPENDENTLY WITH ASSISTANCE INDEPENDENTLY WITH ASSISTANCE INDEPENDENTLY WITH ASSISTANCE INDEPENDENTLY WITH ASSISTANCE EQUIPMENT IN PLACE FOR DISCHARGE HYGIENE NEEDS ASSESSED AND TAUGHT (E.G. TEDS, SHOWER/TUB TRANSFERS) TOTAL HIP ROUTINE REVIEWED PSYCHOSOCIAL SUPPORT/ EDUCATION TEACHING THE USE OF AIDS REVIEW/DISCUSS SURGICAL COMPLICATIONS PATIENT TAUGHT USE OF MOLECULAR WEIGHT HEPARIN POST DISCHARGE IF APPLICABLE DISCHARGE PLANS REVIEWED WEEKLY DUE: DISCHARGE PLANNING HOME SUPPORTS REVIEWED DISCHARGE PLANS DISCUSSED WITH PATIENT AND FAMILY: DESTINATION: : ASSESS DISCHARGE CRITERIA DAILY 24

25 Grey Bruce Health Network TOTAL HIP REPLACEMENT CLINICAL PATHWAY SITE: GBHS - Owen Sound PATIENT ID PROCESS DISCHARGE CRITERIA MET INITIAL AFEBRILE ASSESSMENT (OBSERVATIONS/ MEASUREMENTS/ ELIMINATION) VITAL SIGNS STABLE WOUND INTACT NIL DRAINAGE FREE OF SIGNS/SYMPTOMS OF THROMBUS/PHLEBITIS VOIDING QS RETURN TO NORMAL BOWEL ROUTINE CONSULTS DIAGNOSTICS/ LABORATORY MEDICATIONS TREATMENTS/ INTERVENTIONS NUTRITION FOLLOW UP APPOINTMENT ARRANGED ARRANGE FOR INR AT HOME IF PATIENT ON ANTI-COAGULANT HEALTH TEACHING RELATED TO MEDS PRESCRIPTION FOR ANALGESIC AND/OR ANTI-COAGULANT AS ORDERED ASSESS DRESSING DRESSING CHANGE REGULAR DIET SAFE, INDEPENDENT TRANSFERS MOBILITY/ACTIVITY SAFE AMBULATION WITH AID ON LEVEL AND STAIRS EQUIPMENT IN PLACE INDEPENDENT EXERCISES PSYCHOSOCIAL SUPPORT/ EDUCATION DISCHARGE PLANNING AWARE OF PRECAUTIONS UNDERSTANDS SIGNS AND SYMPTOMS OF WOUND INFECTION PATIENT TAUGHT USE OF MOLECULAR WEIGHT HEPARIN POST DISCHARGE IF APPLICABLE CCAC AND/OR OUTPATIENT PHYSIO ARRANGED PLANS FOR ANTI-COAGULATION KNOWN & DOCUMENTED ON TRANSFER SHEET DISCHARGE SUMMARY COMPLETED ON VARIANCE RECORD 25

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27 GREY BRUCE HEALTH NETWORK TOTAL HIP REPLACEMENT VARIANCE RECORD SITE: GBHS - Owen Sound THIS VARIANCE RECORD IS USED FOR EVALUATIVE PURPOSES ONLY. DO NOT PUT PATIENT INFORMATION ON THIS FORM. REMOVE AND SEND TO SITE CHAMPION AT PATIENT DISCHARGE. Patient Age: Gender: Admission Date: LEFS Score: Targeted LOS: 5 Days Patient transferred from another hospital? Yes (specify) Pathway Day: No TIME FRAME INDICATOR MET NOT MET /TIME INITIAL CODE DESCRIBE CORRECTIVE ACTION (or N/A if not applicable) RESOLVED (or N/A) INITIAL PRE-ADMIT DAY PHYSIO VISIT 2 ANTIBIOTIC DISCONTINUED 24 HOURS POST SURGERY DISCHARGE SUMMARY: (To be completed upon discharge off pathway or unit) Date Pathway Completed: Days on Pathway: Total Hip Replacement Post-Op Pre-Printed Orders used: Yes No Weight Bearing Status: Patient education materials given to Patient: Yes No If no, reason: Patient teaching completed: Yes No If no, reason: Patient removed from Pathway before discharge: Yes Reason: Discharge Destination: Home Home with CCAC Rehab Hospital (specify) Other (specify) See back of page for instructions re: Transfer Patients or CCAC Clients Signature: Date: 27

28 . On Admission: Complete the demographic section: patient age, gender, admission date. Place the Variance Record behind the clinical pathway on the chart. 2. Documenting the Variance: For each indicator, tick whether met or not met, indicate the date, time and initial. If not met, the indicator becomes a variance. State variance code as either A, B or C, and the number within the category. Indicate your action plan to correct the variance, or indicate N/A if not applicable. Indicate the date variance was resolved and initial, or indicate N/A if not applicable. 3. On Discharge: Complete the Discharge Summary. If patient is being discharged home, send Variance Record to Site Champion to be forwarded to Evidence-Based Care Program Coordinator. If appropriate, send a copy of the following to the receiving service provider: Variance Record Smiley Face Tool Discharge Criteria Blaylock Discharging Planning Tool A) Inability to learn skill needed for B) Lack of or inadequate documentation C) Bed availability self-care B2) Physician/provider response time C2) Schedule conflict A2) Inadequate social support or systems B3) Physician preference C3) Consultant unavailable at home B4) Pre-Printed Orders not used C4) OR time unavailable A3) Failure to respond to treatment B5) Orders outside clinical pathway C5) Results/data unavailable A4) Patient/caregiver unavailability parameters C6) Supply/equipment unavailable A5) Unable to return to pre-admission B6) Treatment or intervention omitted C7) Department closed environment B7) Other (please specify) C8) Placement unavailable A6) Patient/caregiver decision C9) Home health care unavailable A8) VARIANCE DOCUMENTATION GUIDELINES Variances to clinical pathway activities will be documented on a Variance Record. Upon completion, this form is to be sent to the Evidence-Based Care Program Coordinator for evaluation purposes. 4. Transfer Patients: If patient is transferred to another hospital in Grey-Bruce, send the following: Variance Record - copy with patient to receiving hospital - original to Evidence-Based Care Program Coordinator Discharge Criteria - copy with patient to receiving hospital - original to stay on patient chart MAR Sheet - copy with patient to receiving hospital - original to stay on patient chart Anticoagulant Record - copy with patient to receiving hospital - original to stay on patient chart Smiley Face Tool Blaylock Discharge Tool - original with patient to receiving hospital - copy with patient to receiving hospital - original to stay on patient chart A new Variance Record should be started in the new facility for the remainder of the patient s stay. When the patient is discharged from the transfer facility, fill out Discharge Summary, staple both Variance Records together and send to Site Champion to be forwarded to Evidence-Based Care Program Coordinator. PATIENT OUTCOME VARIANCES VARIANCE CODES PERFORMANCE VARIANCES A) PATIENT/FAMILY B) CARE PROVIDER C) SYSTEM A7) Complication of condition C0) Transportation unavailable (physiological/psychological) Other (please specify) C) Other (please specify) 28