As hospitalists become more prevalent in facilities nationwide, administrators and others increasingly seek out these practitioners to take a clinical leadership role. More than ever, this includes implementing clinical practice guidelines to maximize outcomes and standardize care processes. Guidelines may be called pathways, order sets, or protocols, but these evidence-based tools are being embraced by hospitals; and facilities leaders are encouraging physicians to jump on the bandwagon.
Why Use Guidelines?
Studies already show that hospitalists have a positive effect on lengths of stay and efficiency of care, and some have documented a correlation between hospitalist programs and outcomes. So why are guidelines necessary?
Guidelines use a foundation of evidence-based medicine, which promotes the use of proven practices and interventions. “Evidence-based medicine is tough to refute,” says Ken Simone, DO, founder and president of Hospitalist and Practice Solutions in Brewer, Maine. “Typically, when you see evidence-based medicine within a guideline, you can assume that you are improving medicine if you use the tool accurately.”
There are two reasons to employ guidelines, according to Richard Rubin, MD, MBA, chief medical officer, Seton Health Systems, Troy, N.Y. One is to ensure efficiency in providing care that is clinically based. The second reason is to ensure consistent quality by preventing variations in care from practitioner to practitioner.
“These tools serve as a road map, giving you an idea of where to go and how to get there,” says Dr. Rubin.
There are limited data from the literature documenting the value of guidelines in the hospital setting. However, one study looked at the effect of a clinical pathway on six outcomes of care in patients hospitalized for community-acquired pneumonia.1 The authors found that those patients managed by using a pathway were significantly less likely to die in-hospital compared with non-pathway patients. Pathway patients also were more likely to receive blood cultures and appropriate antibiotic therapy.
In patients with the most severe pneumonia, those managed via pathway had an 80% reduction in the odds of respiratory therapy requiring mechanical ventilation. Overall, the authors concluded that patients who were managed using a clinical pathway for pneumonia were more likely to experience positive outcomes than patients treated without these tools.
Another study looked a multidisciplinary approach to creating “templated” order sets for chemotherapy. The authors concluded that such tools reduced the duplication of effort by significantly lowering the number of changes made during the order verification process.2
Dr. Rubin undertook an internal study at his facility that found that using order sets was linked to shorter lengths of stay. He discovered that pathways were used 18% of the time for cases with the longest lengths of stays and 54% of the time with the shortest.
“There’s not much I don’t like about order sets,” says Dr. Rubin.
Todd Popp, MD, clinical partner, Critical Care and Pulmonary Consultants, Denver, agrees. “Of course, we want to use tools that help patients, and effective order sets help improve quality and efficiency,” he says.
Dr. Popp adds that guideline use has an added advantage for hospitalists. Those practitioners, he notes, who have a demonstrated ability to develop and implement order sets increasingly will be in demand.
“There is a fair amount of competition between hospitalist groups. If you can prove that you can develop, implement, and use these standards,” he says, “it helps hospitals and their patients, and it helps hospitalists get better contracts and have solid relationships with their facilities.”
In fact, says Dr. Simone, hospitalists who have experience and knowledge about guideline development and implementation will be considered tremendous assets by hospitals. “If the nationwide use of guidelines in hospitals isn’t common yet, it will be in the coming years. And hospitalists are perfectly positioned to take the lead on the effective development and use of these tools,” he offers.
Tools that Teach
Guidelines encourage standardization of care and help physicians and other clinicians quickly select appropriate assessments and interventions for various conditions. They also help prescribers make appropriate medication and dosage selections quickly and accurately. For example, an order set for admissions to a coronary care unit (CCU) for acute coronary syndrome likely will address considerations such as nursing orders, IVs, medications, diagnostic tests, consults, discharge planning, and primary care follow-up.
Used properly, these tools do not promote “cookbook” or “cookie cutter” medicine—as some opponents suggest; instead, they guide decision-making and enable practical, evidence-based choices for each patient.
Hospitals and hospitalists most frequently employ guidelines regarding the clinical conditions that most commonly lead to ED visits or hospital stays. These include community-acquired pneumonia, COPD, CHF, chest pain, MI, and stroke.
In choosing topics on which to implement guidelines, Dr. Simone suggests considering the demographics, needs, and challenges of the particular facility. For example, “if you have guidelines addressing diagnoses for which patients generally are put on 24-hour observation prior to hospital admission, you can ferret out who needs to be admitted and who doesn’t,” he says, adding, “and you can make these decisions in a consistent manner.”
Buy-in and Barriers
Hospitalists who use guidelines agree that they are natural leaders when it comes to the development, implementation, and use of these tools.
“As a hospitalist, I am employed by the hospital and have more of a stake in overall quality and cost-effectiveness of care,” says Justin Psaila, MD, of St. Luke’s Hospital in Bethlehem, Pa. “Some of the private attendings are doing their own thing and just see guidelines as creating more work.”
“Hospitals are looking for more standardized approaches to medical care via guidelines and order sets, and hospitalists can deliver this,” says Alex Strachan, Jr., MD, medical director for the Hospitalist Program at St. Joseph Hospital in Eureka, Calif., and medical director of Team Health West Hospital Medicine Programs. “There is a tremendous amount of teamwork involved in guideline implementation and use, and hospitalists are natural team players.”
In addition to working with facilities to develop and implement guidelines, hospitalists can help increase buy-in from other clinicians. This may involve working with facility leadership to develop materials to promote the guidelines to stakeholders, such as letters to attending physicians that outline how the guidelines will work, where they can obtain copies, how they can obtain electronic versions (if available), the advantages of using these tools, what to do if they don’t follow a step in the guideline (e.g., document the patient’s refusal to receive a particular treatment), and who to contact if they have questions about the guideline.
Despite all of the positives about guidelines and the growing number of physicians who use and embrace them, there continues to be some resistance to guideline use. “Many physicians still are hesitant to use guidelines,” explains Dr. Simone. “They feel as if they will lose some creativity and that it may obligate them to go in a particular direction.”
Even when a facility’s hospitalists are on board with guidelines, attending physicians—who usually are in the majority—who resist can prevent the documents from having a positive impact. Dr. Strachan offers an example: “If you have 50-100 medical staff admitting, they will use the antibiotics that they are most comfortable with—regardless of cost, staff time involved in medication administration, and so on. If even half of these buy into a guideline addressing antibiotic use, it can streamline medication management, administration, and costs considerably.”
Some physicians worry that guidelines put them at risk for lawsuits. “One physician said, ‘You put my back to the wall if I don’t do these things,’” says Dr. Simone. “However, good guidelines don’t set you up; they protect you. If you don’t follow a step or recommendation, you just need to document why.”
Often, some basic revisions can help overcome objections to guideline use. As Dr. Simone explains, “We had an order set that was five pages in length, and physicians balked at using it. They said that it was too complicated. So we winnowed it down to two to three concise pages, and now they all use it.”
He cautions that if guidelines are too confusing, complex, or long, they seem overwhelming and are less likely to be used.
Birth of a Hospitalist Guideline
While there are many clinical practice guidelines in existence that address a range of clinical issues and conditions, hospitalists and other physicians are more likely to use a tool they have helped create. Arun Tewari, MD, program director of the Hospitalist Program, Ball Memorial Hospital Medical Consultants, Muncie, Ind., has experienced this first-hand and has been involved in guideline development at his facility for the past three years.
“We’re just starting to track data, but we’ve already realized a reduced length of stay for all the pathways we use, including stroke, CHF, COPD, pneumonia, chest pains, MI, and GI bleed,” he says. “To date, the numbers are only statistically significant for pneumonia. However, we expect to see significant results in the other areas over time.”
Dr. Tewari and his group use a multidisciplinary approach to pathway development. “We invite key individuals from different disciplines and specialties to serve on a committee that is run by a physician and a nurse leader. These individuals are responsible for reviewing articles and other information and performing specific assigned tasks,” he explains.
The group starts with a tremendous amount of information. In addition to articles from the literature, they review national guidelines on the topic being addressed, as well as pathways used by other facilities or organizations.
The group takes the best clinical evidence and information they find, and they incorporate it into a tool that is useful and practical for the hospital.
“To be truly effective, these tools have to be institutionalized to your facility and practical in terms of what can be done or handled in this setting,” suggests Dr. Tewari.
Once the group reaches consensus on a completed draft, the document goes to several hospital committees for review. The original group then compiles the comments, makes any revisions or additions deemed necessary, and produces a final pathway. “This isn’t a short process,” cautions Dr. Tewari. On average it takes six months to a year from start to finish.
The final pathways are posted online, and physicians can print copies. Elsewhere, the pathways are available on the floors and in the emergency department as well. Currently, the pathways aren’t available for electronic applications such as PDAs. However, Dr. Tewari doesn’t rule this out as a possibility for the future.
Of course, Dr. Tewari emphasizes, just publishing a pathway or making it available to clinical staff isn’t enough. “You have to educate people about the pathways and gain their buy-in,” he notes. At his facility, each clinical department staff meeting involves a representative who will talk about pathways and spell out how to use them. This also presents another opportunity for practitioners and team leaders to have input on the tools.
The pathways aren’t mandatory, Dr. Tewari emphasizes, but they are strongly encouraged. “We don’t have statistics yet, but throughout the hospital, utilization probably is at about 50%. Within our hospitalist group, utilization is close to 100%. We hope to have some hard numbers soon to back this up.”
No Crystal Balls Needed: Guidelines Have a Future
Guidelines soundly rooted in evidence-based medicine have a future, predicts Dr. Simone.
“I think these are essential for the Medicare pay-for-performance measures that are coming down the pike. Medicare is likely to identify three to five different diagnoses to look at and may want hospitals to develop guidelines for these. Hospitals—as well as hospitalists and other physicians—will be rewarded if their performance is good in these areas based on these guidelines.”
Some hospitals already are using guidelines or order sets to prove quality. “We put our order sets together partly because we are part of a CMS [Centers for Medicare and Medicaid Services] pay-for-performance project,” says Dr. Psaila.
Guidelines that are commonly available via laptop or PDA also are coming. “Hospitalists tend to use technology more than other physicians, and they increasingly will want guideline applications for handheld devices,” notes Dr. Strachan.
There already are several companies offering such products. “Some of these are really useful tools,” he continues. “They allow you to pull up an order set for a particular illness and use it. You can click on medications and check the evidence basis for their use. You then can print out this information or transmit it electronically.”
The real future is to have electronic medical record solutions that interface with orders, predicts Dr. Strachan. However, he suggests that current availability and use of such systems is less than 10% of hospitals and hospitalists.
“I feel that it is essential that we develop various guidelines and use them in the hospital setting,” concludes Dr. Strachan. “We need to standardize our practice so that we can measure outcomes and quality of care doesn’t vary from one practitioner to another.” TH
Writer Joanne Kaldy also writes about hospitalist programs in this issue.
- Hauck LD, Adler LM, Mulla ZD. Clinical pathway care improves outcomes among patients hospitalized for community-acquired pneumonia. Ann Epidemiol. 2004;14(9):669-675.
- Dinning C, Branowicki P, O’Neill JB, et al. Chemotherapy error reduction: a multidisciplinary approach to create templated order sets. J Pediatr Oncol Nurs. 2005;22(1):20-30.