TOTAL HIP REPLACEMENT CLINICAL PATHWAY - … · cerner order consults mobility/activity total hip...

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TOTAL HIP REPLACEMENT

CLINICAL PATHWAY

SITE: GBHS - Owen Sound PATIENT ID

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.

Please indicate any variances to Indicators on the Variance Record.

NAME (Please Print)

INITIAL SIGNATURE

POSITION

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Grey Bruce Health Network

CP-THR-117©2003-2006 Grey Bruce Health Network

Approved (May, 2006)1

Annual Review (May, 2007)

OTHER (SPECIFY)

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NAME (Please Print)

INITIAL SIGNATURE

POSITION

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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.




DATE ___________

PERFORMANCE INDICATOR 1

Record as "Met"or "Not Met" on

Variance Record

HEIGHT AND WEIGHT

REVIEW PRE-ANAESTHETIC QUESTIONNAIRE

ALL NON-SHADED BOXES TO BE INITIALLED UPON COMPLETION OR MARKED N/A AND INITIALLED

OTHER:

INTERNAL MEDICINE

ANESTHESIOLOGIST

PATIENT ON ANTI-COAGULANT THERAPY

PHYSIO CLINIC

CCAC IF REQUIRED (SEE BLAYLOCK DISCHARGE PLANNING RISK ASSESSMENT SCREEN)


COMORBID CONDITIONS:

PHYSIO VISIT

VITAL SIGNS WITH O2 SATS: BP

REVIEW PCA VIDEO AND PAMPHLET

OTHER:

MEDICATIONS

OTHER:

INSTRUCT PATIENT TO REVIEW MED NEEDS WITH PHYSICIAN

CHEST X-RAY

OTHER:


CLINICAL PATHWAY

PRE-ADMISSIONPROCESS

CONSULTS

ECG

ASSESSMENT (OBSERVATIONS/ MEASUREMENTS/

ELIMINATION)

DIAGNOSTICS/ LABORATORY

OTHER:

COMPLETE NURSING HISTORY

CONSENT SIGNED BY PATIENT

START PRE-OP CHECKLIST

CBC, Na, Cl, K, CROSSMATCH G&S, URINE C&S





DATE ___________

ATTEND PHYSIO CLASS


PSYCHOSOCIAL SUPPORT/

EDUCATION

DISCHARGE PLANNING

COMPLETE LOWER EXTREMITY FUNCTIONAL SCALE (LEFS) AND PUT SCORE ON VARIANCE RECORD DISCHARGE SUMMARY

COMPLETE BLAYLOCK DISCHARGE PLANNING RISK ASSESSMENT SCREEN

REVIEW HOME SUPPORT

SHOWER PRIOR TO COMING TO HOSPITAL

DISCHARGE PLANS DISCUSSED WITH PATIENT

REVIEW SURGICAL INFORMATION BOOKLET AND VIDEO: DEEP BREATHING AND COUGHING, CALF PUMPING, ETC.

HOSPITAL POLICY RE: DISCHARGE TIME

MOBILITY/ACTIVITY REVIEW TOTAL HIP REPLACEMENT INFORMATION PACKAGE

TREATMENTS/ INTERVENTIONS

REVIEW CLOTHING REQUIREMENTS

REVIEW USE OF BEDPAN, URINAL, CATHETER

OTHER:

ATTEND OT CLASS

SPECIFIC INSTRUCTIONS BY SURGEON OR INTERNIST

REVIEW PRE-OP INSTRUCTIONS RE: DIET, NPO

PRE-ADMISSIONPROCESS

OTHER:

NUTRITION




Today, do you, or would you have any difficulty at all with:Extreme

Difficulty/ Unable to Perform Activity

Quite a bit of Difficulty

Moderate Difficulty

A little bit of Difficulty

No Difficulty

1 0 1 2 3 4

2 0 1 2 3 4

3 0 1 2 3 44 0 1 2 3 45 0 1 2 3 46 0 1 2 3 4

7 0 1 2 3 4

8 0 1 2 3 4

9 0 1 2 3 4

10 0 1 2 3 411 0 1 2 3 412 0 1 2 3 4

13 0 1 2 3 4

14 0 1 2 3 415 0 1 2 3 416 0 1 2 3 417 0 1 2 3 4

18 0 1 2 3 4

19 0 1 2 3 420 0 1 2 3 4

Total Score /80

TOTAL HIP REPLACEMENTCLINICAL PATHWAY

Lower Extremity Functional Scale


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)

ActivitiesAny of your usual work, housework or school activitiesYour usual hobbies, recreational or sporting activitiesGetting into or out of the bathWalking between roomsPutting on your shoes or socksSquattingLifting an object, like a bag of groceries from the floorPerforming light activities around your homePerforming heavy activities around your homeGetting into or out of a carWalking 2 blocksWalking a mileGoing up or down 10 stairs (about 1 flight of stairs)Standing for 1 hourSitting for 1 hour

Rolling over in bedColumn Totals

Goal - score of 50 by discharge from services

Running on even groundRunning on uneven groundMaking sharp turns while running fastHopping





0 0

1

2 1

3 1

0 11 12 13 14 1

5 1

None in the last 3 months 0 1One in the last 3 months 1 1Two in the last 3 months 2 1

More than two in the last 3 months 3 0

Up to three medical problems 0 1

Three to five medical problems 1 1

More than five medical problems 2 1

Fewer than three drugs 0 1

Three to five drugs 1 0

More than five drugs 2 1

0 2

1 3

2 0

3 1

4 2

5

0-10

11-19

>20


Blaylock Discharge Planning Risk Assessment Screen


Circle all that apply and total. Refer to scoring index for recommendations regarding discharge planning.

Age

55 years or less

Functional Status

Independent in activities of daily living and instrumental activities of daily living

56-64 years Dependent in:

65-79 years Eating/Feeding

80+ years Bathing/Grooming

Living Situation/Social

Support

Lives only with spouse Toileting

Lives with family Transferring

Lives alone with family support Incontinent of bowel function

Lives alone with friend's support Incontinent of bladder function

Lives alone with no support Meal Preparation

Nursing home/residential careResponsible for own medication administration

Number of Previous

Admissions/ Emergency Room

Visits

Handling own finances

Grocery Shopping

Transportation

Behaviour Pattern

Appropriate

Number of Active Medical Problems

Wandering

Agitated

Confused

Number of Drugs

Other

Mobility

Ambulatory

Ambulatory with mechanical assistance

Cognition

Oriented Ambulatory with human assistance

Disoriented to some spheres (person, place, self, time) some of the time

Nonambulatory

Disoriented to some spheres (person, place, self, time) all of the time

Sensory Deficits

None

Disoriented to all spheres (person, place, self, time) and some of the time

Visual or hearing deficits

Disoriented to all spheres (person, place, self, time) all of the time

Visual and hearing deficits

Comatose

Total Score: ____________ Signature: _____________________ Date: ____________________

Scoring Index

Probable outpatient physiotherapy or occupational therapy follow up, refer to Discharge Planner

May require CCAC services, refer to Case ManagerMay require alternative level of care, refer to Discharge Planner





CERNER ORDER

CONSULTS

MOBILITY/ACTIVITY


CLINICAL PATHWAY


PROCESS PRE-OP ADMISSION/DAY OF SURGERY

DATE _____________


ELIMINATION)

VITAL SIGNS WITH O2 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)

OTHER:

OTHER:

REVIEW MEDS TAKEN USING NURSING HISTORY

PRE-OP MEDS

OTHER:

OTHER:


TO OR: WALK q STRETCHER q


EDUCATION

MONITOR ANXIETY LEVEL

FAMILY INSTRUCTED RE: SURGICAL WAITING AREA

DISCHARGE PLANNING

PLANS FOR DISCHARGE DISCUSSED WITH FAMILY

OTHER:

TOTAL HIP REPLACEMENT PATHWAY

NUTRITIONNPO AS ORDERED

CLEAR FLUIDS UNTIL 0800 (IF SURGERY IN PM)


MRSA & VRE SWAB (NARES AND RECTUM)

OTHER:

OTHER:

OTHER:

MEDICATIONS






NUTRITION


CLINICAL PATHWAY


PROCESS POST-OP DAY OF SURGERY

DATE _____________


ELIMINATION)

VITAL SIGNS WITH O2 SATS: Q4H

ASSESS DRESSING

MONITOR INTAKE / OUTPUT

FOLEY CATHETER PRN

OTHER:

CONSULTSINTERNAL MEDICINE IF REQUIRED

PHYSIO


BLOOD WORK AS ORDERED

OTHER:

OTHER:

MEDICATIONS

PCA AS ORDERED

SEE MAR SHEET

OTHER:

ANCEF GIVEN IN OR

OTHER:


IV AS ORDERED

SUPPLEMENTARY O2 AS PER PROTOCOL

EMPTY DRAIN Q SHIFT AND PRN

CIRCULATION / SENSATION / MOTION Q4H

APPLY TED STOCKINGS IN PACU

BED BATH

OTHER:

OTHER:


q SIPS - REGULAR DIETq SIPS - SPECIAL DIET: _________________________________________

MOBILITY/ACTIVITY

BED REST

POSITIONING Q2-4H WITH PILLOW BETWEEN LEGS

OVERHEAD TRAPEZE





PROCESS POST-OP DAY OF SURGERY

DATE _____________


EDUCATION

REVIEW PCA

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 DATE OF DISCHARGE AND DESTINATION KNOWN AND DOCUMENTED ON PROGRESS NOTES

OTHER:




DATE_______

DATE_______

DATE_______

RISK FACTOR 1 2 3 4

Sensory Perception: Ability to respond meaningfully to pressure—related discomfort

Completely Limited

Very LimitedSlightly Limited

No Impairment

Moisture: Degree to which skin is exposed to moisture

Constantly Moist

Often MoistOccasionally Moist

Rarely Moist

Activity: Degree of Physical Activity

Bedfast Chair FastWalks Occasionally

Walks Frequently

Mobility: Ability to change and control body position

Completely Immobile

Very LimitedSlightly Limited

No Limitations

Nutrition: Usual food intake pattern

Very PoorProbably Inadequate

Adequate Excellent

Friction and Sheer ProblemPotential Problem

No Apparent Problem

LOW RISK(SCORE > 15)

Ongoing assessment for change in status related to any of the six risk areas


Braden Risk Assessment


SCORING (Key on Reverse)

SCORE

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.

MODERATE RISK (SCORE 13-14)

HIGH RISK (SCORE < 12)

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) -Physiotherapy-Continence management -Occupational Therapy-Monitoring of pressure point areas -Dietitian

-Patient education re: prevention

-Monitor nutritional status-Skin care tools used: prevention mattresses or treatment (i.e. air mattresses), creams, bed hoop, trapeze, dressings





RISK FACTOR

Moisture

Degree to which skin is exposed to moisture

1. Constantly MoistSkin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned.

2. Often MoistSkin is often, but not always moist. Linen must be changed at least once a shift.

3. Occasionally MoistSkin is occasionally moist, requiring an extra linen change approximately once a day.

4. Rarely MoistSkin is usually dry, linen only requires changing at routine intervals.

Activity

Degree of physical activity

1. BedfastConfined to a bed.

2. Chair FastAbility to walk severelylimited or nonexistent. Cannot bear own weight and/or must be assisted into chair or wheelchair.

3. Walks OccasionallyWalks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair.

4. Walks FrequentlyWalks 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

1. Completely ImmobileDoes not make even slight changes in body or extremity position without assistance.

2. Very LimitedMakes occasional slight changes in body or extremity position, but unable to make frequent or significant changesindependently.

3. Slightly LimitedMakes frequent, though slight changes in body or extremity position independently.

4. No LimitationsMakes major and frequent changes in position without assistance.

Nutrition 1. Very PoorNever eats a complete meal. Rarely eats more than 1/3 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.ORIs on NPO and/or maintained on clear fluids or IV for more than 5 days.

2. Probably InadequateRarely eats a complete meal and generally eats only about 1/2 of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement.ORReceives less than optimum amount of liquid diet or tube feeding.

3. AdequateEats 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.ORIs on a tube feeding or TPN (Total Parenteral Nutrition) regimen, which probably meets most of nutritional needs.

4. ExcellentEats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eatsbetween meals. Does not require supplementation.

Friction and Shear

1. ProblemRequires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures or agitation leads to almost constant friction.

2. Potential ProblemMoves feebly or requires minimum assistance. During a move, skin probably slides to some extent against sheets, chair, restraints or other devices. Maintains relatively good position in chair or bed most of the time, but occasionally slides down.

3. No Apparent ProblemMoves 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.

SCORE/DESCRIPTION

Sensory Perception

Ability to respond meaningfullyto pressure related discomfort

1. Completely LimitedUnresponsive (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 LimitedResponds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness.ORHas a sensory impairment, which limits the ability to feel pain or discomfort over 1/2 of body.

3. Slightly LimitedResponds to verbal commands but cannot always communicate discomfort or need to be turned.ORHas some sensory Impairment, which limits ability to feel pain or discomfort in 1 or 2 extremities.

4. No ImpairmentResponds to verbal commands. Has no sensory deficit, which would limit ability to feel or voice pain or discomfort.




PERFORMANCE INDICATORS 2

CONSULTS

NUTRITION


MEDICATIONS


q SIPS - REGULAR DIETq SIPS - SPECIAL DIET: _________________________________________

OTHER:

SEE MAR SHEET

OTHER:

OTHER:

REMOVE DRAIN ORDERED


HIP X-RAY

BED BATH WITH ASSIST


SITE: GBHS - Owen Sound

VITAL SIGNS WITH O2 SATS: Q4H

IV AS ORDERED

REMOVE CATHETER (24 HOURS POST-OP)

CLINICAL PATHWAY

OTHER:


ELIMINATION)

OTHER:

Record as "Met"or "Not Met" on

Variance Record

POST-OP DAY 1

PATIENT ID

DATE _____________

TED STOCKINGS REMOVED FOR SKIN CARE

OTHER:

OTHER:

EMPTY DRAIN Q SHIFT AND PRN

CBC & LYTES

ANTIBIOTIC DISCONTINUED 24 HOURS POST SURGERY

CATHETER

CHEST ASSESSMENT


ASSESS DRESSING


PROCESS






EDUCATION

DISCHARGE PLANNING

DATE _____________

UP IN CHAIR


MOBILITY/ACTIVITY

UP WITH WALKER IN ROOM

PROCESS POST-OP DAY 1


PLANS FOR DISCHARGE DISCUSSED WITH PATIENT/FAMILY AND DOCUMENTED ON PROGRESS NOTES

ESTIMATED DATE OF DISCHARGE DISCUSSED WITH PATIENT/FAMILY

OTHER:

REVIEW PATIENT PATHWAY

FOOT AND ANKLE EXERCISES

ISOMETRIC QUADS AND GLUTS

ROUTINE POST-OP TEACHING

POST-OP NEEDS—DEEP BREATHING & COUGHING, CALF PUMPING

PHYSIO DATABASE INITIATED

ASSESS DISCHARGE CRITERIA DAILY

WEIGHT BEARING STATUS ORDERED

POSITIONING IN BED WITH PILLOW BETWEEN LEGS

LIE TO SIT WITH USE OF RAIL




NUTRITION


CLINICAL PATHWAY

VITAL SIGNS WITH O2 SATS: QID

CHEST ASSESSMENT

SEE MAR SHEET


OTHER:


PHYSIO DATABASE COMPLETED

AMBULATE 3 METRES WITH WALKER AND ASSISTANCE

ACTIVE ASSISTED HIP ROM EXERCISES

PATIENT ID

DATE _____________

POST-OP DAY 2


PROCESS

TRANSFER TECHNIQUE REVIEWED WITH PATIENT


CONSULTS

CBC & LYTES

OTHER:

OTHER:

MEDICATIONS OTHER:

q REGULAR DIETq SPECIAL DIET: ______________________________________________

MOBILITY/ACTIVITY

MONITOR BOWEL MOVEMENT

OTHER:

CCAC IF NECESSARY

OT - DRESSING IN STREET CLOTHES


DISCONTINUE IV FLUID AND ASSESS NEED FOR INTERMITTENT SET

ASSESS DRESSING

REDUCE DRESSING TO ISLAND DRESSING



OTHER:

OTHER:


ELIMINATION)






EDUCATION



VERBALIZES UNDERSTANDING OF PLAN OF CARE

PATIENT TAUGHT USE OF MOLECULAR WEIGHT HEPARIN POST DISCHARGE IF APPLICABLE

REVIEW WITH SURGEON, NOTIFY APPROPRIATE RECEIVING HOSPITAL OR UNIT OF POTENTIAL TRANSFER IF APPLICABLE

DISCHARGE NEEDS ASSESSED BY PHYSIO

DISCHARGE PLANNING

OTHER:

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

DATE _____________





NUTRITION


OTHER:

OTHER:

CHEST ASSESSMENT



OTHER:


CBC & LYTES

OTHER:

VITAL SIGNS WITH O2 SATS: TID


ELIMINATION)

SEE MAR SHEET


OTHER:

MEDICATIONS

IV DISCONTINUED AS PER ORDERS


TREATMENTS/ INTERVENTIONS TED STOCKINGS REMOVED FOR SKIN CARE

OT - IF PATIENT GOING HOME AND DESIRE FOR TUB BATH

OT - TEDS DRESSING TRAINING IF APPROPRIATE

PROCESS


CONSULTS

DATE _____________

PATIENT ID

OTHER:

OTHER:

VOIDING QS

POST-OP DAY 3

CLINICAL PATHWAY


ASSESS DRESSING

DRESSING CHANGE





MOBILITY/ACTIVITY

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

EQUIPMENT FOR HOME ARRANGED IF NECESSARY

REVIEW TRANSFER TECHNIQUE WITH PATIENT

Date: ______________________________________________

DISCHARGE DISCUSSED WITH PATIENT/FAMILY

DESTINATION AND DATE FOR DISCHARGE KNOWN

Destination: _________________________________________


DISCHARGE PLANNING


DATE _____________

PROCESS


EDUCATION


POST-OP DAY 3

REVIEW TOTAL HIP REPLACEMENT TEACHING BOOKLET

PATIENT TAUGHT USE OF MOLECULAR WEIGHT HEPARIN POSTDISCHARGE IF APPLICABLE

OTHER:

DISCHARGE NEEDS ASSESSED


PATIENT PREPARED FOR DISCHARGE (E.G. CLOTHING)

REHAB ASSESSMENT COMPLETED AS NEEDED




ASSESS DURATION OF DVT PROPHYLAXIS ACCORDING TO RISK FACTORS

CONSULTS

NUTRITION


DRESSING CHANGE


ELIMINATION)






CLINICAL PATHWAY

OTHER:

ASSIST WITH AM CARE

DATE _____________

INDEPENDENT EXERCISES

TEDS DRESSING TRAINING IF APPLICABLE

TUB TRANSFER TRAINING IF APPLICABLE

ASSESS STAIRS IF REQUIRED

MOBILITY/ACTIVITY

PROGRESS TO CRUTCHES IF REQUIRED

MEDICATIONS



SEE MAR SHEET

OTHER:

OTHER:

ASSESS DRESSING


INDEPENDENT TRANSFERS IN AND OUT OF BED

OTHER:

INDEPENDENT LIE TO SIT UNDER HOME CONDITIONS


OTHER:

OTHER:


DISCHARGE PLANNING REFERRAL FOR ALC IF REQUIRED

OTHER:

CHEST ASSESSMENT

VITAL SIGNS WITH O2 SATS: BID






DISCHARGE HOME q


ONE OF:

DISCHARGE PLANNING

TRANSFER TO HOME HOSPITAL q

OTHER:


VERBALIZES UNDERSTANDING OF PLAN OF CARE

TRANSFER TO REHAB q


EDUCATIONPATIENT TAUGHT USE OF MOLECULAR WEIGHT HEPARIN POST DISCHARGE IF APPLICABLE



DATE _____________




ARRANGED: ___________________________

NUTRITION

ASSIST/TEACH DRESSING IN STREET CLOTHES

OTHER:

ASSESS DRESSING / CHANGE PRN

REMOVAL OF SUTURES / STAPLES:

ASSESS WOUND PRN

REMOVE DRESSING IF WOUND CLEAN & DRY


OTHER:

CCAC AND/OR OUTPATIENT PHYSIO

DISCHARGE PLANNING IF REQUIRED

FOLLOW UP APPOINTMENT


q REGULAR DIETq SPECIAL DIET ________________________


MEDICATIONS

SEE MAR SHEET

SELF-MED PROGRAM IF APPROPRIATE

OTHER:

OTHER:

OTHER:

DATE: _________________________________

TEDS REMOVED FOR SKIN CARE


ELIMINATION)

CONSULTS


OTHER:

OTHER:

SKIN ASSESSMENT

VITAL SIGNS WITH O2 SATS: Q SHIFT

CIRCULATION / SENSATION / MOTION

CALF PUMPING

VOIDING QS

ONGOING POST-OP CARE

SIGNS/SYMPTOMS OF THROMBUS/PHLEBITIS


PROCESS

DATE ___________

DATE ___________

DATE ___________


CLINICAL PATHWAY





REVIEW/DISCUSS SURGICAL COMPLICATIONS


EQUIPMENT IN PLACE FOR DISCHARGE

EXERCISES:

INDEPENDENTLY q

WITH ASSISTANCE q

TRANSFERS:

AMBULATION: INDEPENDENTLY

DISCHARGE PLANNING

DISCHARGE PLANS REVIEWED WEEKLY

HYGIENE NEEDS ASSESSED AND TAUGHT(E.G. TEDS, SHOWER/TUB TRANSFERS)

TOTAL HIP ROUTINE REVIEWED

TEACHING THE USE OF AIDS

DATE DUE: _____________________________

DESTINATION: __________________________

DATE: _________________________________

OTHER:

MOBILITY/ACTIVITY


HOME SUPPORTS REVIEWED

DISCHARGE PLANS DISCUSSED WITH PATIENT AND FAMILY:

INDEPENDENTLY q

WITH ASSISTANCE q


EDUCATION PATIENT TAUGHT USE OF MOLECULARWEIGHT HEPARIN POST DISCHARGEIF APPLICABLE

BED MOBILITY

AWARE OF PRECAUTIONS

PROCESSONGOING

POST-OP CARE

DATE ___________

DATE ___________

DATE ___________

STAIRS:

INDEPENDENTLY q

WITH ASSISTANCE q

INDEPENDENTLY q

WITH ASSISTANCE q




CONSULTS


NUTRITION

ASSESS DRESSING

DRESSING CHANGE

INDEPENDENT EXERCISES

UNDERSTANDS SIGNS AND SYMPTOMS OF WOUND INFECTION

AWARE OF PRECAUTIONS

SAFE AMBULATION WITH AID ON LEVEL AND STAIRS

EQUIPMENT IN PLACE


CLINICAL PATHWAY


FREE OF SIGNS/SYMPTOMS OF THROMBUS/PHLEBITIS

VOIDING QS

RETURN TO NORMAL BOWEL ROUTINE

PATIENT TAUGHT USE OF MOLECULAR WEIGHT HEPARIN POST DISCHARGE IF APPLICABLE

CCAC AND/OR OUTPATIENT PHYSIO ARRANGED

DISCHARGE SUMMARY COMPLETED ON VARIANCE RECORD

PATIENT IDSITE: GBHS - Owen Sound

DISCHARGE CRITERIA DATE MET INITIAL

MOBILITY/ACTIVITY


ELIMINATION)

AFEBRILE

VITAL SIGNS STABLE

WOUND INTACT

NIL DRAINAGE

PRESCRIPTION FOR ANALGESIC AND/OR ANTI-COAGULANT AS ORDERED

PROCESS

ARRANGE FOR INR AT HOME IF PATIENT ON ANTI-COAGULANT

FOLLOW UP APPOINTMENT ARRANGED

DISCHARGE PLANNING

MEDICATIONS

REGULAR DIET

SAFE, INDEPENDENT TRANSFERS



EDUCATION

HEALTH TEACHING RELATED TO MEDS

PLANS FOR ANTI-COAGULATION KNOWN & DOCUMENTED ON TRANSFER SHEET





METNOT MET

DATE/TIME INITIAL CODEDATE

RESOLVED(or N/A)

INITIAL

1 q q

2 q q

PRE-ADMIT PHYSIO VISIT

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

TIME FRAME

INDICATOR DESCRIBE CORRECTIVE ACTION

(or N/A if not applicable)

Patient transferred from another hospital? Yes (specify) q ______________________________ Pathway Day: ________ No q

TOTAL HIP REPLACEMENTVARIANCE RECORD

SITE: GBHS - Owen SoundGREY BRUCE HEALTH NETWORK

Total Hip Replacement Post-Op Pre-Printed Orders used: Yes q No q

Discharge Destination: Home q Home with CCAC q Rehab q Hospital q (specify) ____________________________

DAY 1ANTIBIOTIC DISCONTINUED 24 HOURS POST SURGERY

Other q (specify) _____________________________

DISCHARGE SUMMARY: (To be completed upon discharge off pathway or unit)

See back of page for instructions re: Transfer Patients or CCAC Clients

Signature: Date:

Date Pathway Completed: __________________________ Days on Pathway: ___________________________________

Weight Bearing Status: ____________________________

Patient education materials given to Patient: Yes q No q If no, reason: ________________________________________

Patient removed from Pathway before discharge: Yes q Reason: ______________________________________________

Patient teaching completed: Yes q No q If no, reason: ____________________________________________________




1. On Admission:l

l Place the Variance Record behind the clinical pathway on the chart.

2. Documenting the Variance:l For each indicator, tick whether met or not met, indicate the date, time and initial.l If not met, the indicator becomes a variance. State variance code as either A, B or C, and

l Indicate your action plan to correct the variance, or indicate N/A if not applicable.l Indicate the date variance was resolved and initial, or indicate N/A if not applicable.

3. On Discharge:l

l If patient is being discharged home, send Variance Record to Site Champion to be

l

m m

m m

4. Transfer Patients:l

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m

m

m

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A1) B1) C1) B2) C2)

A2) B3) C3) B4) C4)

A3) B5) C5) A4) C6) A5) C7)

C8) A6) C9) A7) C10)

C11)

A8)

- original to stay on patient chart

VARIANCE DOCUMENTATION GUIDELINESVariances 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.

Complete the demographic section: patient age, gender, admission date.

Complete the Discharge Summary.

the number within the category.

forwarded to Evidence-Based Care Program Coordinator.If appropriate, send a copy of the following to the receiving service provider:

Variance RecordBlaylock Discharging Planning ToolSmiley Face Tool

Discharge Criteria

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

Smiley Face Tool - original with patient to receiving hospital

MAR Sheet - copy with patient to receiving hospital - original to stay on patient chart

Anticoagulant Record - copy with patient to receiving hospital

Blaylock Discharge Tool - 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 thepatient’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.

VARIANCE CODESPATIENT OUTCOME VARIANCES PERFORMANCE VARIANCES

A) PATIENT/FAMILY B) CARE PROVIDER C) SYSTEM

Inability to learn skill needed for Lack of or inadequate documentation Bed availabilityself-care Physician/provider response time Schedule conflictInadequate social support or systems Physician preference Consultant unavailableat home Pre-Printed Orders not used OR time unavailableFailure to respond to treatment Orders outside clinical pathway Results/data unavailablePatient/caregiver unavailability parameters Supply/equipment unavailableUnable to return to pre-admission B6) Treatment or intervention omitted Department closedenvironment B7) Other (please specify) Placement unavailablePatient/caregiver decision Home health care unavailableComplication of condition Transportation unavailable(physiological/psychological) Other (please specify)

Other (please specify)




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