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POSNA PreCourse Quality, Safety, Value: From Theory to Practice Management Session 4 Deliverables Supracondylar Clinical Pathway.

C linical pathways are designed to standardize care processes, reduce variability, and promote patient safety. They use the principles of “process management” emphasizing teamwork while detailing the various steps a patient undergoes during an episode of illness. They try to capture foreseeable events that occur along the pathway of care and apply practices based on the best evidence for safety and effectiveness. Metrics are gathered simultaneously. More than half the patients admitted to Seattle Children’s Hospital are managed using a clinical pathway. The orthopaedic department has developed several evidence-based pathways and the supracondylar pathway is one example. The AAOS evidenced-based clinical practice guidelines on management of children with supracondylar fractures of the humerus1 served as the foundation for the clinical pathway. Clinical pathway development involved: (1) Delineating patient flow diagrams for patients entering through the emergency department and progressing through to surgery and then to discharge home. (2) Developing standardized ordersets to avoid duplicate and contradictory orders with options to add specific orders as needed. The orders were arranged in our electronic medical record in a sequence that mirrors how residents think. (3) Safety process checklists were then developed. Safety process checklists are well established tools for improving process and performance. They are known to improve team communications and reduce errors. They include process steps where there may not be conclusive evidence and they allow for individual variability while at the same time promoting safe and sequential care for patients. Our checklists used a yes/ no option with a “no” check requiring a “text box” justification. (4) The checklists are then imbedded in the ordersets, being triggered when the orders are readied for signature. Checklists must be completed by the resident before the patient is handed off from one locale to another (eg, emergency department to operating room; operating rooms to the PACU; and hospital to home) for a total of 3 checklists per patient. (5) The attending surgeon is responsible for safe, highquality performance by the residents and thus attending attestation of the resident’s checklist is required. (6) Metrics were added to monitor resident/physician compliance and patient outcomes. In addition, standard hospital metrics such as length of stay and cost are included. The supracondylar fracture pathway was initiated in August 2012. We analyzed the results of our first 315 patients, and 3 lessons learned are summarized: (1) Compliance was better than expected. The goal was to achieve 100% checklist activation by the resident and 100% checklist attestation by the attendings. Although compliance was good it was not ideal. Since