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.”