Development of a Critical Pathway for Patients with Coronary Artery Bypass Graft

Kim, Gi Yon

Abstract

The purpose of this study was to develop a critical pathway for case management for patients who have received Coronary Artery Bypass Graft(CABG) because of Ischemic Heart Disease(IHD) which is a factor of rising medical expenses. For this study, a conceptual framework was developed through a review of the literature including six critical pathways which are currently being used in USA. In order to identify the overall service contents required by these patients and to draw up a preliminary critical pathway, 30 cases of medical records of patients who had CABG because of IHD between January, 1995 to June, 1996 at the Cardiovascular Center of Yonsei Medical Center in Seoul were analyzed. An expert validity test was done for the preliminary critical pathway and clinical validity test was also done using seven IHD patients with CABG between November 11 and 23, 1996. After these processes, the final critical pathway was developed. The results of this study are summarized as follows : 1. The vertical axis of the critical pathway includes the following eight items, nutrition medications, consultations, activity, assessments, treatments, education discharge planning and the horizontal axis includes the time from the start of hospitalization to discharge. 2. Analysis of the 30 medical records indicated that the average length of stay was 20.2 days with the average length of stay from hospitalization day to operation day being 6.2 days, and the average length of stay from operation day to discharge day was 13.9 days. Analysis of the service contents showed that the horizontal axis of the preliminary critical pathway was set from hospitalization to the 14th post operation day and the vertical axis was set to include eight items, the contents which ought to have occurred, according to the time frames of the horizontal axis. 3. As a result of the experts validity, it was found the among the total of 571 items, there was over 83% agreement for 482 items, less than 83% for 89 items, which were then deleted and a revision of the critical pathway was done. 4. A clinical validity test was done using seven, IHD patients with CABG. During the process, three patients were deleted because they were out of the criteria the investigator set. Finally, four patients were used. The result of study indicated that only one patient was discharged on the tenth post operation day. which was one day later than the expected day. Three patients were discharged later than the expected day from three days to nine days. All the cases progressed on schedule until the operation day and the first post operation day. but from the second post operation days, there were differences between the critical pathway and the actual practice. The differences came from tests, assessments, and treatments. 5. On the basis of the results of the clinical validity test, the following revisions in the final critical pathway were made : the transfer from ICU to step down ward would be the second post operation day, and the transfer to a general ward, the fifth post operation day, for patients who complained of lack of sleep from the fifth post operation day to discharge, a sleeping pill would be prescribed, skin observations would be performed routinely from immediately after the operation until the third post operation day, and would continue if there was a sign of skin injury on the fourth post operation day, and assessment of chest pain would be done from the third post operation day, and the "stairs climbing" item, expected to be done on the ninth post operation day would be deleted. In conclusion, this critical pathway is partially applicable to the care of patients with CABG but there are some parts needed to be further investigated.