Rhyan Sickle Cell patient smilingTamnysha Roberson knew the drill. Her 5-year-old daughter, Rhyan, had spiked a fever, so once again they were off to Children’s Hospital of Philadelphia.

Rhyan has sickle cell disease, which, among other complications, puts her at risk for serious bacterial infections. For years, established practice had been to admit sickle cell patients to the Hospital anytime they develop fever.

When Rhyan and Tamnysha arrived at CHOP’s Emergency Department, Rhyan was given IV antibiotics, carefully monitored for several hours and then, to the immense delight of both mother and daughter, sent home. They were spared a Hospital admission thanks to an innovation known as a Clinical Pathway.

The land of variation

“It’s a great time to be in medicine,” says Jane Lavelle, MD, associate director, Emergency Medicine. The explosive growth of new knowledge, coupled with technological innovations, creates more possibilities to help patients than ever before. It also creates new challenges. Changes in practice are constant. Millions of scholarly articles are published each year. No matter how diligent the physician, keeping up can be difficult. Which can foster what Lavelle calls “the land of variation,” a place of widely differing ways of treating similar patients, with the potential for widely differing outcomes.

The team in CHOP’s E.D., who see the broadest imaginable spectrum of illness — including nearly 70 percent of the patients admitted to the Hospital — had an idea: Gather clinicians from multiple disciplines and collectively figure out how to standardize care.

And so the idea for Clinical Pathways was born.

Minds over matters

“We bring together a multidisciplinary group of experts who are up to date on the latest literature, who have a lot of experience with a particular condition or process of care,” says Ron Keren, MD, MPH, chief quality officer. The teams that create the pathways reconvene at regular intervals to measure outcomes, review evidence and consider: Should we do anything differently? Should we change our recommendations? It is a continuous cycle of learning and improvement.

Ron Keren MD, MPH and Jane Lavelle MDRon Keren, MD, MPH, and Jane Lavelle, MD, have spearheaded institution-wide work to create nearly 90 Clinical Pathways. Thanks to a Pathway addressing fever in sickle cell disease patients, Rhyan, 5, spends much less time in the Hospital.
And what about those who see standardization as “cookbook medicine”? Keren stresses that pathways are a guide, not a mandate. In fact, having a protocol in place that streamlines care “opens up time to talk about the kids who don’t quite fit the pathway, to customize care for kids who need it.”

Today there are nearly 90 clinical pathways in place (with more coming online all the time), spanning topics from asthma to appendicitis, and informing care in all CHOP settings — inpatient units, ORs, primary care practices, as well as the E.D. Keren’s Office of Clinical Quality Improvement has also created tools to make following the pathways easier for clinicians, such as order sets built into the electronic medical record with recommended tests and treatments preselected.

For the wider world

The team takes particular pride in providing Clinical Pathways to clinicians everywhere. All are available on CHOP’s website, and about half of the 30,000 views they receive each month are from outside the Hospital. “It’s a way for CHOP to provide leadership and have an impact on the quality of care kids receive around the world,” says Keren.

Rhyan with her familyFor Rhyan, the benefits live much closer to home. Thanks to a pathway based on evidence that sickle cell patients deemed “low-risk” can safely be treated for fever at home, Rhyan’s yearly Hospital admissions have been cut in half. That leaves more time for much more important activities like playing with her dog, Foxy.

“We are surrounded by excellence in this Hospital,” says Lavelle. “If we can engage clinicians in creating standards of care, unleashing the creative energy and brilliance of people throughout the institution, that’s incredibly powerful.”