Continuum-focused CHF care cuts LOS to 4 days
Telemanagement reduces readmissions to 2.6%
A congestive heart failure (CHF) pathway at Evanston (IL) Hospital has reduced length of stay there from 6.2 days to four - almost three days below the national average, according to Health Care Financing Administration MEDPAR (Medicare Provider Analysis and Review) statistics. Hospitalization rates have dropped by 50%. At the same time, direct treatment costs dropped by 60% over two years, boosting the facility's annual revenue by $1.6 million.
Lisa Mischke, RN, MSN, inpatient CHF coordinator at Evanston, says the main reason for the pathway's success is that it allows clinicians and staff to access resources quickly. On admission, the house staff fill out a set of preprinted orders for each heart failure patient, she says. "Then the cardiac rehab team is consulted, dietary is consulted, and the case manager gets a phone call saying,'There's this patient in room X.' It gets things moving quicker, and it makes clinicians consider options on admission rather than waiting three or four days."
Evanston's continuum approach has been vital to the pathway's success, Mischke says. She points out that the hidden cost of CHF for hospitals is the readmission of Medicare patients within 30 days of discharge. During that time frame, the hospital is typically unable to bill Medicare for additional costs. One way Evanston has been able to lower its 30-day readmission rate from 19% - already 4% lower than the national average - to only 2.6% is through the development of an innovative telemanagement program. CHF patients who have been referred to the program by their primary care physicians dial into the hospital's automated system on a daily basis. During the call, patients enter their daily weight and answer 10 questions related to their heart failure, such as whether they're short of breath or experiencing fatigue or swelling.
"After they hang up, we get a computerized screening," Mischke says. "If they fall out of a certain range, then they appear on the computer. If they're up two pounds and they complain of shortness of breath, we give them a call at home and counsel them on what to do with their medications."
Monitoring systems such as the one used at Evanston have a portable monitor, scale, blood pressure cuff, finger probe for blood oxygen, and a pulse rate and glucose monitor. If measurements aren't received or deviate from a preset level, an alarm sounds prompting a follow-up call.
Evanston is a 350- to 400-bed acute care teaching facility. The payer market for the cardiac department is 30% managed care and 70% Medicare. The CHF pathway was implemented 22 years ago following the creation of a series of successful surgical pathways, including one for coronary artery bypass graft. The CHF track was one of the hospital's first nonsurgical pathways, and was well-received because physicians had positive experiences with previous pathway efforts, Mischke says. Physicians and staff were used to Evanston's multidisciplinary approach to pathway development, bringing together representatives from different disciplines - such as cardiology and pharmacy - to hammer out differences and craft a workable pathway.
Get physician buy-inThe real key to getting physician buy-in is making internists, cardiologists, and emergency department physicians feel as though they're all a part of the decision-making process, Mischke says. The team met once a month, then biweekly as the pathway developed.
"I can't tell you how many times I heard the term 'cookbook medicine,'" she continues. "The younger physicians, especially the house staff, were resistant to pathways in general." The team handled that by connecting their pathway to the Advanced Cardiac Life Support (ACLS) certification, which specifies a particular way of doing things. "We emphasized that we weren't trying to think for them. Rather, this was the best practice."
To keep physicians from having to juggle schedules to hold separate meetings, the hospital made a point of introducing the pathway during physician-led grand rounds, attended by all house staff and some attending physicians. They used that forum to go through what the pathway involves and how it should work as a way of getting everybody up to speed.
"We had grand rounds to which everyone was invited," says Mischke. "We taught the document's key components and why we felt the pathway was important." Because grand rounds are physician-led, Mischke says that was key to the pathway's success. "I'm a nurse," she says. "And I'd never put down what I do, but it's important that physicians get buy-in from other physicians."
Searching for CHF patientsAs the primary case manager for the pathway, Mischke identifies CHF patients early by checking in with the specific areas of the hospital where heart failure patients are most likely to be admitted. "I go through their Cardexes and identify heart failure, pulmonary edema, and any other diagnosis that would lead one to believe there's heart failure," she says. "At the beginning, you really have to encompass everybody that comes in with a diagnosis requiring IV diuresis and a chest X-ray with heart failure."
Following preliminary screening, Mischke goes through each patient's chart and begins data collection. Patients diagnosed with CHF are placed on the pathway. Once there, Mischke assumes a supervisory role, making sure patients receive the proper clinical intervention and education at the appropriate time. "Education is the crucial aspect of the CHF pathway," she says. Unit nurses provide each patient with a folder of educational material and show them a video detailing their condition and how to manage it. Patients are then instructed to take all this information home with them, Mischke says. (See patient education sample, CHF discharge instructions, pp. 57-61.)
The place to educate people, she says, isn't in the hospital. In the hospital, patients nod their heads and say "Yes, yes." Their focus changes when they get home. "You have to follow them across the continuum by getting home care involved," Mischke says. "There should be communication between the inpatient case manager and the home care nurse so one can say to the other, 'We started this, but they didn't quite understand, so could you follow up?'"
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