Facility attains 6.8% CHF recidivism; LOS drops by more than 50%

Pathways increase home care and outpatient services referrals

A Delaware hospital was having problems with its management of congestive heart failure (CHF) patients. More than 90% returned within the year, and their average length of stay (LOS) reached 11 days. A multidisciplinary team joined forces with the cardiac department and met the challenge: Together they initiated clinical pathways that increased referrals to home care and outpatient services.

The results have been remarkable, says Heidi LeGates, MSN, RN, clinical outcomes specialist for Milford (DE) Memorial Hospital, a 180-bed community hospital that serves the town and surrounding rural area.

After one year of the program, only two out of 29 CHF patients returned to the hospital - a 6.8% recidivism rate, she says. None were treated for myocardial infarction, and the LOS fell from 11 days to four. Referrals to home care have increased from less than 30% to more than 51%. In addition, the number of patients who return to the hospital after being admitted to home care has dropped, says Barbara Peterson, RN, MSN, director of home health services for Milford.

Before the program started, patients were treated at home for three months; now they are referred simultaneously to outpatient cardiopulmonary rehabilitation within two to three weeks, says Cathy Schenker, RN, BSN, manager of home health.

The CHF clinical pathway has worked so well that Milford also has set up pathways for pneumonia, orthopedic conditions, asthma, cerebral vascular accident, and other diseases.

Here is how the multidisciplinary team succeeded:

They looked at data from other hospitals.

"Everyone in the group was looking at benchmarked data," LeGates says. They looked at clinical studies from Voluntary Hospitals of America in Dallas and guidelines from the American Heart Association, also in Dallas, as well as other data. Team members also compared Milford's data on CHF patients with guidelines published by the Agency for Health Care Policy and Research, part of the Department of Health and Human Services in Washington, DC. The team adopted those guidelines and used them to devise a clinical pathway.

Each discipline contributed to the pathway.

Nurses looked at nursing care; physical therapists contributed their segment; and X-ray technicians, laboratory workers, dietitians, and other clinicians added sections. Milford's home health providers, for example, met with the cardiopulmonary rehabilitation providers to discuss how home care would lead patients to the rehabilitation portion, Schenker says.

"We said, 'If our goal is to have our patients come to you as quickly as possible, what criteria do they have to meet so they can do that?'" They came up with a list of eight criteria that would have to be met for three consecutive visits.

The pathway was divided into sections, and each subgroup had a goal - the expected outcomes of patients upon discharge. "Then we'd build the pathway around physician orders as well," LeGates explains.

"The team worked with physicians to see what would be the best practice," she says. The team met weekly at first; later the meetings slowed to biweekly and finally once a month.

Pathway components include lab testing, the emergency department (ED) process, patient education and home care, nursing, and respiratory care. Physicians were a part of the overall group. Numerous other hospital committees reviewed the pathway to make sure it met legal criteria, and then the team presented it to the medical staff.

The team worked to obtain buy-in from medical staff.

"Rather than present this as a pathway, which is sometimes mistaken for cookbook medicine, it was presented as a new standard for care," LeGates says. Some physicians, including those in family practice, embraced it immediately, she adds. But some of the internal medicine physicians, who had been in practice for a long time and who had not adapted to thinking in terms of managed care, were reluctant.

Team members continued to lobby staff to try it. They focused on how the pathway was based on national standards, and the pathway only required providers to do the things the patients need to have done anyway, LeGates adds. "We can't tell them how to practice medicine, but we practice nursing so that we deliver the same standard of care whether a physician has ordered the pathway or not."

The team created a version of the pathway for patients.

The team developed a chart version and a patient version written at a sixth-grade reading level. "Patients have in their hands from the time they are admitted what is expected of them and what is expected of the staff," LeGates says. The patient's pathway, for instance, might say that the patient should get out of bed on a certain day and try walking. Or it might show what types of tests the nurses will need to conduct on certain days. The patient's pathway also includes the following information:

- what the discharge plan will be;

- how the hospital will communicate with the insurer;

- how to take medicine;

- what activities the patient should do;

- who the provider will be when the patient returns home;

- when the home care provider will visit.

"We make an educational assessment of what the patient needs to know and what the patient doesn't know, and then we collaborate with the home health providers so the information is sent to them," LeGates explains.

The team implemented the pathway and educated staff.

The hospital started a pilot project with the CHF pathway, starting with outpatient services. It lasted two months and involved six patients. Then the hospital started a six-month trial of the entire pathway, which involved 18 patients.

The outpatient pathway specifies that if a patient is admitted to the ED and needs to be treated aggressively with diuretics, he or she is admitted to the hospital on an observation basis for 12 to 24 hours to check the response to treatment, LeGates says. If the CHF is not severe and the patient's condition improves after treatment, the patient is discharged and referred to home health care.

The hospital staff on the intermediate care unit underwent eight hours of inservice education and were given an extensive review of cardiopulmonary physiology and assessment, LeGates says.

"The nurses on this pathway are expected to measure jugular venous distension, which means you've got a right-sided heart failure," she explains.

They were taught to listen to heart sounds in detail and to measure the circumference of patients' ankles, rather than use subjective measurements for ankle edema.

The home health nurses also underwent eight hours of education, and the hospital held multiple inservices for staff over a two-month period. "The intermediate care staff and home health nurses were required to attend the inservices, but we had interest from the medical-surgical nurses as well," LeGates adds.