Pathways incorporate best practices, shorten LOS

In additional to reducing ancillary costs, Erlanger Medical Center in Chattanooga, TN cut lengths of stay (LOS) by 1,085 days annually by implementing pathways for open heart surgery and angioplasty. (See charts, at right.)

For example, the total LOS for DRG 106 (coronary artery bypass graft with catheter) went from 10.5 days to 8.9 days — almost meeting the national benchmark of 8.3 days as established by LBA Healthcare Solutions, an HCIA company headquartered in Englewood, CO. Similarly, the total LOS for angioplasty was reduced from five days to 3.9 days, compared with LBA’s benchmark of 2.7 days. (Outpatient volume, which was not included in this benchmark, grew from less than 5% to 50%.)

Get outside the box

They achieved these savings by using care paths and case management that stress the following best practices, says Nina Styles, RN, BSN, CCM, cardiovascular case manager. The benchmarking team identified these benchmarks through literature searches and careful examination of care practices at benchmarked hospitals in the Southeast and on the West Coast. (See related story, p. 137.)

1. Break with tradition to reduce nonmedical delays in pre-op.

Styles works with three other hospitals in Erlanger’s network to have patients transferred early the morning of surgery rather than the night before. Over the past two years, her teams have decreased preoperative waits from an average of 3.8 days to 0.6 days. But this entailed more than scheduling those patients for an 11 a.m. or later surgery.

"In order to increase staff knowledge at the other hospitals, we provided nurses with both video and print material as well as shared a copy of our care paths," she explains.

In fact, nurses from the other — and sometimes competing — facilities were invited to attend an orientation and inservice where they were given a copy of the pathway to modify for their institution. "We have them stay for a day so they can see exactly what happens with our bypasses and how we do patient education," Styles says.

She also worked with the executive management team at each hospital to facilitate transfer. "You have to handle this delicately because of the politics involved," she stresses. "You just can’t go in and say, ‘You need to do this for us.’"

2. Implement a rapid recovery program.

For coronary artery bypass graft patients, the team set a post-operative LOS of five days. "The percentage discharged within five days of surgery is now 52% compared to our baseline of 43.1%," Styles says.

A rapid recovery program is possible because of components such as early weaning from ventilators, early ambulation, discharge to home health, and patient pathways, she adds. "With an early vent weaning, we can transfer them out of critical care sooner so they can get up to their room and start ambulation."

The target time for ventilator weaning is six to eight hours, but getting patients off vents in a timely manner depends on the type of drug administered during surgery, Styles explains. "We had to work with anesthesiologists to alter the drug regimen so that we could reach our extubation goal of six to eight hours."

Early weaning also is reassuring to patients and family, she says. "When they’re on a vent-ilator, they can’t talk or drink or cough as effectively. Removing them from the ventilator often helps them to normalize as quickly as possible."

For diabetic patients who take medications by mouth and need to get back to their diet, early weaning is especially important and can prevent complications.

3. Early and comprehensive patient education.

Patients learn what to expect during preadmission teaching with their own version of the care path, a concise easy-to-read document that outlines the steps before during and after surgery. For each day, these questions are answered:

• What room will I be in?

• What tests will I have?

• What kind of equipment/tubes will I have?

• What treatment will I get?

• What medicine will I take?

• What can I eat?

• What can I do?

• What will I need to know?

• How will I feel?

4. A pathway that bridges the continuum to home care.

A home health care pathway continues after discharge, Styles explains. "This plays an important part in reducing LOS. In addition to in-home monitoring by home health nurses, the hospital also pays one or two courtesy visits to make sure there are no problems," she says.

The visits are conducted even if insurance does not reimburse for the service. "It pays for itself by keeping readmission rates down," she explains.

LOS for angioplasty patients with coronary stents also has been reduced with a rapid recovery program that features use of aspirin and Ticlid, a new antiplatelet drug. Aspirin and Ticlid are taken 24 hours before the procedure and 30 days after.

"When we were using Coumadin and Heparin, patients had to stay in the hospital just to be monitored and regulated, but with this change in medication regimen, about 50% of patients are now discharged after 23 hours," she says. (Acute myocardial infarction patients are an exception, with an LOS of two to four days, she notes.)

Outcomes remain the same. "In addition to tracking readmission, we conducted a two-month follow-up with cardiologists who checked patients for bleeding and clotting," she says.

(Editor’s note: For more information, contact ina Styles, Erlanger Medical Center, 975 E. 3rd St., Chattanooga, TN 37403. E-mail: tstyles@utc.