Joint replacement path slashes LOS by eight days

New pathway concept stresses analysis of resources

To better encourage physician and staff support for their total joint replacement efforts, a multidisciplinary team at the Hospital for Joint Diseases Orthopaedic Institute (HJDOI) in New York initiated a "new direction" for their critical pathways, says Steven Finch, RN, ONC, director of case management at HJDOI.

The vertical pathway initiative supplemented the hospital’s more traditional horizontal pathway for joint replacement, which had slashed length of stay (LOS) from 13.5 days in 1994 to 5.5 days 1997 for the 1,000 total joint replacement patients who are admitted to the hospital annually. (For sample pathway, see p. 185.)

Despite the significant drop in LOS as a result of the vertical pathway, the hospital found itself in the difficult position of having to negotiate contracts with payers who wanted bigger discounts, case rates, and even capitated specialist global rates, says Finch. "We realized that reducing the length of stay only got you into the game, but to be successful you have to control costs," says Finch.

Indeed, a financial analysis revealed that almost 60% of the hospital’s costs for total joint replacement were consumed in the first 24 hours of care. The days reduced following a clinical pathway initiative for a resource-intensive procedure like total joint replacement are usually the cheapest in terms of hospital costs. "In the present market," adds Finch, "there are diminishing returns for efforts expended to further reduce the length of stay, particularly since it is possible to spend the entire reimbursement before the patient is out of the OR."

Finch and Steven Stuchin, MD, an attending orthopedic surgeon at the hospital, developed the vertical pathway as a tool to identify the resources used on a daily basis for a given procedure. Typically, Stuchin says, physicians are turned off by discussions of cost containment because the decisions are made by administrators, not clinicians. Finch and Stuchin believed they could encourage more cost-effective patient care by giving physicians a mechanism for looking at those resources.

"In developing the pathway, we assumed that the attending surgeons, when given enough information, would select the best course of action in the interests of the patient and the hospital," Finch says.

In addition to identifying and analyzing the cost-efficiency of daily resources, the vertical pathway also calls for a literature search to identify previously published articles for comparative analysis. The results of this analysis and literature search are presented to the Chairman of Orthopaedics and to the medical director for review. Then they’re taken to the entire orthopedic department, where recommendations and protocols are developed, Finch says. "This last step is the most crucial," Finch says. "We realized we were taking a giant leap of faith to assume that the attendings, when presented with the data, would draw the same conclusions we had."

Saving $135,000 on blood donation

The vertical pathway was first used in the area of autologous blood donation. Data demonstrated that patients undergoing primary total joint replacement received on average less than one unit of blood following surgery, yet routinely donated two or more. The vertical pathway further identified that 52% of these autologous blood units were destroyed because the patients did not receive them. The literature search identified a concurrent study underwritten by a manufacturer of erythropoietin, a drug that stimulates red blood cell production, confirming these results in a larger patient group. "When we showed this data to the surgeons, they had no idea this was happening," explains Finch. As a result, a protocol identifying a suggested presurgical donation of one unit was developed, saving the hospital an estimated $135,000 a year.

Since this initial study in January of this year, the vertical pathway has been used to analyze other resources including prosthetics, orthotics, and various drugs, including those used in anesthesia. "In addition, there was the use of blood," he adds. "Whether or not a cell saver in the OR was used, for example. We costed that out at about $600 to $700 per use. And whether a postsurgical blood salvage device was used, at a cost of about $200 per use." Since January of this year, such efforts have resulted in an estimated annual savings of over a quarter of a million dollars.

Finch and Stuchin are confident the vertical pathway concept can be replicated for other resource-intensive procedures such as neuro- and cardiac surgery. In the meantime, the concept will likely be applied to some of the hospital’s high-volume outpatient procedures, including arthroscopy, anterior cruciate ligament repairs, and some shoulder and rotator cuff repairs.

The original pathways that resulted in a dramatically reduced LOS had been developed in conjunction with a multidisciplinary group that included physicians, attending surgeons, nurses, physical and occupational therapists, and discharge planners. Led by Finch and Stuchin, the group provided regular, positive feedback to the rest of the medical and clinical staff throughout the development and implementation process. As a result, the use of the pathway was not threatening to any of the clinical team.

Finch and Stuchin argue that the success of the vertical pathway concept is based upon the premise the hospital should support the physician in his or her mission of providing the patient with optimal, quality care. By allowing the physicians to analyze the data themselves and to incorporate the findings into their own practice, adds Finch, "the vertical pathway bridges the clinical needs of the patient with the fiscal needs of the hospital."

For more information about HJDOI’s vertical pathway for total joint replacement, contact:

Steven A. Finch, RN, ONC, director of case management; Steven Stuchin, MD, Hospital for Joint Diseases Orthopaedic Institute, Bernard Aronson Plaza, 301 East 17th St., New York, NY 10003. Telephone: (212) 598-6000.