CABG path yields savings, but proves ‘user unfriendly’

Path team goes back to the drawing board

The introduction of clinical and patient paths for coronary artery bypass graft (CABG) and valve replacement procedures at Bakersfield (CA) Memorial Hospital in August 1994 could not have gone better. Or so it seemed.

"Charges fell $246,000 in in the year after initiation of the path for CABG DRGs 106 and 107 procedures," says Chris Maupin, RN, MN, CCRN, nurse manager for case management services at Bakersfield Memorial. Much of this resulted from the up-front savings of fewer ventilator hours and transfer to telemetry. Due to a change in the anesthesia regimen, extubation times dropped every year for the 450 cardiac surgery patients treated at Bakersfield, from an average of 18 hours after surgery to 11 hours, with 60% of patients falling in the five- to seven-hour time frame.

As successful as the paths seemed, something was wrong, Maupin says. Initially, about 90% of all cardiac surgery patients were put on the clinical path. A year later, only about 40% of patients stayed on the path to the end. By June 1996, the care path team made the difficult decision to suspend its use and find out what was the matter.

Maupin offers the following explanations:

• a cumbersome format;

• insufficient training of telemetry floor staff to prepare them for the higher-acuity patients leaving the intensive care unit (ICU);

• no permanent and formal group to monitor the path’s use;

• difficulty in understanding and following the path.

"It just didn’t have a user-friendly feel," Maupin says. "It was seen as another piece of paper, not accessible, [requiring] double charting. We needed to make the pathway more manageable and meaningful."

Another problem was that the original path team, which included representatives from surgery, anesthesia, finance, and critical care nursing, met only informally, with "no set expectations of participation," Maupin says. As a result, the project gradually lost steam. Now, new job descriptions have been developed that formally spell out committee participation and responsibilities for monitoring and managing clinical paths.

Maupin also initiated a more formalized approach to launching the revised pathway, introducing it at all the staff meetings, as well as in the hospital newsletter and physician newsletter for final comments and criticisms.

"Full involvement by the staff in the process is very important," Maupin says. "They have to know at least that a member of their individual team is involved in the development process. Then, those people going back can share their enthusiasm."

The path’s new format places each day on its own page. A care path progress sheet is also attached to the care path so pertinent focused charting and variances can be documented. The cardiac paths are now placed in binders at each patient room doorway for easy access.

Maupin is confident now that the pathway — and the staff who created it — have weathered the storm. She reports that the revision process has led to better teamwork and greater efficiencies. "Prior to the new care path, patients were transferred to the telemetry floor on post-op day two," she says. "We currently transfer 50% of patients on post-op day one and many in less than 24 hours post-op." In addition, complaints of endotracheal tube discomfort have decreased and unplanned ICU readmissions and reintubations have not risen, Maupin says.

While the clinical path had its problems, the patient care path met with significantly more success. The patient care path, which is posted in the hospital room, is used as an education and reference tool for patients and their families. All elective surgical patients receive the care plan as part of the preadmission process. Besides setting patient expectations for surgery and recovery, the plan answers questions about family visiting, patient rights, tests, and typical physician consultations.

"It was well-implemented by the cardiac educator and fairly well-utilized in CV [cardiovascular] recovery, where it was kept at the bedside," Maupin says. Since its introduction, preadmission times have dropped from five hours to 21¼2 hours. The hospital has also produced English and Spanish language teaching videos to work in conjunction with the patient care path. It is available at the surgeons’ offices, at the preadmission appointment, and on the nursing units for inpatients.

Maupin and her colleagues at Bakersfield Memorial have been pleased with the review-and-revise process. The hospital will likely use the same or a similar process to reassess several other paths that have also seen decreased use.

For more information about the CABG pathway, contact: Christina Maupin, RN, MN, CCRN, nurse manager for care management services at Bakersfield Memorial Hospital, 420 34th St., Bakersfield, CA 93301. Phone: (805) 327-4647, ext. 3383.