Lap choly pathway leads to efficiency, savings

Nurses love to document on pathway

The Promina Gwinnett Health System pathway on laparoscopic cholecystectomy (gall bladder removal) has helped case managers for the Lawrenceville, GA-based system’s surgery programs to standardize supplies and some physician practices, and to implement documentation by exception, says Judy Addy-Keller, RN, MSN, CS, director of coordinated care. (See sample pathway, pp. 126-127.)

Already, Addy-Keller notes that there have been some clear cost benefits. For example, Promina Gwinnett Health System eliminated the use of sequential compression devices, which are used to prevent clotting or deep vein thrombosis for patients who are bedridden, for a savings of $200 a day per patient, she says. Promina Gwinnett Health System’s lap choly patients are admitted to an observation area for just a 23-hour stay, down from two days before implementation of the pathway in July 1996.

Getting a handle on costs has become a mission for Judy Skinner, RN, director of inpatient perioperative services at Promina. "I feel pretty confident when I say that, while a lot of hospitals know their charges, they do not know their cost," says Skinner. "I say this from my past experience. We were always benchmarked on hospital charges, which of course have very little relationship to cost."

She’s rectifying that situation at Promina by doing cost comparisons from surgeon to surgeon for a number of procedures. The comparisons are broken down into four components: supplies, endomechanicals, time, and number of personnel present. "We’re benchmarking them on those four parameters," says Skinner. Promina Gwinnett’s main hospital, Gwinnett Medical Center, is also part of a national benchmarking system — Boulder, CO-based OR Manager — which allows Skinner a national comparison for benchmarking in addition to benchmarking the physicians against one another.

Perioperative pathways reduce paperwork

Because of the low risk of infection related to the lap choly procedure, routine use of pre-op antibiotics has been curtailed, Addy-Keller says. Nurses particularly appreciate the time savings the pathway provides, she says. "Everybody likes the idea of documentation on the pathway," says Addy-Keller. Exceptions to the pathway are noted on a variation sheet, she says. The pathway includes physicians’ standing orders, and any changes must be noted by physicians, she says.

Promina Gwinnett Health System has also just implemented a complete perioperative pathway, including the intraoperative phase, which can be used for most outpatient procedures, says Mary Nash, RN, CNOR, director of outpatient perioperative services.

For patients who undergo the lap choly procedure at Promina’s Joan Glancy Memorial Hospital, an outpatient facility, the pathway begins with an interview a few days before surgery, and continues on through the preoperative and intraoperative stages, as well as phase one and phase two of recovery. Patients stay in the clinic for about six hours of observation before being placed on the hospital lap choly pathway.

One major advantage of the perioperative pathway is that it dramatically cuts paperwork through documenting by exception, says Nash. "Sometimes when we’re doing these very short cases, it takes longer to do the documentation than it does to do the procedure," she says. "We do have to write variations, but we’ve established standard practices and set up guidelines about what gets included where. When you chart that something happened, then that’s all you do. You don’t have to chart a lot of arratives."

As usual, docs are slow to buy in

Nash and Addy-Keller developed the perioperative pathway with the help of a team including representatives from the same-day surgery centers at both Gwinnett Medical Center and Glancy Memorial, the director of inpatient surgery services, two performance improvement chairpersons, the laser/endoscopy coordinator, a surgical clinical nurse specialist, and a nurse educator. Addy-Keller also sought input from each physician.

Most physicians have adapted well to the lap choly pathway, but Addy-Keller acknowledges that gaining physician acceptance isn’t always easy. While some are "champions" of the effort to improve both efficiency and quality, others are resistant to change, she says.

Physicians are not required to use the pathways, she says. Some physicians fear that the pathways remove their autonomy, Addy-Keller says. "This isn’t taking away their autonomy," she says. "It’s standardizing practice." Physicians still make individual decisions about patients as necessary.

To gain physician acceptance, Addy-Keller often meets with physicians one on one. She also posts a list of physicians who are using the pathway and its standing orders, which provides some peer pressure.

For more information about Promina Gwinnett’s lap choly clinical pathway, contact:

Judy Addy-Keller, Director of Coordinated Care, Promina Gwinnett Health System, P.O. Box 348, Lawrenceville, GA 30246. Telephone: (770) 995-4643. Fax: (770) 682-2249.

Mary Nash, RN, CNOR, director of outpatient perioperative services at Promina Gwinnett Health System. Telephone: (770) 995-4179.

Judy Skinner, RN, director of inpatient perioperative services at Promina Gwinnett Health System. Telephone: (770) 995-4662.