Preadmission testing, assessment reduce cesarean LOS

By Liz McKinlay, RN

Project Manager

Nyack (NY) Hospital

Expectant mothers who require a cesarean delivery are benefiting from a preadmission testing phase and earlier assessment for home health intervention as a result of a clinical pathway for uncomplicated cesarean that begins before hospitalization.

Average length of stay (LOS) for cesareans has dropped from 4.28 days in 1992 to 3.54 in 1995. The pathway was implemented in August 1992. Annual reviews of the pathway by the pathway development team have led to two revisions of the original pathway. First, the pathway was revised from a five-day LOS to four-day LOS to reflect improvements in average LOS. Lactation suppressants originally were administered on day two of the path, but now are administered only if indicated. (To see other medications administered on day two, see the medications and IV therapy column under day two of the uncomplicated cesarean section path, p. 56.)

Most recently, the path has begun incorporating earlier introduction of home care services to patients. Delays in getting patients referred to home health agencies during hospitalization led to a meeting with home health agency representatives in early 1995. The collaborative efforts between the pathway development team and home health nurses resulted in a set of guidelines for OB/GYN patients at our 250-bed community hospital.

Patients are informed about home health care six weeks before scheduled delivery. An inservice was conducted by the home health care maternity director to educate hospital staff nurses about treatments and services provided by a home health nurse. Posters also are displayed in the OB/GYN unit informing patients about the availability of home health care.

Additionally, home health nurses received a copy of the hospital's clinical pathway to see what treatments and actions are performed while the patient is hospitalized. Currently, home health pathways are being developed by the agency for vaginal and cesarean deliveries.

Pathway development projects are identified by a hospitalwide council that includes department chairs for each specialty. After a procedure or treatment is identified, a development team is assembled by the project manager. Internal practice pattern data, research materials, and literature citations are assembled prior to the development team's first meeting. Typically, pathways are developed within two to three meetings. Annual revisions of existing pathways are conducted through the mail or by a team meeting.

The cesarean pathway development team consisted of representatives from the following departments:

* obstetrics medical staff;

* nursing;

* dietary;

* social services;

* discharge planning;

* patient education.

The pathway development process at Nyack involves the completion of three documents used by nurse managers: a clinical pathway, a clinical outcomes pathway, and a variance tracking record.

Clinical outcomes are formatted on a document similar to the clinical pathway. That tool assists caregivers in determining variances and eliminates the collection of insignificant data. The four-page path for clinical outcomes is not a documentation tool and is a separate document from the clinical version. Outcomes listed on the document cover the entire patient stay in the hospital.

Under patient care needs on the clinical outcomes path, for example, a clinical outcome is established for changes in patients' comfort levels due to incisional pain and other pain resulting from surgery. A positive patient outcome during the pre-op phase is: Patient will verbalize understanding of type of anesthesia and post-op pain management schedule.

Additional clinical outcomes categories are used for the following:

* potential for impaired uterine involution;

* potential for hemorrhage;

* potential for infection related to surgical procedure and breast engorgement;

* potential of impaired circulation/thrombophlebitis due to immobility;

* alteration of fluid balance due to surgical procedure/epidural anesthesia;

* alteration in bowel elimination related to abdominal surgery;

* potential change in parenting due to cesarean;

* fear and anxiety related to knowledge deficit in self/infant care and hospitalization;

* potential for altered self-concept related to unplanned cesarean.

Variances are documented on a separate tracking record by any caregiver involved in treating the patient. Currently, data are analyzed manually by the project manager, but a new management information system will be fully operational by this summer. After management and staff are trained, clinical data will be entered into a clinical pathway analysis module of Atlanta-based HBO & Company's software.

Cesarean patients are surveyed prior to discharge using an internally developed questionnaire. An additional survey is conducted for hospitalwide use approximately two weeks following discharge. Patients previously at Nyack for cesareans, for example, are surveyed about their most recent visit.

Currently, pathways are initiated by staff nurses on each unit of the hospital. A unit-based case management model was piloted on the cardiology unit in late 1995. The pilot involves a case manager who tracks the patient from admission to discharge. Plans are to implement case management hospitalwide by June.

Other pathways developed at Nyack include:

* asthma;

* pneumonia;

* congestive heart failure;

* total hip replacement;

* transurethral resection of the prostate;

* laparoscopic open cholecystectomy;

* myocardial infarction;

* cerebrovascular accident;

* angina pectoris;

* cellulitis;

* pediatric diabetic ketoacidosis;

* hemorrhagic gastritis;

* intestinal obstruction;

* septicemia;

* syncope;

* tonsillectomy and adenoidectomy;

* elective cardioversion. *