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Ventilation time is cut from 12 hours to six
Timing was everything when it came to developing the successful coronary artery bypass graft (CABG) pathway at St. Francis Hospital and Health Centers in Beech Grove, IN.
Five years ago, members of the cardiac team proposed the idea of pathways to the cardiac surgeons with whom they worked. "We said, we really want to do pathways, they’re the wave of the future," says Kathy Fox, RN, MSN, cardiac service line director at St. Francis. The response they got back was typical: "They gave us the same old story about it being cookbook medicine. They still had that perception."
Two years later, however, the situation at St. Francis had changed so drastically that the physicians themselves were requesting that pathways be developed, Fox says. "When we started talking to managed care companies and getting cardiac carve-outs, everybody started asking, What about pathways?’ Because that was the buzzword," Fox says. "Then physicians were coming to us and saying they really needed those pathways."
The movement to create a CABG pathway gained steam when hospital management implemented eight service lines divided by diagnosis-related groups.
"To go to the service line concept required an entire redesign of how we provide care to patients," explains Jerri Devaney, RN, a cardiac service line care manager at St. Francis. "With that in place, we went to work on our length of stay. Back then, our patients stayed two and a half or three days. [Our goal was] a one-day stay in recovery, so we had some work ahead of us to make that happen."
"If we were going to decrease length of stay in the recovery unit, the staff in the step-down unit needed to be prepared to take care of those patients," says Fox. For that reason, she initiated staff cross-training in Levels 1 and 2 of the cardiac surgery unit (CSU) — the open-heart recovery unit and the step-down unit. "We sat down with the physicians and administration and said, [Decreased length of stay] is what we want to achieve; this is how long it will take to do it.’ We told them that we needed to cross-train all the staff in the step-down unit to CSU Level 1."
Devaney points out that when you decrease the length of stay (LOS) in higher acuity levels, you substantially decrease cost. The room rate for the CSU Level 1 is about $1,200 per day.
When it came to designing the CABG pathway, Fox and her colleagues didn’t have to start from scratch. The physicians who had originally resisted the pathway concept were already using a lot of preprinted orders and protocols, to the extent that most pathways already followed a sort of informal pathway, says Kelli Kappus, RN, BSN, CCRN, manager of the CSU Levels 1 and 2.
"Our starting point was to take what we already had as far as their preprinted routines for all patients, set these against a time frame, and then develop a pathway," Kappus says. "We used that as a starter, then set goals for what we wanted to achieve." Some of those goals included transferring the patient from the CSU on the first postoperative day, ambulating the patient on the same day, and discharging the patient on postoperative day four. (See sample pages from the pathway, pp. 128-129.)
The service line has decreased recovery LOS to one day (80% to 90% of patients move out on post-op day one). Because of that, the hospital is going to open up some ventilator beds in the unit. The reason most patients don’t transfer out of the CSU on the first post-op day is because pulmonary problems often exist and need to be monitored; therefore, the patients must stay longer.
Another goal was to extubate patients earlier, in accordance with accepted national guidelines. To achieve that, the staff had to promote change in the anesthesia department’s protocols on providing short-acting medicines. "We went from a 12-hour to a six-hour ventilation time," says Devaney. "Patients do better on shorter time, because staying on the ventilator overnight is not good for the respiratory system. When patients are extubated sooner, their risk of pneumonia is decreased, as well as problems like phlebitis."
However, she says, there is a point at which you can safely and cost-efficiently push the envelope, and a point at which you have to stop. "That’s where we are now with our ventilator hours. We’ve decreased them to six, and we haven’t seen an increase in our reintubations."
St. Francis occasionally has patients who can move out of the CSU the evening after their surgery — as quickly as six to seven hours after minimally invasive surgery.
"There may be opportunity for improvement there," says Fox, "but we have to be cautious and monitor those cases. You don’t want patients coming back because they’ve been moved out too quickly." The cardiac department has decreased its LOS without increasing readmissions to the unit.
The ultimate goal of the cardiac line staff is to eventually have the recovery area and the step-down unit combined. "Our goal is to not have to transfer patients at all," says Fox. "It’s not efficient to have two separate units and two separate staffs."
With a reduced LOS, the cardiac team finds that some patients need more time for education than is possible during their short stay. St. Francis provides pre- and postoperative housing and training for patients and family that provides a transition to home.
"Education nurses there go over rehabilitation, incision care, when to call the doctor, and other matters so the patients and families understand completely what’s going on," says Devaney. "Some readmissions occurred because patients didn’t understand some aspect of their care when they were discharged. That may be the result of anxiety, or perhaps they were under the influence of their pain meds." Sometimes, she explains, a patient is on a medicine preoperatively, but doesn’t realize that his post-op meds may be the same but have a different name. There’s a risk of doubling up.
St. Francis operates 480 to 540 beds and comprises two hospitals and two clinics. The facility did 525 hearts — bypasses and valves — and 3,800 caths and interventions in 1998. There are three large competing heart programs in the Indianapolis area, where St. Francis is located.
For more information about the CABG pathway at St. Francis, contact Kathy Fox, RN, MSN, cardiac service line director, St. Francis Hospital and Health Centers, 1600 Albany St., Beech Grove, IN 46107. Telephone: (317) 783-8367.