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In 1993, the average length of stay (LOS) for a total hip replacement at University of Colorado Health Sciences Center in Denver was eight days. The next year it was brought down to six. "We were discussing a path then, but not yet implementing it," says Kathy Nold, RN, manager of the office of clinical practice there. "We looked at comparative data locally as well as at other academic centers around the country and decided we needed to be addressing the situation."
The process of building the center's hip pathway helped staff identify a goal that some other facilities were achieving: four-day LOS. Now the center's total hip replacement LOS fluctuates between four and five days. Reimbursement issues are affecting the center's ability to discharge patients any earlier than that.
"We can't sacrifice clinical outcomes to payer issues," Nold states. "Part of our difficulty revolves around issues related to discharge planning, who's going to be home when the patient gets home and whether the family can get a home nurse."
One of the facility's major cost savings came about when it launched an initiative to get all the hip replacement surgeons to use one company's orthopedic appliance. "We were at about 50% at the time, and now we're well above 75% and trying to push it to 80%. One obstacle is that we know that sometimes a surgeon is not able to use a particular product when another company's [product] would be more suitable for a peculiar case."
Now the center is discussing issues such as changing patients from IV to PO meds quicker and managing their pain better so they can get up and out of bed sooner.
Kelly McDevitt, RN, MS, ONC (Orthopedic Nurse Certified), orthopedic clinical case manager at University Hospital (part of the Health Sciences Center), says the pathway (see pathway, pp. 176-177) is just for the primary hip procedure. "If the patient had a replacement 10 years ago and the physician now needs to revise it, for example, we might use a lot of the same information, but those patients are not on the [same] pathway as those with a primary joint replacement would be."
The age range for these patients is vast — from 30 into the 90s. McDevitt says age is not a factor on the pathway unless a patient needs to stay in the ICU because of his or her cardiac history. In that case, an extra day or two is added for the cardiac monitoring phase. If a patient is young with no comorbidity, he or she might be out a day or two earlier. But in each case, the goals or expected outcomes are the same.
"We started developing this path in 1996," she says. "Before then, there was no path for total hip. We find it valuable because now care is streamlined, and nursing and therapy staff know what is expected of everyone. They now have it on paper." Staff are not yet documenting on this path.
"We go over the form with the whole multidisciplinary team every month — nurses, physicians, case managers, and all residents because they rotate — to evaluate what we're changing and what we need to add and delete. Pathways are only a guide to care. The path is not static; it's always changing," she says.
"It's taken a long time to get everyone on board with thinking about critical plans," McDevitt says. "Our department of clinical outcomes helped tremendously because they look at trends. With its help, the staff can see how to make improvements overall instead of relying on individual physicians doing their own thing."
There was some resistance to any critical plan at first. McDevitt says the physicians saw no value in it. "We got them to come around through the office of clinical practice. The physicians in the office tapped into the attending physicians of each service and charged them with creating the pathways. That's how we really got it going and how more and more pathways were created here."
The office of clinical practice developed an internal severity of illness scale. When they look at utilization for patients under 65 with no secondary diagnoses of pulmonary, cardiac, or bleeding disorders, Nold says, "it's flat — there's no variability. But when we look at patients over 65 and with secondary diagnoses, there's wide variation in their lengths of stay, charges, and costs." Those are the types of data the office continues to monitor.
"We recently went through a benchmark project with a university health systems consortium," she says, "and this facility was identified along with four others as being one of the top performers for excellence in primary hip replacement. Out of 15 categories of benchmarks, we met or exceeded 62%."
Part of what makes University Hospital successful, she says, is its multidisciplinary team that looks at data and talks about ways to improve practice.
For more information, contact:
Kathy Nold, RN, manager, office of clinical practice, University Hospital, University of Colorado Health Sciences Center, Denver. Telephone: (303) 372-8235.
Kelly McDevitt, RN, MS, ONC, orthopedic clinical case manager, University Hospital, University of Colorado Health Sciences Center, Denver. Telephone: (303) 372-8536.