Hospital halves LOS for CHF patients
Hospital halves LOS for CHF patients
Process approach brings down hidden costs
Case managers at Rowan Regional Medical Center in Salisbury, NC, take a unique approach in developing their clinical pathway for congestive heart failure (CHF). (See Rowan's CHF clinical pathway on p. 74.) By addressing the underlying issues that affect costs and length of stay (LOS), they managed to achieve a 50% drop in LOS just three months after implementing the path.
When the pathway was introduced three and a half years ago, the average LOS was 7.4 days, while charges averaged $5,100 per patient. By the first quarter of 1995, LOS had fallen to 3.7 days, where it remains, and charges had dropped to $3,600. Reimbursements exceed costs.
LaVaughn Beaver, RN, CPHQ, ABQAURP, utilization review and quality management supervisor at Rowan, attributes the sharp and sudden drop in LOS to the center's process approach to pathway development. "By the time we get ready to use a pathway, a lot of the changes have already been made," she says. "We don't just write the pathway down, hand out copies, and say `Here, do it.' We actually change processes as we go." By the time they get ready to implement a pathway, a lot of the things that were causing longer lengths of stay, higher charges, and inferior quality of care have already been improved.
CHF was selected to be Rowan's first pathway because of its high volume and the wide variety in physician practice patterns identified by the center's utilization reviewers. "One thing we identified up front before we started any pathways was that one definition of quality was to decrease variation," Beaver says. "A pathway should define the best practice pattern of taking care of the patient. So by doing that and changing some processes as we went, we decreased some variation."
Compare apples to apples
In developing a pathway and analyzing variations in physician practice patterns, Beaver stresses the importance of collecting severity-adjusted data. Before we had severity-adjusted data, doctors would claim their patients were sicker, Beaver explains. Severity adjustment takes that component out of the comparison data so you can compare apples to apples. For its severity-adjusted data, Rowan contracts with Iameter, a San Mateo, CA-based consulting firm that produces software for benchmarking and quality improvement.
The process changes identified during pathway development are so important that "by the time we get ready to implement the pathway," Beaver contends, "we could probably tear up the original and throw it away." The pathway itself is fairly plain and doesn't go into a lot of detail.
One process improvement identified during the development process concerned the lack of pulse oximeters on the nursing units. Whenever a patient required an oximeter, a nurse had to contact a respiratory therapist, who would then visit the unit and check the patient's oxygen level. By making the machines available on all nursing units, nurses are able to take readings with their morning rounds and convey the results to the physicians. "Because nurses didn't have to wait and get an order and then wait on respiratory therapy, it speeded up the process," Beaver says.
Other process improvements identified for CHF patients include the following:
· less IV fluid use;
· increased IV lock use;
· improved admission and daily weight recordings to help quantitate diuresis;
· development of a process for documenting which scales were used, and using the same scales for patients when possible;
· calibration of scales;
· earlier discontinuance of nasal oxygen;
· earlier ambulation;
· reporting of cost accounting to departments of internal medicine and family practice;
· evaluation and refinement of occurrence screens for data collection;
· use of PRO discharge quality indicator screens.
The focus on identifying improvements has had the added benefit of encouraging physician and staff support for the pathway. Beaver says, "We encourage multidisciplinary and interdisciplinary approaches, and we have good physician buy-in to our program. Our way of doing it creates more of a sense of ownership from all the different disciplines."
During the pathway development process, the team establishes department-specific focus groups to elicit suggestions on possible improvements. Beaver says, "Someone in nursing probably had an idea of how to improve something a long time before it ever surfaced. But they didn't know the right place to tell it or where to get attention with their ideas." The pathway groups create an avenue for people to voice their opinions.
Similarly, changes to the pathway are usually made at the suggestion of someone in the affected area. "For instance, if there were to be a change in radiology, that's probably where [the idea] would originate," Beaver says. "Then we would take it back to our whole group." In addition to such periodic changes, the pathway is reviewed on a yearly basis.
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