‘One-stop post-op’ unit reaps praise — and results
One-stop post-op’ unit reaps praise — and results
CABG LOS cut to 5.5 days, and patients love it
A scant eight months ago, St. Clair, a 314-bed community hospital in Pittsburgh, initiated its innovative "one-stop post-op" program. Already the word is that staff and physicians love it, and most important, so do the patients.
"There’s no question that this is working," says Jackie Johnson, RN, MBA, Principal of the consulting firm Health Care Visions in Pittsburgh. Johnson was the planning consultant for St. Clair’s open-heart and angioplasty program that began in May 1997. "The cost-benefit ratio is clearly favorable. I have worked with other institutions that have initiated cardiac surgery programs recently, and their lengths of stay are, on average, two days longer for the same patient population."
St. Clair’s new cardiovascular service unit (CVSU) saves money by eliminating unnecessary or duplicate work processes. Process redesign or re-engineering is not a strategy that will necessarily generate new revenue, but it will increase efficiency and better use of the health care dollar. Each time you transfer a patient from bed to bed to bed, costs are incurred. Ob-vious costs involve housekeeping and nursing; actually 15 departments are affected by each transfer, says Lucy Shoupp, RN, executive director of the Heart Center. Patients typically step down twice, from critical care to less critical care area, then to semi-private room (see chart, p. 147).
St. Clair expended about $8 million to get its program off the ground, and it also paid for new operating rooms, a perfusion room, and catheterization labs. "Any start-up program involves a major capital outlay," says Johnson. "The question is: Should existing programs invest significant dollars to create a one-stop program like St. Clair’s? If an organization has old facilities, it might be the right time to do this. It takes a sizeable investment, but the return is definitely there."
The CVSU opened with its first patient in April 1998, and more than 80 patients passed through. "Our average length of stay for DRG 107 is 5.5 days," says Phillip Pandolph, manager of CVSU. The average local LOS is 6.7-7.6 days. "Several patients have been ready for discharge on day three; but as the acuity of the patients has increased, our average length of stay went from 4.7 to 5.5." For valve surgery, St. Clair’s LOS is 7.1 days.
The unit is comprised of six private rooms that transform from ICUs to med-surg rooms just by moving the intensive care equipment such as ventilators and pumps. The cardiac surgery patient never moves from the unit from OR through discharge. The unit is staffed with experienced cardiac surgical, ICU, and CCU nurses who successfully completed a cardiac surgery educational program.
"We weren’t sure how well the new unit would work at first," says Pandolph. "We ran a staff satisfaction survey last month and got outstanding results." The nurses enjoy seeing the whole picture running from pre-op to discharge. They meet with each patient pre-operatively to do individual patient teaching. The also meet the family at that time and show them around the CVSU. Then they see the intensely ill patient come in immediately after surgery.
The nurse-patient ratio with the post-op patient is one-on-one. "That’s for at least 12 hours," says Pandolph, "more often for an 18-24 hour period, based on acuity." The nurse is not responsible for other duties.
After post-op day one, if everything goes as planned, the patient advances to step-down care or intermediate care. At that point, depending on the acuity of other patients in the unit, the nurse could have a two- or three-patient assignment. After day three or four when the patient progresses, the nurse-patient ratio rises to one to four.
St. Clair Hospital’s board of directors recently instituted an angioplasty and open heart surgery program. It was formulated by Johnson when the opportunity presented itself to go one step further and create an innovative program akin to one often seen in maternity wards.
The new cardiac surgery program called for the renovation of evacuated space on the hospital’s ground floor close to the operating rooms. The architects designed the space to centralize two new catheterization labs, a seven-bed catheterization recovery suite, and the non-invasive cardiology area that would house reception, echocardiography, treadmill, and EKG. The design also included a six-bed cardiovascular surgery ICU placed next to the catheterization labs and the OR, ideal for continuum of care.
|
|
|
|
Work Hours Eliminated | 433 |
Dollars of Work Time Saved | $65,800 |
Source: St. Clair Hospital, Pittsburgh,
1998.
|
Making lemons into lemonade
The innovation came from trying to solve a problem. At the close of the design phase, the identification of the post-op telemetry area remained unresolved as several issues were identified. The existing surgical telemetry area was running at high occupancy. Administrators believed adding a new cardiac program would limit bed availability for other surgical programs. The existing medical telemetry unit lacked the observational structure needed for the post-op cardiac surgery patient.
For more than a month Johnson and the other planners were struggling with the design to determine where the patients were going to go post-operatively. "We had to find the ideal spot," she says. "We were brainstorming and came up with the solution: the one-stop post-op’ concept. During start-up, we realized we had extra capacity in the unit, and it made good practical sense to integrate that patient population. It was worth a try."
Johnson began with a feasibility study and supervised all aspects of the unit’s implementation, including planning and design, hiring personnel, and choosing equipment.
Shoupp, Pandolph, and Cynthia Loughman, RN, director of cardiac critical care services, put it to work. Following acceptance by the cardiac surgeons, a task team adopted a plan to revamp the six-bed unit from a traditional ICU scope to a fully integrated post-op cardiac surgical unit; progressing from immediate OR recovery to hospital dis-charge. The new design, dubbed "one-stop post-op," prompted many changes and new efficiencies in the nursing care process. "The conceptual and design side and watching it all work has been very gratifying," says Johnson.
For billing purposes, the staff adjusts the accommodation code to not charge for intensive care every day the patient is in the CVSU. "We adjust the charges based on the intensity of service the patient demands," says Shoupp. "Our charge structure allows for a very intensive patient care level on day one and a less intensive level for day two. Day three could be telemetry unit charge."
St. Clair’s one-stop program has had even better outcomes than was first expected. "We surveyed each patient a week or two after discharge and got excellent results," says Pandolph. "Patients said they liked the idea of staying in one room that had all the amenities of a general hospital room — television, telephone, high-tech beds, and so on."
"We’re managing all services that involve heart patients as a product line," says Shoupp. " We look at patient care along a continuum from outpatient evaluation and education, through admission and discharge, to cardiac rehabilitation." The cardiac product line at St. Clair includes diagnostic, cardiac catheterization, OR and post-op areas, CCU and intermediate care for those patients who have cardiac illnesses but are not open-heart cases.
About two years ago St. Clair implemented the labor-delivery-recovery-postpartum (LDRP) concept for its maternity department — a model that many organizations and patients find satisfying. Women stay in one room throughout labor, delivery and recovery. The mother labors there, then the bed is transformed into a delivery table. She recovers, and postpartum care is provided there.
The one-stop post-op model captures that concept. Services come to the patient rather than vice-versa. The patient stays in one private room and has the same nursing staff throughout.
"The nursing department in LDRP found that having the patient stay in one area resulted in considerable savings in terms of time and cost for nursing, housekeeping, and supplies," says Shoupp. When Johnson and the planners were looking at the cardiac program, they thought, Why wouldn’t that same concept apply here?
Cross-training makes for efficient utilization
"One of the big advantages of having patients in the CVSU," says Loughman, "is that the nursing staff is competent and cross-trained. That makes for good staff utilization." A patient in bed one may be "a fresh heart," while the patient in bed six may be ready to go home. "When we adjust staffing within the product line, we match the competency of the nurse to the needs of the patient," says Loughman. There’s always an assignment that’s safe and appropriate for them.
"What matters here is service," says Loughman. "If you meet patients’ needs for medical care, they come back and tell others. The Heart Center gets an extraordinary amount of positive feedback from family and patients. People are clearly very satisfied."
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.