St. Francis Hospital speeds up CABG recovery to one-day goal
St. Francis Hospital speeds up CABG recovery to one-day goal
Cross training helps it happen
The cardiac staff at St. Francis Hospital and Health Centers in Beech Grove, IN, knows in order to stay competitive and improve patient outcomes while saving money, staff members have to keep abreast of the best national practice standards. When they saw the latest recommendations of the Cardiology Preeminence Roundtable, they decided they had to redesign how they provide care.
The Advisory Board in Washington, DC, focused its recent Roundtable on coronary artery bypass graft (CABG) surgery recovery and decreasing postoperative length of stay (LOS). Included in the report was advice on an aggressive regimen, telemetry staffing, early extubation, and bypassing critical care.
When you decrease the LOS in higher acuity levels, says Jerri Devaney, RN, cardiac service line care manager at St. Francis, you substantially decrease cost. The room rate for the cardiac surgery unit (CSU) Level I is about $1,200 per day.
"From the Roundtable advice, we pulled out pieces where we thought we could improve our outcomes," says Devaney.
She says hospital management implemented eight service lines by dividing the facility’s DRGs and assigning them to lines based on care provided. For example, anything cardiac now falls within the cardiac service line, and anything oncology within the oncology service line.
"To go to the service line concept required an entire redesign of how we provide care to patients," she explains. "With that in place, we went to work on our CSU length of stay. Back then, our patients stayed two and a half or three days. The Advisory Board recommended 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 Kathy Fox, cardiac service line director at St. Francis and member of Cost Management in Cardiac Care’s editorial advisory board. For that reason, she initiated staff cross training in Levels 1 and 2 of the CSU — the open-heart recovery unit and the step-down unit.
"We sat down with the physicians and administration and said, [Decreased LOS] 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."
Hospital began orientation program
Over the next six to nine months, that’s what the hospital did. It began an extensive critical care orientation program, including 89 hours of classroom didactic, and all the staff rotated through that area. Each nurse spent six weeks one-on-one with a preceptor or Level 1 nurse. CSU Level 2 rotates through Level 1 at least once a month. (See articles on Fox’s cross-training regimens including the one on hemodynamics, p. 16.)
St. Francis was able to discontinue its use of outside registry nurses once the cross training was completed; as a result, the facility offers an enhanced level of care.
"We have our own staff working," says Fox. "If we have problems with staffing in CSU Level 1, we can put someone else from cardiac on Level 2 and put one of the Level 2 nurses in recovery. That’s what cross training accomplished."
The cost of cross-training was less than the cardiac line team estimated it would be: $100,000, or $4,560 to $6,080 per nurse trained. "We thought it would cost more than twice that. It paid for itself by eliminating the use of outside registry, she says. "Cross training improved quality, improved continuity, the physicians loved it, and it helped to decrease LOS."
Before these changes went into effect, the St. Francis staff was sometimes forced to go home without pay when the census was down — known as "hospital convenience." They are happy that they no longer have to do that because the staff can rotate between levels.
"The staff doesn’t like to float," says Fox, "but they’d rather float than go home without pay. This was a godsend for them."
The physicians like the new cross-trained staff because they get one call when a situation arises and receive most of the information they need at once. They’re now confident when Level 2 nurses call about a problem, because they know those nurses are competent to handle an acute problem.
"When physicians are called about a patient problem," says Fox, "they don’t like to have to wait for information. Now that we’ve increased the level of understanding and knowledge on the part of our step-down nurses, they’re aware of what questions the physicians are going to ask."
CSU is now down to one-day LOS
The service line has decreased recovery LOS now 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.
The Cardiology Roundtable called for fast-track extubation; to comply, 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. (See graph on ventilator hours, above.) "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 de-creased, as well as are problems like phlebitis."
However, there is a point at which you can safely and cost-efficiently push the envelope, she says, and when 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 some 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."
While the cardiac department has decreased its LOS, it has not increased readmissions to the unit. (See graph on cardiac surgery recovery, lower left.)
The ultimate goal of the cardiac line staff is to eventually have the recovery area and the step-down unit combined. (See the December 1998 issue of Cost Management in Cardiac Care, p. 145, for an account of how another facility accomplished that.)
"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."
The line staff would like the patient to stay in one bed while staff provides different levels of care based on need. Rooms that were single rooms in the step-down unit are being renovated to become two-bed ventilator rooms. Then, when the ventilator comes off, the patient can stay in the same room.
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 post-operative housing and training for patients and family that provides a transition to home. (See the December 1997 issue of CMCC, p. 149, for a description of St. Francis’ Alternative Recovery Area.)
"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 is comprised of 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.
"Our open-heart pathway is the ultimate PI process: It’s never finished and is always ongoing. Revise, revise, revise," quips Devaney. "One reason we have pathways is that managed care contracting companies want them."
Fox explains: "Two years before the service line started, we proposed pathways to our physicians, but they said, We don’t want cookbook medicine.’ But then, the contract people said, Show us your pathways,’ and our docs said, Where are our pathways?’
"When the student is ready, the teacher appears."
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