Cancellations cut by three-fourths

Lumbar discectomy path hailed as success

At Blodgett Memorial Medical Center in Grand Rapids, MI, use of a critical path for lumbar discectomy has reduced cancellations from 6% or higher to 1.5% to 2%.

How? By adding a preoperative telephone call that includes education, instructions on having lab work done before the day of surgery, registration, and even discharge planning.

About 50% of the lumbar discectomy patients stay on the pathway with a 23-hour stay. Others go home the same day or stay longer than 23 hours because they have variances in their condition, such as problems with mobility, says Jeanne Engelhard, RN, coordinator of critical paths. (See sample critical path, p. 107.)

The shorter length of stay can be attributed to standardizing the care physicians give, Engelhard says. The critical path is accompanied by protocols that elaborate on the care to be administered, as well as a doctor’s order sheet. In addition, "nursing can anticipate what has to be done and tell patients what to expect," she says.

This situation is a far cry from the days when 6% or more of surgeries were being cancelled due to patients being ill on the day of surgery or just not showing up. At that time, the hospital was doing the preoperative telephone call the night before surgery and conducting laboratory tests on the day of surgery. Frequently, the hospital would find problems with potassium, hemoglobin, or the EKG, and the surgery would have to be cancelled.

Now, a preoperative telephone call is placed one to two weeks before surgery.

"We do as much education as we can, as much as the patient is ready for," says MarKay Riippa, RN, assistant director of ambulatory medicine/ surgery. "We assess needs that way and prepare them for what to expect."

Patients are instructed to have their lab work done ahead of time. The general time line for lab tests are:

• pregnancy tests within 48 hours;

• bleeding time (PT or PTT) within seven days;

• hemoglobin or hematocrit within 30 days;

• potassium within 14 days;

• EKG within one year.

The lab tests are reviewed at the hospital as soon as they are received, which is generally one to two weeks before surgery for most tests.

Patients are preregistered, including insurance information, so patient charts are ready on the day of surgery. Precertification is conducted prior to the day of surgery, if needed.

Nurses ask about home needs

"We’re also able to do discharge planning at the time of the preprocedure call," Riippa says. "We anticipate any home needs they have."

For example, nurses ask:

• What changes do you anticipate with this surgery?

• You may have limited mobility. Do you have someone at home to help you and drive you to appointments?

• Do you have steps at home?

In addition to reduced cancellations and shorter lengths of stay, the hospital has seen patient satisfaction increase 6% after the pathway was implemented.

Despite its successes, the hospital isn’t stopping with this critical pathway. It plans to develop a new critical pathway for its patients going home the same day, as well as a patient process path for lumbar discectomy that will be mailed to patients.

"It will tell them in layman’s language what will happen to them while in the hospital," Engelhard says. The path also will discuss aids and services they may need, such as canes and physical therapy, when they get out of the hospital.