Save $400 per case with carpel tunnel pathway

ACL pathway adds up time savings

[Editor’s note: In last month’s issue of Same-Day Surgery, we profiled a documentation pathway from Florida Surgical Center in Gainesville, FL, that saves 20 minutes per patient. This month, we profile two more critical pathways from the same facility. If you’d like to have your critical pathway or other document profiled in SDS, contact: Joy Daughtery, P.O. Box 740056, Atlanta, GA 30374. Telephone: (404) 262-5420. Fax: (404) 262-7837. E-mail:]

Standardized care and supplies, avoided duplication of documents, and saved costs — who would have thought little pieces of paper could do all this? Florida Surgical Center in Gainesville has done all this and more with perioperative clinical paths for carpal tunnel release and anterior cruciate ligament (ACL) reconstruction. The carpal tunnel release pathway alone resulted in cost savings to patients of $400 per case. (See pathways, inserted in this issue.)

While the center hasn’t determine the cost savings with the ACL reconstruction pathway, the time savings are certain, says Gail Avigne, RN, CNOR, nurse manager in the OR. "There’s a time savings in more than one way," she says. "Because we’ve standardized the care, everyone knows what the care is." For that reason, no time is wasted trying to determine what the next step should be in the patient’s care.

When the carpal tunnel pathway was developed, the care for those patients was standardized in several says, Avigne says. The surgery center went from using esmarch, which costs about $7 per case, to using an Ace bandage, which costs about 70 cents per case. The center also stopped providing a sling postoperatively to every patient, which saved about $4 per case, Avigne says.

When the critical pathway was implemented, the center also stopped using antibiotics in the preoperative and intraoperative phases, Avigne says. The center staff determined they were unnecessary for soft-tissue cases. In addition, a stockinette was no longer used as part of the draping, Avigne says.

Crutch walking taught at the clinic

When the ACL reconstruction pathway was developed, crutch walking began to be taught at the clinic before surgery. Formerly, it was taught at the surgery center. "This helped streamline where care was given," Avigne says. It saved the patients an extra trip and was a big boost to patient satisfaction, she adds. "And it definitely saved us time," Avigne adds.

Another part of the pre-op process that was shifted to the clinic was the HIV test for patients who were having allografts, she says.

The hemovac blood evacuation system was targeted in the pathway. "We decided as a group that if it were less than 100 cc, we would discontinue the hemovac prior to discharge," Avigne says. "That allows us to let them go home sooner from PACU."

Standardization was a key part of the ACL reconstruction pathway. The two surgeons who perform the procedure were involved in the process, Avigne emphasizes. Preoperative antibiotics and postoperative pain medication were two areas targeted for standardization. For example, Toradol (Roche Pharmaceuticals, Nutley, NJ) is now the standard pain medication administered.

"We feel we control pain much better now with that pathway," says Linda Pittman, CNOR, clinical coordinator at Florida Surgical Center.

The improvement in the pain control regime is primarily due to Toradol, but also to a block anesthetic that numbs the area, Pittman says.

And that’s not all. Education has improved, partially because it begins in the preoperative phase at the clinic, Pittman says. Even prescriptions are focused on early, in the pre-op phase, so that patients can have them filled before coming in for surgery.

A couple of years ago, the standard was to admit ACL reconstruction patients, she points out. "When we first starting send them home [from outpatient surgery], we sent them with home health," Pittman says. "It’s now so much more streamlined, we don’t even need home health." Instead, the center merely performs routine postoperative checks.

"It’s a cost savings and a convenience savings for the patient, and the continuum of care is improved in that process," Pittman says.