Periop pathway cuts costs, improves efficiency

Fewer preference cards contribute to savings

How would you like to cut your supply costs per case by almost 33%?

The day-surgery program at Vanderbilt University Medical Center in Nashville, TN, achieved this result by implementing a perioperative pathway for endoscopic sinus surgery that helped surgeons and staff focus on what is actually needed for sinus patients. (See endoscopic sinus surgery perioperative pathway, enclosed in this issue.)

The pathway was implemented in 1996 after almost three months of development that included data review, writing, and evaluation by nursing staff and physicians. Supply cost per case in 1996 was $967.13, and in 1999, the cost per case dropped to $650.23, a decrease of 32.8%.

Implementing perioperative pathways within day surgery began six years ago and was not a difficult task, says Nancye R. Feistritzer, RN, MSN, assistant hospital director and administrative director of perioperative services. "We were a very case management-oriented facility, and our inpatient units were very big into pathway utilization, so introduction of pathways into our ASC went smoothly," she says.

After taking a look at data collected on the different types of surgery performed on an outpatient basis, Feistritzer and her staff identified sinus surgery as one area that pathways could have an immediate effect on cost savings and efficiency. "We have one surgeon who performs the majority of our sinus surgeries, so we worked primarily with him to look at changes," she says.

Combining preference cards cuts costs

One of the first steps in developing the pathways was to combine similar surgeries onto one pathway, explains Feistritzer. Not only did this step cut down on the number of pathways with which staff have to work, it enabled the surgery program to cut the number of preference cards for sinus surgery from 10 individual preference cards for different surgeons to one basic card for all sinus surgeries. By working with the surgeons, Feistritzer’s staff were able to get them to look at the supplies used and agree to standard supplies that each of them are comfortable using.

The review and elimination of the different preference cards has reduced the cost per case because everything on the case cart is used, says Ken Peercy, director of the ambulatory surgery center.

The biggest effect of the pathway is the staff’s efficiency, says Peercy. Most of the ear, nose, and throat surgeons were ordering the same items each time, "but we still had to wait for the order to prepare for the case. Now, we are more able to anticipate what is needed and prepare ahead of time."

The nurses knew what was needed so well that they primarily wrote the sinus surgery pathway, explains Peercy. "From experience, they knew what items were routinely used or thrown out. They were able to put together a pathway that met with the surgeons’ approval because it reflected their practice anyway."

After evaluating the data, the staff saw one immediate way to become more efficient. "The surgeon who does most of our sinus surgery was meeting with his patients the day of surgery to conduct his pre-op assessment," explains Feistritzer. "We showed him that he could easily schedule more surgeries if he conducted the meeting in his office prior to the day of surgery and eliminate these 30-minute meetings on the day of surgery."

The surgeon had previously scheduled no more than four surgeries per day, and now he averages five procedures per day, says Peercy.

Although Vanderbilt’s same-day surgery program has an on-line charting system that captures the patients’ history and physical, lab results, nursing pre-op assessment, and discharge planning, there were some items identified during development of the pathway as responsible for holding up surgery, says Feistritzer. "One of our surgeons frequently orders CT scans for his patients, but the documents weren’t placed in the patients’ charts prior to the day of surgery. So we delayed surgery as we looked for the information."

A simple fix was put into place when the staff realized that the charts of this surgeon’s patients were not flagged as surgery patients. "Now we make sure the charts are flagged so that the scans are read and the documents prepared in time for surgery," she adds.

"We also reviewed pre-op standards and eliminated some tests that were unnecessary for most patients," says Feistritzer. "Chest X-rays, urinalysis, and EKGs are not ordered unless there is a special need." A pre-op protocol was also established, and pre-op assessments are performed by nurse practitioner, she adds.

Anesthesiologists were included in the pathway development to help identify anesthetics that would work well for sinus patients but enable them to wake quickly and reduce the amount of time in recovery.

Good data essentially

The best way to develop pathways is to focus on your top procedures, says Peercy. "Get detailed data concerning costs and time per procedure, and present it to the physicians."

Because physicians are scientists, they like objective information such as numbers; however, don’t expect them to suggest the changes from data only, he says.

"Offer alternatives and suggestions on how the preference card might be changed or how he might alter his practice," Peercy says. The pathway has to reflect what the surgeon wants, or it won’t be used, he adds.

Feistritzer admits that the data are crucial, but she says she wasn’t prepared for the difficult task of collecting them. "Make sure your program has forms to track the basic items such as costs, times, and reasons for delays," she says. "You can’t base your decisions on anecdotal information because things are not always what they seem."

For example, they believed a particular surgeon was the most expensive one because of the supplies and equipment he used. "But once we evaluated the data, we discovered that he was one of the less costly surgeons for that procedure," Feistritzer says.

For more information about perioperative pathways, contact:

Nancye R. Feistritzer, RN, MSN, Assistant Hospital Director and Administrative Director of Perioperative Services, Vanderbilt University Medical Center, VUH3108, 21st Ave. S., Nashville, TN 37232. Telephone: (615) 322-3354. Fax: (615) 343-1500. E-mail: nancye.