Pathway keeps LOS low for young diabetes patients

Standardized family education is key

Since Children’s National Medical Center in Washington, DC, implemented its diabetes clinical pathway, the hospital’s average length of stay for diabetes patients has been significantly lower than the national average, and the 72-hour readmission rate has been less than 1%.

The hospital’s average length of stay for diabetes patients for fiscal year 2005 is 1.49 days, compared to nearly 2.5 days for the hospitals that submit data to the Pediatric Health Information System database, a collection of data from a number of freestanding pediatric academic medical centers. In fiscal year 2004, the length of stay was 1.53 days.

"Largely because of the level of diabetes education contained in our pathway, our length of stay is nearly a day lower than the average length of stay for the benchmark," says Fran R. Cogen, MD, CDE, director of the diabetes program.

At the same time, the hospital’s readmission rate within 72 hours consistently has been less than 1%.

"We know that the fact that we’re getting them out faster doesn’t mean we’re sending them out sicker. They’re getting all the care they need here and talking with the nurse on the telephone every day," she adds.

The pathway — one of 55 used by the hospital — was designed by a physician-led multidisciplinary team including diabetes educators, endocrinologists, social workers, nurses, and pharmacists who started work in 1997 and implemented the pathway in 1998.

The diabetes pathway dramatically reduced the length of stay and improved coordination of care to the point that a large payer contracted with the hospital to be its disease management entity for children with diabetes.

"We knew from the beginning that our length of stay was good, but we didn’t have the data to show our payers graphically that it was the case. We wanted to show that we were providing clinically appropriate care in the most timely and efficient way, that our patients were receiving the best medical care, and that we were able to discharge them safely," says Pat A. Johnson, PhD, LCMFT, practice facilitator.

The team’s goals included reducing the variability in the way care was being provided; identifying specific skill sets for diabetes educators to guarantee that every patient and caregiver has the same level of education prior to discharge; ensure that education is provided on weekends to ensure a timely discharge; and provide some kind of outpatient education to shorten the stay.

The pathway includes everyone who is admitted with a primary diagnosis of diabetes, whether it is Type I or Type II. The only variances would be when a patient has a different primary diagnosis with diabetes as a secondary diagnosis. For instance, a patient with cystic fibrosis-related diabetes would not go on the pathway.

If the patient is readmitted and not newly diagnosed, the team still follows the pathway but omits the education component.

Patients are started on the pathway as soon as they arrive in the emergency department. Young diabetes patients may be admitted to the intensive care unit or the floor, depending on how ill they are. The pathway includes specific instructions based on where the patient is admitted and discharge goals.

"Many of these patients are hospitalized because they are so sick that they require care. Another group that is not that sick are hospitalized because if they start insulin early and get on the pathways quickly, everything is done in a timely manner and they are stabilized quickly," Cogen says.

The diabetes clinical pathway is a combination of medical treatment and education. Patients get medical treatment, usually throughout the night, with the medical education component starting the next morning.

The hospital calls its diabetes education program Survival Skills. Patients are not discharged unless they are capable of giving themselves their own insulin injections.

In the case of patients whose maturity level or psychosocial situation makes it difficult for them to learn to give themselves injections, the caregiver is taught to give the injection.

The training goes on throughout the day, with physicians and nurses monitoring the patients to make sure they are receiving the appropriate medications. At dinner, the floor nurse makes sure the patient or caregiver knows how to give the injections and discharges the patient.

Following discharge, caregivers are instructed to check the child’s blood sugar level four times a day and call the diabetes education nurse each afternoon for an insulin dose adjustment until the blood sugar is stable.

"We have a long umbilical cord from the hospital to the home. The caregivers know how to get in touch with the doctor on call and are encouraged to call if there is a problem," Cogen says.

A lot of questions are not addressed until the next day when the patient goes home and the caregiver calls the hospital with questions.

The diabetes education nurse handles the calls during the week. On weekends and at night, the physician on call answers the questions and coordinates the dosage adjustment.

"We are always aware that people who are diagnosed with a chronic illness face many psychosocial issues. We know that parents are traumatized and sleep-deprived, and it’s hard to address all the issues. For the first month, the caregivers or patients are on the phone every day with either a nurse or a doctor, going over the insulin injections," Cogen explains.

After two weeks, the young patients and their families attend what the hospital calls Concepts Class, where diabetes educators teach caregivers and family members to learn more about what they’re doing and why.

"As a result of our increased population and through our continuous quality improvement initiatives, we determined that the classroom setting is the best place for the second round of education to happen," Johnson says.

When the hospital implements or revises a pathway, it is publicized through posters in the lounges, table tents in the cafeteria, notices to all the residents and nursing managers, and e-mail to everyone who should be following the pathway.

The hospital has pre-printed standing orders on the pathway, making things easier for physicians because they don’t have to write individual orders.

At the end of the year, the hospital is switching to on-line physician order entry with all of the pathways and other order sets included in the computerized order-entry form. If a physician orders something other than a standing order, the system will flag it and the physician will have to override the flag.