COPD pathway cuts costs per case by $900
COPD pathway cuts costs per case by $900
Revisions are often made with the stroke of a pen’
During summers in the Gulf Coast city of Mobile, AL, stifling humidity can drive the heat index well into triple digits. For case managers at Mobile Infirmary Medical Center (MIMC), that invariably means an influx of older patients with a variety of cardiovascular and pulmonary ailments, especially chronic obstructive pulmonary disease (COPD).
Given the fact that Medicare patients make up about 65% of MIMC’s patient population, the medical center’s leaders decided in 1991 to target COPD as MIMC’s first inpatient pathway, says Carol Krogsgard, RN, MSN, director of utilization and case management at the 704-bed facility. That year, MIMC’s length of stay (LOS) for COPD patients suffering acute exacerbations was 7.8 days. With a cost per case of $4,050, the medical center was losing about $250 per patient stay. Now, LOS is down to 5.6 days, with a cost per case of $3,170. "At the end of this past fiscal year, we had actually turned things around to where we were making $650 per case," Krogsgard says. "When you consider that we had 465 COPD patients, that translates into more than $300,000 in profits."
Krogsgard says making COPD the center’s first pathway made sense for a number of reasons. In addition to the high cost and relatively high volume of COPD patients, Krogsgard and her colleagues found a great deal of support for the idea from staff pulmonologists. Five more pathways were developed less than a year later, largely on the basis of physician support. For example, the president of the medical staff, a vascular surgeon, expressed interest in developing a pathway for lower extremity revascularization. "That wasn’t a huge volume for us," Krogsgard says. "It also wasn’t so much a problem in terms of cost. But because he was supportive, we chose it. So the politics had a lot to do with it."
Pathway revisions key to success
Even so, case managers at MIMC recognized that in order to create long-term success, they would have to be open to revising the paths to address the needs and concerns of staff members.
Indeed, one reason for the success of MIMC’s pathways in general has been the willingness of Krogsgard and her colleagues to change the pathway as needed with a minimum of red tape. "We change ours at the stroke of a pen if we need to," she says. For example, revised pathways aren’t sent outside the hospital for typesetting or printing. Rather, Krogsgard’s secretary types in the revisions and prints them on a photocopier as needed.
One early revision to the COPD pathway was to identify and list specific goals for patients on each day of the pathway. (See sample pathway, p. 157.) At the same time, they recognized that too much specificity might alienate some clinicians. "With a conservative medical staff like we have, we’ve kind of had to take it easy in terms of how specific our criteria were for what we wanted to do with patients," Krogsgard says.
A second and more significant revision involved incorporating the pathway into the medical record. Originally, when the pathway was used as an adjunct to the medical record, "nurses really didn’t look at it," Krogsgard says. "So between 1992 and 1994, it was really a fight to get the staff to see the value." During that time, the pathway was used for only about 20% of COPD patients, well short of Krogsgard’s goal of 60%.
Case managers did two things to rectify this problem. First, they implemented a computerized system that instructed nurses at the time of admission to enter whether the patient had been placed on a critical pathway. "Then we would compare that information to the total number of patients discharged in that case type at the end of the month," Krogsgard says.
In addition, they enlisted the help of the nursing education staff, whom they assigned to different nursing units in the hospital. "They all worked together to determine how to transition our medical record so that the critical pathway could be incorporated into it, and that has been a tremendous success," Krogsgard says.
Finally, the COPD pathway was revised to include a one-page medical staff-approved protocol for oxygen therapy. "The advantage of doing that is that the protocol is right there for reference for the physician, nurse, or respiratory therapist," says Krogsgard. "If it’s in a procedure book, they’re liable not to go look for it."
[Editor’s note: For more information about MIMC’s COPD pathway, contact:
Carol Krogsgard, RN, MSN, director of utilization and case management, Mobile Infirmary Medical Center, P.O. Box 2144, Mobile, AL 36652. Telephone: (334) 431-5760.]
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