Rehab center cuts LOS with interdisciplinary teams
Rehab center cuts LOS with interdisciplinary teams
Team solicited input from physicians, staff
Two years ago, case managers at Mount Vernon Hospital’s Inova Center for Rehabilitation knew they had a problem. Patients with rehab diagnoses, including spinal cord injury, represented the largest number of admissions to the hospital, but average lengths of stay exceeded national and regional averages by as much as 20 days.
"Even then, with our market at 26% penetration from managed care, a length of stay of 44 days was way too long," says Nancy Thorson, administrative director of the Inova Center Mount Vernon in Alexandria, VA. "We knew we were going to have to do something to make sure we had ourselves more in line with regional and national data."
Judy Perry, CPHQ, director of quality leadership, clinical support, and physician services at Mount Vernon, facilitated the efforts of an interdisciplinary group charged with developing and implementing a clinical pathway that would bring LOS for spinal cord-injured patients in line.
First, the team studied Mount Vernon’s spinal cord patient population and examined general information contained in the hospital’s financial databases and clinical information systems. Then, the team looked at benchmarking data to compare its length of stay with that of other rehabilitation facilities. "Also, we were able to look at a change in functional status and some other outcome indicators to give ourselves a benchmark of where we wanted to be," Perry says.
Finally, they asked what would be the ideal course of treatment for spinal cord patients. After some discussion, it became clear that, unlike most acute care pathways, the pathway for spinal cord could not be broken down into daily units. "If we had that kind of pathway, it would be 18 pages long," says Perry. "So we started thinking more in terms of phases of care."
Although Mount Vernon tries to remain flexible in tailoring treatment to individual patients, team members insisted that certain actions be taken at specific points in the pathway. For example, deep venous thrombosis (DVT) screening always takes place on the second day of a patient’s acute care stay. "That gives us a head start, because often, if a DVT is developing but isn’t found until later on in the treatment, it limits patients’ ability to take therapy and can really delay their progress."
Other aspects of the pathway are more flexible, though members of the writing team decided on a regimented approach to family training and discharge planning. "Those are the sorts of things that can fall through the cracks," says Perry. "All of a sudden it’s time for the patient to go home, and nobody’s ordered the durable medical equipment they’re going to need. So some things are flexible, and some things, of course, depend upon the patient’s own progress. Other things need to be rigid," says Perry. (See sample clinical pathway, p. 70.)
The spinal cord pathway wasn’t a hard sell, either to physicians or staff, Perry reports. One advantage was that, unlike certain pathways introduced on the acute side, the path for spinal cord involves a confined group of patients, staff, and physicians. "On the other hand, when you do a pneumonia pathway or a congestive heart failure pathway, the whole entire department of medicine has to buy into it," says Perry.
Another factor contributing to the success of the pathway was the pre-existing spirit of interdisciplinary cooperation in rehab, Thorson says. "There is a seeming lack of disciplinary hang-ups and very few quarrels between therapists and nursing here, which is extremely unusual," she says.
Perry also notes that, with the exception of the physician-specific orders, the pathway arranged by areas of outcome is working well. "We had talked about having a discipline-specific pathway delineating specific responsibilities for physical therapy, occupational therapy, social work, and discharge planning during the different phases. But when we talked about that with the staff, they said that approach just doesn’t fit with how they worked," Perry says.
"[For example,] OT doesn’t automatically own all the goals associated with the activities of daily living," says Perry. "Everybody owns those goals. So actually, it was more that we took the pathway and made it fit our already existing multidisciplinary model, rather than the pathway making us multidisciplinary."
Upon hearing that a spinal cord-injured patient is being admitted to the hospital, the spinal cord treatment team gathers to decide their plan of operation, says Thorson. When the patient arrives, team members and the patient discuss their expectations of the treatment plan. Both sides discuss the patient’s rights and responsibilities and work out a schedule of treatment collaboratively. Patients’ rounds are also interdisciplinary, with representatives from nursing, PT, OT, and neuropsychology present.
One unusual feature of Mount Vernon’s spinal cord pathway is that every caregiver is allowed to write in the patients’ progress notes. "We’re practically the only hospital I’ve ever encountered that allows that," says Perry. "Our dietitians, social workers, therapists, speech pathologists, and even our chaplain can all document in the progress notes. We don’t have restrictions that you can only be a nurse or a physician."
Two years after the pathway was implemented, LOS for spinal cord patients had dropped to an average of 24 days 20 days below the original LOS. (See chart on LOS, p. 71.) Perry is even more pleased that, concurrently, the spinal cord team has kept its change in functional status above the national benchmark. "With this patient population in particular, you have to balance the realities of the marketplace," she says. "We’re only going to get these patients for a certain length of time, and it’s not us who’s driving that; it’s the insurers. So we really have to maximize what we can do for patients while keeping the quality up."
Staff keep an eye on quality by performing concurrent monitoring of compliance with the pathway. "Every quarter on the rehab unit, when they do their quarterly quality monitoring, they go through and identify what they feel are the five or six most important elements of the pathway and ask how many patients we met our goal on. That gives us other outcomes measures besides just length of stay, or cost per case, or other financially driven outcomes."
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