Continuum-focused CHF path cuts LOS to four days
Continuum-focused CHF path cuts LOS to four days
Pathway gets things moving,’ CM says
A congestive heart failure pathway at Evanston (IL) Hospital has allowed case managers there to reduce length of stay from 6.2 days to four almost three days below the national average. At the same time, direct treatment costs have dropped by 60% over the last two years, boosting annual revenue by $1.6 million.
Lisa Mischke, RN, MSN, inpatient congestive heart failure coordinator at Evanston, says the main reason for the pathway’s success is that it has allowed clinicians and staff to access resources more quickly.
"On admission, there’s a set of pre-printed orders that the house staff fills out for each heart failure patient," Mischke says. "Then the cardiac rehab team is consulted, dietary is consulted, and the case manager gets a phone call saying, There’s this patient in room X.’ It gets things moving quicker, and it makes clinicians consider options on admission rather than waiting three or four days."
The congestive heart failure (CHF) pathway was implemented in November 1995, following the creation of a series of successful surgical pathways, including one a year earlier for coronary artery bypass graft. It was one of the hospital’s first experiments with non-surgical pathways, and it benefitted from the physician goodwill given to previous efforts, Mischke says.
Physicians and staff were already used to Evanston’s truly multidisciplinary approach to pathway development, bringing together representatives from different disciplines such as cardiology and pharmacy to hammer out differences and craft a workable pathway.
"The real key to getting physician involvement is making them feel as though they’re a part of the decision-making process," Mischke says. "And if you get internists and cardiologists and emergency department physicians, you really have to include everybody in order to get buy-in from the physicians."
To keep physicians from having to juggle schedules in order to hold separate meetings, the hospital made a point of introducing the pathway during physician-led grand rounds, attended by all house staff and some attending physicians. "We used that forum to go through what the pathway involves, how it’s going to work and why it’s important, as a way of getting everybody up to speed," Mischke says.
As the primary case manager for the pathway, Mischke identifies CHF patients early by checking in with the specific areas of the hospital where heart failure patients are most likely to be admitted. "I go through their Cardexes and identify heart failure, pulmonary edema, and any other diagnosis that would lead one to believe there’s heart failure," she says. "At the beginning, you really have to encompass everybody that comes in with a diagnosis requiring IV diuresis and a chest X-ray with heart failure."
Following preliminary screening, Mischke goes through each patient’s chart and begins a data collection tool. All patients then diagnosed with CHF are placed on the pathway, except for renal dialysis patients. "Their problem is more fluid overload rather than anything pertaining to the heart," Mischke explains.
Get home care involved in education
Once patients are on the pathway, Mischke assumes a supervisory role, making sure patients receive the proper clinical intervention and education at the appropriate time. "Education is really the crucial aspect of the CHF pathway," she says. Unit nurses provide each CHF patient with a folder of educational material and show them a video detailing their condition and how to manage it. Patients are then instructed to take all this information home with them, Mischke says. (See patient education sample, p. 28.)
"The place to really educate people doesn’t appear to be in the hospital. In the hospital, they nod their heads and say Yes, yes.’ Their focus is different when they get home," Mischke says. "You have to follow them across the continuum by getting home care involved. There should be a connection between the inpatient case manager and the home care nurse, where you can say, Well, we started this, but they didn’t quite understand, so could you follow up?’"
Evanston’s continuum approach has been vital to the pathway’s success, Mischke says. She points out that the hidden cost of CHF for hospitals is the readmission of Medicare patients within 30 days of discharge. During that time frame, the hospital is unable to bill Medicare for additional costs.
One way Evanston has been able to lower its 30-day readmission rate from 19% (already 4% lower than the national average) to only 2.6% is the development of an innovative telemanagement program. CHF patients who have been referred into the program by their primary care physicians are able to dial into the hospital’s automated system on a daily basis. During their call, they enter their daily weight and answer 10 questions related to their heart failure, such as whether they’re short of breath or experiencing fatigue or swelling.
"After they hang up, we get a computerized screening," Mischke says. "If they fall out of a certain range, then they appear on the computer. If they’re up two pounds and they complain of shortness of breath, then we give them a call at home and counsel them on what to do with their medications."
For more information about the CHF pathway, contact Lisa Mischke, RN, MSN, inpatient congestive heart failure coordinator, Evanston Hospital, 2650 Ridge Ave., Burch 220, Evanston, IL 60201. Telephone: (847) 570-1194.
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