Special report: Patient education update
Special report: Patient education update
(Editor’s note: As lengths of stays shorten, patient education assumes a heavier burden in helping patients self-manage their conditions. In the following two articles, we profile how two different hospitals have re-engineered the patient education processes to accommodate shorter LOS and a greater need to help patients take care of themselves at home. Then in our Guest Column, quality and case management expert Patrice Spath discusses how to make sure your patient education programs are on the mark.)
Home visits cut LOS for lumbar discectomy
Path includes assessments by inpatient nurses
If you’re looking for a way to decrease postoperative length of stay (LOS) and improve outcomes for surgical patients, consider adding home visits from acute-care nurses before and after surgery, case managers at a Massachusetts hospital recommend.
Nancy Holden Towers, RN, MSN, leader of clinical case management at Charlton Memorial Hospital in Fall River, MA, says home preoperative and postoperative visits from orthopedic nurses have reduced LOS for lumbar discectomy significantly from more than six days in 1994 to fewer than two days.
Towers says cost savings associated with the new system are approximately $800 per case. In addition, the census on the orthopedic floor dropped so much from the decreased LOS for disc and total joint procedures that the hospital was able to close 10 beds. At the same time, the number of patients undergoing the procedures has either stayed the same or increased, which has helped the hospital downsize.
The process began in 1994, when Towers, neurosurgeon Leslie E. Stern, MD, and Joan Therriault, RN, MS, nurse manager for orthopedics, "brainstormed" ideas about how to keep acute care costs down.
"We realized that if we were going to realize savings in the acute side [of the hospital], then we needed to provide care differently and rethink what we were doing," Towers explains.
Team assesses preoperative teaching
To examine care delivery systems, they formed a multidisciplinary team led by the orthopedic clinical case manager, Harriett Desrochers, RN, BSN, ONC. The team first looked at preoperative teaching.
Towers says the physician’s office typically booked the patient’s surgery. The patient then went through the preadmission testing area to have lab work drawn and receive preoperative teaching by a nurse. Then, the patient came back the day of surgery through the same-day surgery area, had orthopedic surgery, and was admitted to the orthopedic unit. But that system sometimes didn’t reveal specific problems patients had.
"We have an admission assessment that has to be done when a patient has an inpatient procedure, but a lot of times, the patient was on pain medication postoperatively, and we couldn’t find out [much] information about the patient," says Towers. "We’d find out two or three days later that patients had a lot of medical and psychosocial problems that affected their recovery."
The multidisciplinary team decided to send an acute care orthopedic nurse to the patient’s home for a home assessment to address all potential problems before surgery. This was intended to save time and effort later.
"That way, we’d know the patient, and the patient would know us, and there wouldn’t be any surprises after surgery," Towers explains. "The effectiveness of the teaching is improved when you do it in the patient’s home in a relaxed setting. Teaching becomes more appropriate to the individual patient. Not only is the patient prepared for surgery, but the hospital staff is prepared for the patient."
Measurement tool put in place
Towers says the team also set up a tool to measure outcomes postoperatively. (See sample tool, p. 41.) The orthopedic nurse visits the patient in the home 24 to 48 hours after discharge to determine outcomes such as pain management, incision healing, and mobility.
"That nurse assesses the patient, and then if the patient needs to be seen by the physician, we can get the patient to the emergency room or back to the physician’s office if we have to," she notes. "The thing that has surprised us is that the patients are doing much better than expected in their home setting."
For example, 81.25% of patients had their pain well-controlled after being switched from patient-controlled analgesia to oral medication, and 84.38% had the ability to mobilize themselves postoperatively. (See sample path, p. 42.)
"If we start reducing the length of stay and putting people back out into the community sooner, we wanted to be able to make sure they are coping both physically and psychologically after their surgery," says Towers. "We found that they were."
Office staff noticed a difference
A "side benefit" of the new system is that fewer patients were calling back with questions or concerns. She explains that physician office staff called her and said they had noticed a difference in the number of calls they received from patients.
"They told us they had seen a dramatic drop-off in the number of calls with questions about what patients should do prior to their surgery," Towers says. "It dropped down to zero, and it was so significant that the office personnel called us and wanted to ask what we were doing differently."
A patient pathway is part of the new system as well. The patient pathway explains what the clinical pathway is, and breaks down phases of care as follows:
• preoperative care, when the patient will learn about the surgery and undergo necessary testing;
• phase one, which lasts for up to 24 hours, and includes when the patient reports to the hospital, has the surgery, and is sent to the orthopedic unit;
• phase two, which lasts for 24 to 48 hours, and includes when the patient has a dietitian visit, begins taking pain medication by mouth, and can get out of bed with assistance;
• phase three, which lasts for 30 to 48 hours, and includes when the patient’s intravenous catheter is removed, he or she receives discharge instructions, and is walking in the room;
• phase four, when the patient receives a home visit;
• a section on discharge outcomes, when patients are asked questions about pain, mobility, and other aspects of postoperative care.
Total joint patients added to program
Since the path was developed for lumbar discectomy, the hospital has expanded its program to elective total joint patients, and patients undergoing bowel resection will be added soon.
"This is not something for every surgical patient, but for those patients who routinely have problems, such as additional stays," Towers says.
Outpatient rehabilitation clinicians will be added to the pathway team soon, she adds.
"We want to decrease the acute care length of stay even more, and have the patient go home with physical therapy in the home every day for one to two weeks before they go to outpatient therapy," Towers says.
She recommends that other hospitals wanting to decrease LOS for surgical patients make sure the right clinicians are involved in pathway development, such as the orthopedic clinical case manager.
"It was really instrumental having someone who knows orthopedic care, who has the credibility with the physicians to convince them this is the best thing for the patient," she says. "It wasn’t seen as just a cost-cutting, insurance-dictated type of approach. We really focused on the clinical needs of the patient."
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