Critical Path Network
QI program reduces length of stay after hysterectomy
Focus on scheduled hysterectomy admissions
A quality improvement project for hysterectomy patients resulted in a decrease in length of stay from 1.89 days to 1.24 days for patients receiving a vaginal hysterectomy and from 2.59 days to 2.23 days for patients receiving an abdominal hysterectomy at Ingham Medical Center in Lansing, MI.
Before beginning the project in 2002, a multidisciplinary team from the hospital headed by the obstetrics/gynecology department chair, worked with the nursing staff and office staff from physician practices to develop standing orders for hysterectomy patients. The hospital owns the three main obstetric and gynecological practices that admit the majority of patients to the hospital.
The patients receiving hysterectomies had varying length of stays and many times did not meet the length of stay expected by insurance. In most cases, the insurance companies authorized a one-day stay for a vaginal hysterectomy and two days for an abdominal hysterectomy.
"We wanted to raise awareness of reimbursement to the hospital. We don't get paid for each day the patient is in the hospital. We were absorbing the extra care," says Barbara Zielinski, LMSW, CCM, case manager for the hospital's women's and children's unit.
The initiative focuses only on scheduled and planned hysterectomy admissions. Gynecological oncology patients were not included in the initiative because of their varying lengths of stay due to complications and other factors.
Pat Skerritt, RN, utilization supervisor for the hospital, organized a meeting of representatives from each physician office along with Zielinski and the surgical case manager.
"We educated the physician offices about the necessity of alerting the patients to prepare for a one-day or two-day length of stay, depending on the procedure, before they come to the hospital. No patient will be discharged until she is stable but we wanted them to know what length of stay they could expect," she says.
During the meeting, the hospital team educated office staff about the hospital's discharge screen for patients leaving the hospital.
"We discussed the components of the discharge screen and what was considered acceptable for discharge. For instance, most of the patients are going to have some degree of pain when they go home and they receive prescriptions for oral pain medication," Skerritt says.
Skerritt worked with the chief obstetrical/gynecological resident to develop preprinted standard postoperative orders for hysterectomy so that the physician would not have to write out individual orders for each patient.
For instance, most physicians had different methods of advancing patient mobility after surgery. Some might say dangle the legs off the bed the day of the surgery; others were putting it off until the second day.
"The orders don't wait to start progressing activities. They specify how soon after returning to the floor the patient should dangle their legs off the bed," Skerritt says.
The orders specify when the patient-controlled analgesia should be switched off and the patient changed to oral pain medicine and has a checklist of anti-emetics, oral pain medications, bowel stimulants, and other medications, which the physicians use to select the medications they want to prescribe.
Part of the initiative involved communication between the case managers and the nursing staff about the length of stay, Zielinski says.
"I educated them to expect that the patients would be going home in 24 hours or 48 hours, depending on their type of surgery and the importance of progressing care, so that the patients could be discharged in a timely manner," she adds.
Before the initiative began, Zielinski talked to patients who were admitted for abdominal hysterectomies and asked them when they expected to go home.
"They would tell me that their doctor said they should expect to stay three or four days. This was setting the stage for a longer length of stay," says Zielinski.
Now, some of the surgeons dictate into the history and physical that patients have been advised to expect an overnight stay or a two-day stay, depending upon the procedure.
"Not all go home within the time frame we set — medical progress varies from person to person and we are sure that they are stable enough to go home," Zielinski says.
Zielinski encourages physicians to take a proactive approach to discharging patients, making sure that everything is in place for a timely discharge.
"I may ask the physician to reevaluate the patient later in the day for discharge or to review the treatment plan if they are staying longer than expected," she says.
For instance, a patient might not be ready for discharge in the morning but may show significant progress during the day. In these cases, Zielinski suggests that a resident see the patient later in the day and write the orders for discharge, she says.
"Alternatively, physicians are asked to consider writing the discharge order in the morning, conditioned upon the patient meeting the discharge screen," she says.
For instance, the physician may write "discharge if tolerating regular diet."
A key piece of the initiative involved tracking patient length of stay and giving the information to the admitting physicians, she adds.
"Each physician got data about their own length of stay compared to the department's average. The department chair got information on everybody," she says.
The medical director of the case management team provides feedback to the physicians about length of stay and prepares a trend chart, which has shown a steady decline in length of stay since the initiative began.
A quality improvement project for hysterectomy patients resulted in a decrease in length of stay from 1.89 days to 1.24 days for patients receiving a vaginal hysterectomy and from 2.59 days to 2.23 days for patients receiving an abdominal hysterectomy at Ingham Medical Center in Lansing, MI.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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