Bypass project brings many cost savings and other improvements
Here are the strategies behind reductions
Two hospitals that participated in a Health Care Financing Administration demonstration project for cardiac bypass surgery won't go back to the way it was done before. Processes are more efficient, patient care quality is high, and clinical outcomes are so positive that the hospitals involved have greatly reduced costs and fostered a team spirit among all the disciplines involved.
What's at work here is a collective effort to make a global payment for cardiac bypass patients (for DRGs 106 and 107) work through innovative initiatives that have proven successful.
St. Joseph's Hospital in Atlanta experienced several improvements. One of the more remarkable initiatives was the early extubation of cardiac bypass patients, leading to a shorter length of stay in the ICU. The elements of this include:
· Early extubation protocol.
The hospital implemented a protocol to "extubate when ready" but quickly moved to an "extubate in four-to-six hours" during the first 24 hours because of the health benefits associated with it. Patients had less post-operative complications such as pneumonia. Patients also were moved out of the ICU in 24 hours, reducing length of stay (LOS) by one day.
· Less delay in the OR.
The decrease in LOS freed up critical care beds and lessened the delay in the operating room. Staff became more productive because they could change the room and start another case. This eliminated the need for recovery room services because the patient was moved directly to the ICU.
· Fewer supplies in surgery.
Nurses implemented a "just-in-time" program with the inventory used in the operating room. For example, a suture package was opened only when the surgeon needed it. Other surgical supplies were also provided this way during surgery. "This was done in an effort to standardize the inventories we were using. The surgeons met to discuss which supplies, such as sutures and masks, they could all agree on," says Mary Beth Bova, BSN, MS, CNA, director of cardiovascular services at St. Joseph's. "We even renegotiated contracts with vendors for better pricing."
· Development of high-risk respiratory protocol.
A collaboration between nurses and respiratory therapists led to a new protocol to monitor patients who had difficulty weaning from the ventilator.
When patients are moved from the ICU to a telemetry unit, the patient is flagged for close observation. A respiratory therapist regularly visits them to monitor progress, assess their lungs, and take pulse oximeter tests.
· Multidisciplinary team employed.
Nurse managers, case managers, and social workers meet weekly to discuss all cases. A multidisciplinary team meets when appropriate and includes physicians, dietitians, therapists, spiritual care and ethics representatives, and other health care providers.
· ICU emergency cart reductions.
One nurse volunteered to review the ICU emergency cart. The cart, used an average of two to three times per month, had excess inventory. The nurse recommended that only essential supplies be maintained thereby saving $500 per use.
· Fewer laboratory tests.
Nurses make sure that only needed tests are performed and no duplication takes place.
· Scheduling changes.
Nurse managers changed the scheduling of staff to increase efficiency so that nurses arrive when a patient case is ready to arrive.
· Use of patient care technicians.
Nursing assistants are trained in sterile techniques to set up bedsides and prepare certain equipment so that nurses spend more time on patient care duties.
· Customized tubing.
The OR and ICU reduced waste by replacing incompatible tubing and IV lines with a customized system for use in both the OR and ICU.
· Targeting tardiness.
Because physicians were arriving late to scheduled surgeries, as much as 40% to 45% of the OR staff were being paid overtime or waiting for the physician to arrive. The hospital administrators spoke with physicians, and they now arrive on time.
· More managed care contracts.
The hospital has received several managed care contracts and cardiac carve-outs due to quality data.
· Hiring increases.
Because of the growth in cases, the hospital reversed its downsizing practices and began to hire more nurses.
· Purchasing technology.
With the savings from the project, St. Joseph's has purchased new technology to stay competitive.
Martha Adkinson, RN, MS, case manager of cardiovascular surgery at St. Joseph's says other cardiac bypass patients, not just those on Medicare, benefit from the new protocols and the standardization of inventory.
Bova says that in the early stages of the project, the predications for costs savings were $183,000 for moving 30% of patients out of the ICU in one day. Today, 98% of cases are transferred to a telemetry unit in one day. "Nurses continue to look for cost saving opportunities," says Bova. "With 2,000 cases per year, these types of cost initiatives add up."
At the other St. Joseph's
"What the HCFA project did for us was maintain the focus on the clinical issues but expand that knowledge to a wider audience," says Richard Prager, MD, head of cardiac and thoracic surgery at St. Joseph-Mercy Health System in Ann Arbor, MI. "Once we explained the project and its impact to administration, they responded." Prager says
St. Joseph-Mercy began to educate providers to review processes and solve problems. Immediate results were more OR time, more OR nurses, and decreased LOS by moving patients through the system more efficiently.
"We conducted time management studies to make processes better, and it was simple to do," says Prager. He says the hospital was concerned at the outset of the project because of the global payment for cardiac bypass patients. "It was unfounded," he says, we created a more efficient system. As it turned out, we re-invented the rules and made them better."
Consequently, the hospital benefited from the changes. Prager says the physicians and the organization have built a very strong relationship.
At both sites, it was the efforts of teams that made the difference. "We have learned to work as a team to reduce costs and maintain quality," says Adkinson. "No item is too small to consider for a cost savings. Most aspects of care in the OR can be reviewed by a team process. Physicians, nurses, and all other providers need to have input for the projects to be successful. Everyone has to work together."
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