Clinical pathway cuts costs and infection rate
Pre-op showers, antibiotic standardization cited
A clinical pathway designed to reduce nosocomial infections in laminectomy patients has yielded substantial cost savings by decreasing patient lengths of stay at Mercy Fairfield (OH) Hospital, reports Dee Miller, RN, MS, CIC, nurse epidemiologist at the facility.
After initiation of the pathway, the infection rate dropped to zero and the average length of stay decreased by one day per laminectomy. Potential yearly cost savings of the program were projected at $180,000 based upon an average daily cost per patient of $900, she explains.
"We went down to a zero infection rate and we have been able to maintain that," Miller says. "I thought at the beginning that it was just a Hawthorne effect’ that everybody was really into this and looking at it. But since then I really think that it has to with the fact that we have a more standardized, quality approach to our patients."
The program includes a patient education component and a pathway that takes clinicians through the plan from pre-admission to discharge. (See clinical pathway, p. 153; patient information, p. 154.)
"We wanted [patients] to know about the pathway to give them incentive," Miller says. "It doesn’t do any good to do a pathway if we don’t have the client and their significant other and family members [involved]."
Proposed by the infection control committee after an 8.5% post-discharge laminectomy wound infection rate in 1995, the clinical pathway was developed by a multidisciplinary team that included neurosurgeons, an infection control physician, pharmacy and nursing representatives, and patient educators. The involvement of the neurosurgeons who perform the procedures was a critical factor, she says.
"I think a lot of [the success] had to do with the fact that physicians had input," Miller says. "They actually helped do the review of the literature and some of the charts. And maybe they looked at their own practice a little bit differently."
The committee conducted a review of the medical literature to adopt the best practice models, and reviewed the 225 laminectomies performed at the hospital in 1995 to determine usual clinical practice. In addition to the patient education element, one of the major changes implemented was the addition of a chlorhexidine gluconate shower before patients undergo the procedure.
"That was something we used to do in hospitals all the time, but when patient length of stay shortened and they had same-day surgery, it was something that was lost," Miller notes. "It has been proven to help remove a lot of the flora from the skin preoperatively."
Another important pathway element was standardizing preoperative antibiotic administration to a regimen that includes cefazolin, she adds. The overall project revealed that infection control can make an important contribution to such case management models, though many ICPs may not currently be participating in such plans.
"ICPs are not normally involved in care plans and care maps," Miller says. "This is something that they can be involved in and certainly add their expertise for potential prevention of nosocomial infections. I think [ICPs] are interested in getting involved in clinical pathways, but they don’t know how to get started or maybe are not invited. They may need to take the initiative and be the instigator and coordinator of the pathway."
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