CHF path begins in ED, saves hospital $1,000 per patient
By Patricia Roy, RN-C, BSN
Director, Case Management
Ellen Janson, RN, BS
Cardiac Case Manager
Central Maine Medical Center
Lewiston, ME
The average length of stay (LOS) for congestive heart failure (CHF) patients admitted to Central Maine Medical Center has decreased from 7.2 days to 5.6 days since a CHF critical path was implemented seven months ago.
We needed a pathway for CHF, which is called a clinical map at our facility, because of the high volume of patients admitted with a CHF diagnosis and the continued increase in costs associated with the treatment of CHF. The map also was designed to provide more consistent care among the 50 physicians who treat patients at Central Maine.
Implementing the four-page map has reduced costs and reduced readmission rates, as well. Average charges for CHF patients dropped $1,000 per patient in the past six months. The rate of CHF patients readmitted up to 30 days after initial hospitalization decreased from 18% to 7%.
Minor revisions to the map were made in December 1995 based on physician feedback and recommendations from the map's development team. The patient's weight, for example, is monitored more closely each day. Further treatments or interventions can be administered earlier for patients who do not experience weight loss. (To see how patient weight status is monitored throughout the hospital stay, refer to the Cardiopulmonary Treatments/Other Assessments section of the clinical map, p. 24.)
All patients admitted with a CHF diagnosis are placed on the map, which was first introduced in July 1995. The map includes a two-hour section for patients who are first seen in the emergency department (ED) and then admitted to the hospital's cardiopulmonary unit. (To see what actions and interventions take place during the first two hours, refer to the First 2 Hrs. column of the clinical map, p. 24.)
Development of the path began in April 1995 and included multidisciplinary involvement from the following departments:
* medical staff;
* intensive care unit;
* emergency department;
* cardiology;
* pharmacy;
* dietary;
* respiratory therapy;
* laboratory;
* utilization review;
* social services;
* radiology;
* cardiac rehabilitation.
Patient education first begins in the ED and concludes with each patient demonstrating an understanding of four areas by the end of the five-day LOS. In addition to a booklet and viewing a videotape, patients are educated on the following topics throughout their stay:
* diagnosis;
* expected tests and treatments;
* signs and symptoms of CHF;
* current medications;
* importance of checking weight daily;
* nutritional issues, including:
-- sodium effect;
-- importance of reading labels;
-- avoiding foods with high sodium levels;
* activity limitations, restrictions, and progress in:
-- gradual activity increase,
-- planned rest periods through the day,
-- work simplification and conservation techniques.
In addition to the comprehensive patient education component of the map, a patient clinical map also was developed to help caregivers educate patients about CHF. The five-day LOS map is formatted much like the clinical map and includes a diagram of a normal heart for reference. Patients write questions on the back of the map to ask the case manager or physician.
Approximately 80% of discharged patients are telephoned following hospitalization for a patient satisfaction survey. Staff nurses conduct the survey approximately one month after discharge to gather information about the patient's hospital stay and return home. Examples of questions asked include the following:
* Did you understand instructions given to you in the hospital?
* Did the home health nurse arrive at your home on the scheduled day?
* How did you feel about your stay in the hospital?
* Was your hospital and home health care coordinated?
Codes make documentation simple
Documentation is by exception on clinical maps at Central Maine. Maps remain part of the patient's medical record, and for several departments, serve as the only record of documentation. Actions listed for each category on the map are coded for specific departments to assist caregivers in identifying appropriate interventions. Shifts are allocated a column to the right of each day to ensure patients are monitored at all times. (To see how each department is represented on the clinical map, refer to the legend in the upper right corner, p. 25.)
A team communication section is included on the back of each page of the path for caregivers to note additional comments. This section is for communication between departments and is not intended for documenting variances.
Caregivers document variances and actions taken on the Clinical Map Progress Notes sheet. That sheet includes information such as date, code, variance, follow-up plans, and caregiver's signature. The sheets have carbon copies that are forwarded to quality assurance for analysis and review. Variance tracking is not computerized, but all pathways are analyzed at least once every three months.
Case managers were not hired until July 1994, even though Central Maine has used critical paths for four years. Central Maine's case managers follow specific patients from admission to discharge throughout the facility. Case managers are assigned to the following specialties:
* cardiology;
* orthopedic;
* pulmonary;
* trauma.
The CHF map is just one of several in place at Central Maine. Other maps either in development or in use include the following treatments or procedures:
* total hip replacement;
* total knee replacement;
* fractured hip;
* mastectomy;
* transurethral resection of the prostate;
* acute myocardial infarction;
* cardiac catheterization;
* thoracotomy;
* cesarean;
* adult asthma;
* blunt abdominal injury;
* pacemaker insertion;
* cardioversion;
* vaginal delivery;
* normal newborn;
* acute stroke;
* inpatient chemotherapy.
The map development team currently is collaborating with a local home health agency to identify better methods of communication between organizations. For example, home health nurses receive a copy of the patient's map upon discharge. Also, the home health agency is providing the hospital with follow-up information about the patient's care for patients readmitted to the hospital.
[Editor's note: For more information about critical maps in place at Central Maine Medical Center, contact Patricia Roy, director, case management, Central Maine Medical Center, 300 Main St., Lewiston, ME 04240. Telephone: (207) 795-2720.] *
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