Cutting the ICU stay in a CABG critical path
By Donna M. Rosborough, MS, RN, CCRN
Dorothy Goulart Fisher, MSN, RN
Lawrence H. Cohn, MD
Brigham and Women's Hospital
Boston
Managed care and other changes in health care have led to efforts to increase efficiency while maintaining high-quality care. In April 1993, an interdisciplinary team at Brigham and Women's Hospital was formed to lower the cost of treating coronary artery bypass graft (CABG) patients while maintaining or improving quality of care.
Critical pathways were suggested as a way to cut costs without harming quality of care. The team found improvement opportunities in the areas of length of stay (LOS), laboratory tests, and other tests.
The LOS targets for the critical pathway were set as an ICU stay of 24 hours or less, and a postoperative LOS of four days. The standing orders for laboratory tests and other tests were revised to reflect the minimum required for the uncomplicated CABG patient within the new LOS targets. (See plan, p. 115.)
The team developed daily expected patient outcomes. The key outcomes to be achieved were:
· extubation on the day of surgery;
· transfer to intermediate care unit within 24 hours postoperatively;
· tolerating solid foods on postoperative day two;
· removal of pacing wires on postoperative day three;
· tolerating one flight of stairs on postoperative day four;
· discharge on postoperative day five.
After reviewing a draft of the critical pathway, the team decided the care of patients recovering from an uncomplicated valve repair/replacement was virtually the same as for a CABG patient. The team decided to use the pathway for all uncomplicated cardiac surgical patients. Inclusion and exclusion criteria for pathway use were developed.
Initially, a paper format served nurses well in their documentation, but variance tracking was difficult and time-consuming. This led to the decision to automate the pathway in 1995. The care coordination team manager for cardiology/cardiac surgery documents a weekly list of all patients placed on the pathway. The list is faxed to a research assistant who is responsible for tabulating outcome data and variances. Quarterly reports are generated and provided to the care coordination team manager, the chief of cardiac surgery, and the nurse manager of cardiac surgery.
Changes in practice and standards of patient care developed as a result of trends in variances from expected patient outcomes.
Since implementation of the critical pathway, the following key outcomes have been achieved:
· 35% decrease in charges for DRGs 104-108;
· reduction in postoperative LOS to 5.3 days for patients on the pathway;
· extubation within 18 hours of cardiac surgery for 95% of the patients on the pathway;
· 88% of the patients on the pathway being discharged home with services vs. discharge to an extended care facility;
· continued high patient satisfaction with the care received at Brigham and Women's Hospital.
Also, the care coordination team is developing critical pathways in home care agencies and extended care facilities in an effort to enhance the quality of patient care provided to cardiac surgery patients.
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