Better patient education complements LOS cuts
Are your patients ready for discharge?
Shands Hospital at the University of Florida in Gainesville has developed a protocol that reduced the cost of renal transplants by 30%, primarily by cutting the length of stay (LOS) nearly in half. And not being satisfied at that, staff also bolstered the patient education program to make sure the earlier discharges don’t result in readmissions.
A renal transplant team streamlined the procedure to the point where the length of stay (LOS) was cut from 15 to eight days, says Nancy Upthegrove, RN, MSN, renal transplant practice coordinator. One means they used to cut the LOS was to have transplant patients bypass the surgical intensive care unit (SICU) and go directly to the ICU’s post-anesthesia care unit (PACU).
"The renal transplant team had streamlined their protocol so much that patients didn’t need [the SICU stay]," says Upthegrove. "They also found that patients didn’t have complications frequently enough to warrant that high level of care."
Patients still need intensive postoperative monitoring for fluid and electrolyte levels, which can take place in the PACU. Renal transplant patients who may face complications, such as cardiac complexities, are still moved to the SICU.
In a 1996 analysis of 30 patients who bypassed the SICU, Upthegrove says outcomes were good. "We found there were no physical consequences to the patient," she says. "The [PACU] nurses took very good care of the patients, and the patients did well."
But the hospital also realized that patients sometimes were ready to go home before they had achieved all of their educational objectives. "When you’re looking at a length of stay of only five days or so, and when you used to have a week to 10 days [of patient care], you have to streamline your education and get it done sooner and quicker," Upthegrove says.
Focusing on medications
Members of a multidisciplinary renal transplant team, including ICU representatives, looked for ways to improve education. They decided to start having patient classes three times a week. Most classroom teaching revolves around medications, especially cyclosporine.
"The medications have to be taken correctly, and the patients have to understand that if they don’t take them, they’ll lose their grafts," Upthegrove notes. "They also have to understand that they’ll have to take medications for the rest of their lives, and they should know the side effects of the medications, such as weight gain with prednisone."
Patients are taught by the transplant coordinator and PACU staff nurses who have completed a competency module on transplant education. "The module not only teaches the nurses about education, but it teaches them how to teach," she says.
One element included in the teaching module is instruction on how nurses can explain post-transplant expectations related to activity, medications, and incision care. A portion of the module on medications, for example, explains the action, dose, possible side effects, and nursing implications for each drug the patient must take.
Patients are given a booklet titled You and Your Kidney, which explains all aspects of the transplant, from what to expect after surgery to dietary changes and sexual functioning. An audiocassette tape and a large-print copy of the booklet are available to the visually impaired, and interpreters break down language barriers.
Education also focuses discharge education on obtaining medications, Upthegrove says. The costs of the medications are high about $900 to $1,200 a month during the first months after transplant, and about $600 to $1,000 a month thereafter. To ensure patients are prepared for those costs, a pharmacy financial counselor sees patients before surgery to explain the costs and how much insurance, Medicare, or Medicaid coverage will reimburse for medications.
Linking patients, pharmacists
Patients also are seen after surgery by outpatient pharmacists and financial counselors who explain reimbursement for medications and which pharmacies will fill their prescriptions. Some patients elect to have prescriptions filled at the Shands outpatient pharmacy; others who live out of town may be able to use their neighborhood retail pharmacy, Upthegrove explains.
"Before we did this, patients were sometimes ready to leave the hospital with no idea where they were supposed to go for their medications," she says. "Some of them had to come up with a couple of hundred dollars for their medications. Now, we’re trying to get them prepared for [arranging to get their] medications when they’re discharged. So when they get their discharge prescriptions, patients know exactly what to do with them."
Not all renal transplant patients can leave the hospital after eight days because of delayed graft function, Upthegrove adds. "Those patients have a longer length of stay because we have to rule out rejection," she explains. "The signs they have after their transplants, such as an increased creatinine [level] and in some cases, no urine output can also resemble rejection."
She adds that the renal transplant team is developing a protocol for delayed graft function patients, and the renal transplant pathway team will develop a clinical pathway for that diagnosis. "We’re hoping we can get them down to about a seven-day length of stay. We need to rule out rejection, which may require biopsy."
Upthegrove recommends that other hospitals seeking to reduce LOS for renal transplant patients rely on a multidisciplinary group of clinicians to develop a pathway. "Try to find an objective facilitator, and let the group brainstorm," she advises.
"A lot of your ideas for changes will come from within. Participants can usually identify for themselves what opportunities for improvement exist."
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