Laminectomy path saves $180,000 annually
LOS drops from three days to two
A clinical pathway designed to reduce nosocomial infections in laminectomy patients has helped case managers at Mercy Fairfield (OH) Hospital shave average length of stay by one-third and cut costs dramatically, says Dee Miller, RN, MS, CIC, nurse epidemiologist at the facility.
Once the pathway was launched, the infection rate for laminectomy dropped from 8.5% in 1995 to zero in 1997, and the average length of stay decreased from three days to two for this high-volume procedure. Potential yearly cost savings of the program were projected at $180,000, based upon $900 average daily cost per patient, she explains. (See sample pathway, p. 225.)
A laminectomy is a corrective surgical procedure on any part of the spinal column, from cervical to lumbar to thoracic, usually involving the removal of a disk. "There’s a multitude of procedures that fall under laminectomy," Miller says. She adds that, although it’s considered a Class 1 procedure, "the fact that you’re actually going through the skin into areas of the spinal column makes it [an infection] risk."
Another factor contributing to infections is the pain experienced by laminectomy candidates before the procedure, which discourages them from scrubbing the area. "What we used to do with these patients, back in the days when we had longer lengths of stay, is that we would prep them the night before by scrubbing their backs with some type of antiseptic preparation. We don’t do that anymore; we don’t have that luxury."
Because patients aren’t admitted the day before surgery, a case manager provides patients with educational materials a week prior to surgery, when pre-op blood testing is performed. The case manager goes over subjects such as wound care, prevention of pneumonia, and what to expect during the course of the hospital stay. He or she also begins the discharge planning process, inquiring about the patient’s home situation and potential caregivers. (See patient information, p. 226.)
In addition, patients receive surgical scrub soap, which they’re instructed to apply or have someone else apply to their back the night before surgery. "And if not then, we make sure to do it when they come in, so that there’s some preparation of the skin," Miller says. "There’s a lot of literature that supports doing this. But people don’t have the time to do it anymore. So it’s like going through the continuum of care and starting at the home before you even get into the hospital."
Another 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 of 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."
The overall project revealed that infection control can make an important contribution to case management models, though many ICPs may currently not be participating in such plans.
"ICPs are not normally involved in care plans and care maps," Miller says. "This is something 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."
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 in 1995 at the hospital to determine usual clinical practice.
[For more information about the laminectomy pathway, contact:
Dee Miller, RN, MS, CIC, 100 Riverfront Plaza, Hamilton, OH 45011. Telephone: (513) 867-6584.]
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