Renal transplantation path saves $34K per patient
Length of stay drops from 12 days to nine
A clinical pathway designed to standardize the treatment of patients undergoing renal transplantation at the Hospital of the University of Pennsylvania in Philadelphia has saved $33,636 per patient and decreased average length of stay three days, from 12 days to nine, since 1995.
Considering that the hospital averages about 125 renal transplants per year, that’s a total average savings of $4.2 million per year. Meanwhile, average hospital charges per patient fell from $123,979 to $88,343.
Phyllis Gatto, MSN, RN, a nurse on the transplant team who wrote the original draft of the pathway, attributes much of its success to the development of standardized order sheets. "Those helped because then the residents who changed monthly did not have to worry about what exactly they needed for a kidney transplant patient preoperatively or postoperatively."
Kenneth L. Brayman, MD, PhD, associate professor of surgery, agrees that the standardized sheets were a big plus and a big reason physicians got behind the pathway. "On the surface, standardizing orders for lab tests may seem like a minor thing, but the care of patients in hospitals is very complicated," he says. "At small hospitals, you can have multiple consultants seeing a patient. One consultant may order a lab test on one day and another consultant may repeat the test the following day, not realizing that the test results from the previous day are available. A pathway strikes at the very heart of an economy of practice by standardizing everything, from the type of dietary order that a patient receives to the actual laboratory tests that are drawn."
Pathway includes overview of progress
Physicians and staff also liked the fact that the pathway included, as a separate piece, an over view of the patient’s progress during the acute care stay, Gatto says. "The way it was structured, even if you weren’t familiar with the pathway, you could at least go to the overview, look at it, and be able to tell what was happening with the patient. Then, there’s the actual pathway, which is the piece that the nurses, social workers, and others document on." (See sample page from the pathway, p. 7.)
Another component of the pathway was the home-grown variance tool, which was used to gauge the effectiveness of treatment. "We picked out certain questions that we would like answers to," Gatto says. "Some of those questions had to do with whether or not patients’ pain was relieved." Patients were scored along a pain scale according to how much pain they suffered and whether or not the medication they received had any positive effect on their pain.
"We also took account of bowel movements," Gatto says. "Many patients had become constipated, so we looked at whether or not people were placed on the bowel regimen and if that made a difference in their length of stay."
The pathway also features a short booklet for patients, which provides a day-by-day breakdown of what they can expect. "Basically, it goes over their treatments, their tubes, their medication, their diet, their activity, and the teaching that they’ll receive each day until they’re discharged," Gatto says.
Patient education typically includes teaching about symptoms of urinary tract infection and rejection, and when to call the coordinator if problems arise.
The pathway was originally developed in 1995 at the suggestion of members of the quality improvement team. After Gatto wrote the baseline, a multidisciplinary team of of transplant surgeons, nephrologists, nurses, transplant coordinators, and social workers met to evaluate the idea. "Everybody was for it," Gatto says. "There were no ifs, ands, or buts about anything. Everybody thought that it was definitely needed and definitely overdue. And it works."
Currently, the renal transplant team meets every month to receive information back from quality improvement about the status of the patients on the pathway. "You can see some of the points where patients fell off," Gatto says. "You can also see whether or not people were ready for discharge, and if they weren’t, why not. Was it because their blood pressure was out of control, or their blood sugar was out of control? Did they have delayed graft function? Those are things we assess."
Outcomes remain similar
Recently, a study of the effects of the pathway compared the length of stay, hospital charges, and patient outcomes in two groups of patients: 95 recipients who were treated in 1995, before the pathway was implemented, and 124 patients treated in 1997, after the pathway had been in use for nearly a year. The results of the study were presented in October at the 1998 Clinical Congress of the American College of Surgeons in Orlando, FL.
The study showed that early release from the hospital after renal transplantation did not hurt the function of the transplanted organ, the incidence of rejection, or the rate of readmission to the hospital in the first month after surgery. The success rate of immediate graft function was similar in both groups of patients (63% in 1995 and 60% in 1997). The rate of readmission within 30 days of transplantation was 26% in 1995 and 30% in 1997.
For more information on the Hospital of the University of Pennsylvania’s renal transplantation pathway, contact:
Phyllis Gatto, MSN, RN, or Kenneth L. Brayman, MD, PhD, FACS, Hospital of the University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104. Telephone: (215) 662-4000.
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