Pain relief, patient teaching lop 50% off LOS
Physicians taste success and clamor for more
It wasn't flawed surgical techniques that kept patients lingering at Lehigh Valley Hospital in Allentown, PA. Instead, the problems lie in pre- and post-op care gaps. Although the solutions didn't always require direct action by the hospital's physicians, their buy-in was critical.
To capture their attention, Beverly De Bold, BSN, CNOR, Lehigh's Perioperative Division patient care specialist latched on to one of their nagging concerns. "Our surgeons had been struggling with pain management," she comments, "so they were pretty interested in care plans that would alleviate post-op pain.
Doctors look to peers for guidance
"If you're a nurse," De Bold adds, "the best way to communicate with doctors is to show them a literature review so they see what other doctors are doing instead of having a nurse tell them they should do it."
Engaging the physicians' natural tendency to look good among their peers, De Bold showed them length of stay (LOS) stats from Lehigh's benchmarking partner, Fairfax (VA) Hospital. "Doctors are very competitive people," she observes, "and when they saw the numbers, they got interested."
Pain regularly kept many of Lehigh's gynecological oncology patients stuck in the hospital, especially older women with pelvic lymphadenectomy because of their ages and other health problems," De Bold explains, "they weren't getting around very well even before the surgery." The hospital's standard post-surgical pain meds didn't provide enough relief to enable patients to get out of bed within 24 hours after their operations. The same problem persisted with abdominal aortic aneurysm surgeries.
The new techniques involved epidural pain meds administered just before the surgeons closed the abdominal incisions. The medications were injected through a spinal catheter from which an intravenous line was extended and taped to the top of the shoulder. This arrangement allowed injection of pain relievers no matter what position the patient was in on the operating table.
Implementing the changes involved two significant adjustments in staffing and logistics:
1. Commitment from the anesthesiologists to come to work early so they could insert epidural catheters for the first patients of the day.
2. Pre-op patient preparations moved from the operating room holding area to the recovery room.
It was a space issue, De Bold explains. "The OR holding area is so tight that an anesthesiologist literally could not get a stool between the gurneys to sit down and insert a catheter. Then, as a convenience to our patients, we shifted the rest of the pre-op work, [shaving and sedation], into the recovery room instead of making them move into the holding area where we used to prep."
Small adjustment made large difference
That small tweak in the pain control process made huge differences in patients' ability to get out of bed and out of the hospital, De Bold points out. Most are able to walk a few steps or at least sit in a chair within 24 hours. LOS plummeted for abdominal aortic aneurysm patients from 10 or 11 days to 4.5 to 6.5 days, a drop of 49% to 59%. (For an overview of the care pathway, see diagram, inserted in this issue.)
When De Bold began to question the hospital's post-mastectomy LOS rates, she was puzzled to find the immediate medical matters in impeccable order while next-day discharge rates were lower than expected.
"The drains were working, pain was under control, and infection and complication rates were down," she notes. Further investigation revealed the answer: an embarrassing gap in the teaching and counseling vital to a mastectomy patient's full recovery.
"Here we were bragging to the world about our cancer care," she confesses, "and we found out we were not preparing our patients to face the world with a breast missing!" De Bold contends that pre-op education should have started in the physicians' offices the day patients received their diagnoses.
Instead, with little to no counseling, women showed up at the hospital for their pre-op lab work. There, another learning opportunity was missed. Instead of consulting with an oncology nurse to answer their questions, patients dealt with a lab technician trained to test but not to educate.
Education plotted on pathway
That's all changed now. De Bold assembled a team who created a mastectomy care pathway that plots all the points where teaching now occurs. Comprising the team were physicians, nurses, admissions staff, and dietitians, as well as respiratory and physical therapists.
While De Bold and the oncology unit staff have noted an upsurge in next-day discharge rates after mastectomy, the figures are not available as we go to press. Even that will change soon as Lehigh is computerizing its patient care outcomes.
If the accelerating speed of change and physician excitement have any predictive value, De Bold expects a bright future for patient care quality improvement. Though the speed of change still varies with departmental culture and process complexity, the overall rapidity of the planning-implementation cycle is about one-third of what it used to be from 16 weeks to six weeks. But the most promising development is the attitudinal shift of the doctors.
De Bold says, "Now I have surgeons paging me asking when they can have a map in their area."
[For more information contact: Beverly De Bold, Operating room-cc site, Perioperative Division, Lehigh Valley Hospital, Cedar Crest & I-78, PO Box 689, Allentown, PA 18105-1556. Telephone: Dial paging operator at (610) 402-8999, ask him or her to beep Beverly De Bold.]
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