Hershey's cardiovascular observation unit saves $200,000 a year
Integration meets managed care's expanding needs at 455-bed facility
Under increasing pressure to become more cost-effective, Kevin J. McGovern, MSN, RN, at the Milton S. Hershey Medical Center came to realize a few years ago that maintaining the status quo and managing cardiovascular patients on the floor would no longer work. As clinical operations manager for the Cardiovascular Center at Hershey, a part of the Penn State Geisinger Health System in Hershey, PA, he envisioned a cardiovascular observation unit (CVOU) that would have the potential to save money and favorably impact operational components at the center. The goal was to shift a large number of traditional cardiac inpatients, interventional patients, and low-risk chest pain patients to the outpatient setting.
The CVOU's effect soon became apparent, McGovern says. The unit's cost per patient day is considerably less than other units at Hershey - one day in the CVOU costs $279, compared to $988 for the ICU. (See graph, p. 98.) McGovern has calculated that Hershey saves more than 500 inpatient days per year at an estimated savings of $200,000.
The observation unit costs less mainly because of salary-related issues - the staffing and skill mix cost less. "The IMC [intermediate care unit] requires a higher percentage of RNs and more staff than the CVOU," says McGovern. The IMC handles a wide variety of patients, and acuity changes dramatically among the patients. Nine RNs and three LPNs staff the observation unit. The RNs are salaried employees and don't receive overtime pay, keeping down costs. "You have to have every type of equipment at the ready for the 'what-if' [in the IMC]. In the CVOU the 'what-if' is carved out - you have a defined population. It's in the nature of the beast," says McGovern.
The unit also has increased overall operational efficiency. Patients are moved into the system more quickly, and they complete their interventions sooner than in the past. Previously, patients referred to Hershey from outlying institutions for immediate catheterization had to wait until a bed became available on an inpatient unit. Now the patient is sent immediately to the CVOU and prepped for the procedure, saving hours of unnecessary delay. "Typically the desired procedure is completed before the inpatient bed is available," he says.
In addition, the CVOU has increased the facility's cath lab efficiency by providing pre- and post-cath care. Transport delays have been all but eliminated due to the unit's efficiency and location adjacent to the cath labs.
The CVOU is unique from other chest pain or "rule-out myocardial infarction" centers in that it's flexible - it meets the needs of a wide variety of patients who have no other place to go except as admissions. Patients include both children and adults - those with chest pain, those waiting for catheterizations, and those from the clinic waiting for a fluid bolus. "The CVOU is a utility unit that meets the needs of our whole product line," says McGovern. "The original design was narrow - just for pre- and post-cath, but we quickly saw that we needed to expand its utilization and increase its operational efficiency."
The old ways no longer work
The 455-bed Hershey Medical Center operates at an average occupancy rate of 85%, and cardiac units are typically occupied at rates between 85% and 98%. The Cardiovascular Center is fully integrated and encompasses all aspects of cardiac care. The center includes traditional inpatient care areas, such as the ICU and the IMC, and has three cath labs, an electrophysiology lab, cardiology services, echocardiology, and a cardiac rehab program for both in- and outpatients.
Prior to the CVOU, lack of flexibility in the inpatient units was increasing lengths of stay and expenses. Patient satisfaction was suffering, as well. McGovern saw an opportunity for change - an opportunity to use the facility's resources in a new and nontraditional manner.
Today, adjacent to the cath labs is the 12-bed CVOU, open since August 1995. "The original goal of the unit was to move patients to the cath labs. Then we added our chest pain patients and people who come in from outlying hospitals," says McGovern. It functioned as a holding zone for interventional and pre- and post-cath patients. It had, for example, a "groin stabilization unit" that focused on sheath removal and stabilization.
"We realized that the unit had the potential to be more than that," says McGovern, "and we expanded its narrow use to encompass other patient populations from the entire cardiovascular center." The unit now cares for:
· adult and pediatric cardiac patients;
· those scheduled for transesophageal echocardiography;
· cardiac patients who require short-term treatments;
· chest pain patients;
· inpatients requiring an invasive cardiac procedure;
· cardiac patients waiting for a bed;
· clinic cardiac patients who need to be observed as outpatients.
"Rather than traditional hospital beds, we use stretchers that have extra-thick mattresses and heaters," says McGovern. "They allow us to move patients to and from procedures without struggling to change beds." All the stretchers are monitored by a telemetry system that is networked throughout the cath lab.
The CVOU is closed weekends now due to decreased patient volume on those days, but "we've flirted with the idea of opening on the weekend," McGovern says. If an emergency chest pain patient comes in on the weekend now, he's put in one of the IMCs or ICUs.
Before the CVOU opened, outpatients did not receive follow-up calls. Now, every one is called by an RN post-discharge to review the his or her condition and ongoing care.
Since the CVOU's role has expanded, McGovern has seen a major shift in the percentages of outpatient vs. inpatient catheterizations and other interventional procedures. Pre-CVOU, 65% were inpatient, compared to 35% outpatient; post-CVOU, 40% are inpatient, and 60% are outpatient.
When inpatient beds are unavailable, the CVOU is used as an observation area for patients waiting for beds. "Before, those patients would sit unmonitored for several hours," says McGovern.
Patients who present to the ED with chest pain are managed in the CVOU with the guidance of a chest pain protocol. (See Hershey's protocol on p. 99.) Typically, they spend fewer than 20 hours in the unit, then are discharged home. Those admitted can stay in the CVOU awaiting their caths or waiting for an inpatient bed. The protocol includes a list of standing orders so doctors can relay their orders and be assured that they are followed without having to come into the hospital. "The protocol was developed by physicians and has helped make treating chest pain patients more efficient," says McGovern. "On account of that, physicians are more inclined to use this unit rather than the floor, and that saves the hospital money."
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