Pathways bring dramatic clinical results
CM department reduces costs, gains recognition
Physicians with Good Samaritan Health System in Kearney, NE, failed to see the need for clinical pathways until the system’s director of care management proved they work. Now, physicians not only accept clinical pathways; they’re asking her to create more.
"The department is relatively new. We started talking to physicians about pathways, and their response was very negative," says Leigh Bertholf, MS, RN, director of care management. "But we decided to make a commitment to show the clinical value of pathways and their ability to lower costs and length of stay."
Good Samaritan’s first two pathways were for acute hip and knee replacement. The 10-member pathway team adapted the Clinical Value Com pass, developed by Eugene Nelson, DSc, of Dartmouth University, to create its reporting profile for evaluating clinical pathways. "This was a crucial step in developing and promoting the pathways," says Bertholf. "You have to know what you want to report and what is of value and keep those things in mind as you develop your pathways. That data is the key to measuring pathway success."
Outcomes in the pathway profile include:
• number of cases by gender;
• average age of patients;
• average length of stay before and at end of reporting period;
• disposition of patients (home without home care, home with home care, subacute facility, other skilled facility) before and at end of reporting period;
• patient satisfaction;
• blood transaction summary;
• average procedure cost, prepathway and postpathway;
• average total charges, prepathway and postpathway;
• average distance ambulated on days two and three in patients discharged to home;
• average distance ambulated on days two and three in patients discharged to a skilled facility.
Education effort launched
Good Samaritan launched an education effort to explain the pathways to providers and patients. The team produced a video for each pathway to include in each patient’s education packet. The video describes the patient’s care from preadmission through hospital stay and skilled home care.
Team members visited rural skilled facilities to educate system providers on the pathways. To encourage participation, providers were offered free continuing education credit for attending the training sessions. "We did a lot of work to foster a relationship with our outlying providers," Bertholf says. "Our referral area includes a 200-mile radius between Lincoln, Nebraska, and Denver, Colorado. Many of our physicians were uncomfortable sending patients out to local rural areas for care. They didn’t want to send very ill patients to unprepared providers." In addition, a team physical therapist visited each rural site to assess the physical therapy capabilities at outlying facilities.
"Nearly 46% of patients weren’t ambulating according to pathway goals, and 26% were experiencing pain and nausea," she says. "We found that there was almost a perfect correlation between patients who didn’t meet ambulatory goals and Demerol use. We didn’t tell physicians to stop prescribing Demerol, we just showed them the data," Bertholf says, adding that Good Samaritan now uses morphine by pump for pain control in knee patients. "We’ve almost entirely eliminated the use of Demerol for pain. Patients don’t experience any delays due to pain, and they walk earlier. I also think our nurses are more aggressive about calling physicians for changes in pain medication if patients are uncomfortable. The pathways identified the relationship between pain and ambulation, and now nurses are much more proactive."
In the first reporting period for the knee pathway, the average total cost per patient dropped by almost $2,000. In addition, average length of stay dropped eight days and patients ambulated earlier.
Improved pain control also helped raise patient satisfaction rates. "If I’m not in pain, I’m going to be happier," she says. "Patient satisfaction increased dramatically — nearly 10%."
Another major shift in standard practice resulting from the pathways was a dramatic reduction in blood usage. "We were wasting blood," Bertholf says. However, "our last blood use scoring showed we’ve dropped below blood bank guidelines since implementing the pathways," she notes.
One of the most gratifying rewards for the pathway team has been physician buy-in. "Six months before the pathways were implemented, physicians were trying to pass referendums to bar pathway use in the system," she says. "Now, we have physicians calling us and asking whether we can develop a pathway for a specific condition."
She attributes physician buy-in largely to the pathway team’s efforts to avoid creating an adversarial relationship with system physicians. "Phy sicians have to write an order for pathways here. The pathways are not automatically applied," she says. "I think if you look at physician motivation, you realize that physicians only want to do the right thing for their patients. We kept pathway use optional, but by measuring and reporting the effectiveness of the pathways, we now have 99% physician compliance."
In addition, Bertholf has gained the respect of system executives. "I’m on the agenda of the leadership council and given 45 minutes to present the results of the pathways. To reduce skepticism and increase acceptance of the pathways, I document the source for each data element reported on the pathway profiles. I’ve gained a lot of recognition for the work of this department from the system’s leadership."
For more information, contact Leigh Bertholf, MS, RN, director of care management, Good Samaritan Hospital, 10 E. 31st St., Kearney, NE 68847. Telephone: (308) 865-7100.
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