Project cuts admissions for kids with asthma
APR-DRG allows hospital to track outcomes
Readmission rates, average length of stay (LOS), and cost per case for children with low-acuity asthma improved after a clinical redesign initiative at the University of Michigan C.S. Mott Children’s Hospital (UMMCH) in Ann Arbor.
Among the initiatives were correct documentation of comorbidities and complications; standardized preprinted orders created with involvement by pediatric pulmonologists; and standardized, automatic education for parents on the first day of admission.
Over a three-year period, following implementation of the clinical redesign, costs per case and average length of stay dropped, and readmission rates dropped to less than the national average. The average LOS for children with noncomplicated asthma dropped from 2.16 days to 1.75 days. The readmission rates dropped from 2.97% in 1999 to 0.8% in 2002.
The clinical redesign initiative was made possible by the availability of the All Patient Refined Diagnosis Groups (APR-DRG) classification system, says Aileen Sedman, MD, director of clinical management in pediatrics at the hospital, an academic medical center that provides general pediatrics and subspecialty care.
The APR-DRGs were developed by the National Association of Children’s Hospitals and Related Institutions (NACHRI), in collaboration with 3M Corporation, which reformulated DRG categories utilizing levels of acuity. The APR-DRGs take into account pediatric-specific diagnoses but also are applicable to adults. NACHRI maintains a data-base of information from 70 children’s hospitals, allowing participating hospitals to benchmark their data against their peers.
"Clinical redesign of processes in hospitals that care for children has been limited by a paucity of severity-adjusted indicators that are sensitive enough to identify areas of concern. The data from the APR-DRG acuity-adjusted system was useful, allowing us to apply classic clinical redesign strategies to improve cost effectiveness and quality," Sedman says.
When the hospital compared its asthma patient data to the NACHRI database in 1999, it found that UMMCH had a higher cost per case and longer LOS in Level 1 patients, she notes.
Patients with low-acuity asthma were cared for by the general pediatric services, while the higher acuity patients usually were admitted to the pulmonary service, Sedman says. "Our general services lacked standardized protocols for treatment of asthma patients."
The hospital formed a team of pediatric pulmonologists, hospitalists, respiratory therapists, and nurse clinicians to review the data and make plans for changes.
Before the initiative, Level 1 asthma patients would have wheezing that couldn’t be broken in the emergency department, resulting in an admission through general pediatric services with a follow-up visit the next day. "A resident might see the patient in the emergency department at 2 a.m., and it might be the next afternoon before someone else sees them. The patient would be sitting there for a day and not getting the best therapy while we were waiting for the pulmonologist," she explains.
The committee decided to create standardized orders for asthma patients that would allow the nurses and respiratory therapists to wean the patients from oxygen and continuous nebulization without the physician having to write an order for each stage. By using the preprinted orders, the child can be put on continuous nebulized treatment and oxygen with written orders that call for weaning when the oxygen level and respiration rates reach a certain level.
"We are preemptively setting parameters that allow nurses and respiratory therapists to wean medication. If this occurs only every 12 hours when somebody makes rounds, it holds up the process of getting the patient treated and discharged," Sedman says.
The orders contain a component that calls for notifying the asthma education coordinator to work with the patients on Day 1. The asthma education coordinator is a clinical registered nurse who has taken subspecialty training to provide asthma education. "We are bringing the asthma educator in automatically and not waiting for another thought process to take place," she says.
The nurse educator gets a list every day showing what patients have come in the night before with asthma. He or she sits down with the patient and family to make sure they understand what they should do at home to avoid another visit to the hospital.
"The asthma educators have an empathetic ear with the patients and can help them understand what they have to do and why," Sedman adds.
The rest of the standard orders include vital signs, monitoring and setup, and drug treatment, giving the drug ranges and type of drug according to the weight of the patient.
The hospital examined the charts of all its asthma patients and discovered that in many cases, the documentation did not indicate the severity of the illness and the coders had to ask for addition information from the physician to assign the correct codes.
"We wrote up an educational piece for physicians about diagnoses and what needed to be documented," she says. For example, when a child has asthma wheezing and needs to be hospitalized, the chart should include documentation showing respiratory rates, the patient’s temperature, or any electrolyte abnormalities.
The APR-DRGs gave the hospital a meaningful basis on which to compare outcomes on the children, Sedman says.
"For many years, in children’s hospitals, the only data available to analyze cost per case and length of stay across multiple national databases used CMS [Centers for Medicare & Medicaid Services] DRGs, which do not take into account the comorbidities and complications in pediatric patients. Because of this, there was an overall cynicism about these data, and few clinicians at UMMCH would base clinical redesign efforts on national DRG utilization data," she says.
Unlike the CMS DRGS, the APR-DRGs are not a payment system, points out Kris Schulz, director for applied research and analytics at NACHRI.
The DRGs used by CMS to determine payments for Medicare patients aren’t relevant to pediatrics, she explains. "The problem is compounded at children’s hospitals within a health system that develops internal reports using the CMS DRGs to compare the performance of a children’s hospital. The Medicare DRGs don’t represent children accurately."
For instance, a respiratory condition such as pneumonia or asthma would be weighted higher in a Medicare population than in a pediatric population. "It’s very inaccurate to look at a case mix index based on an over-65 population and make staffing and budgetary decisions for a pediatric population," Schulz notes.
"The study at the University of Michigan C.S. Mott Children’s Hospital is an example of using our benchmarking tools to highlight an area where there is room for improvement, to implement a protocol, and to look at progress over time. With pediatrics, the problem that hospitals grapple with is that most cases are high acuity and low volume. There is a huge difference in age and weight and other factors. Without having a database of similar patients you can compare to, you simply can’t get a large enough sample," she explains.
The NACHRI database contains data from many institutions, giving hospitals a representative sample on which to base their analysis, allowing hospitals to home in on benchmarks that make sense, Schulz adds.
For example, hospitals studying outcomes from a highly specialized niche-type of pediatric care or thinking about starting a particular type of care can use the database to obtain data from the leading institutions that provide that particular type of care, she points out."We are able to customize the database and look at just a few hospitals, then go a step further and look at high-acuity patients."
Readmission rates, average length of stay (LOS), and cost per case for children with low-acuity asthma improved after a clinical redesign initiative at the University of Michigan C.S. Mott Childrens Hospital (UMMCH) in Ann Arbor.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content