By Melinda Young
A timely hospital discharge is particularly challenging for urologic oncology patients after surgery. But the results of a new study show including case management-style coordinated care with an advanced practice provider (APP) can dramatically shorten length of stay (LOS).1
“The average decrease in length of stay was approximately 25% to 30% across all operations,” says Jay D. Raman, MD, FACS, professor and chair of urology in the department of urology at Penn State Health Milton S. Hershey Medical Center. “The study’s goal was to see how we can optimize or streamline patient care pathways after surgeries in urology. Does the presence of an advanced practice provider, who is dedicating all their time and effort in an inpatient setting, yield dividends in length of stay, but also improve quality of life and life satisfaction outcomes?”
Investigators studied urologic oncology cases because they result in more complex operations. Typically, the patients are older, and their LOS is longer. “One of the challenges in urology is they’ve transitioned over to short-stay procedures,” Raman notes.
The more complex urologic oncology patients were divided into cohorts of standard care and the APP-led intervention. The standard care group was monitored by residents, nursing staff, and intern trainees. No specific person championed their timepoint metrics, meaning no one was in charge of saying, “We could reduce the LOS of this patient and improve care if we made these changes,” Raman explains.
In the intervention group, the APP was the point person who championed patient pathways. The APP consistently followed the patient’s care from admission after surgery to discharge or transition to a post-acute care facility.
“Someone was following the pathways and making sure the patient and infrastructure around the patient was adhering to the pathways,” Raman says.
At first, the goal was for APP to implement the pathway to see if this shortened the patient’s LOS and improved care. But the project quickly evolved as the APP learned more about the pathways and processes and how they worked in real life. This led to the APP suggesting several ways to improve the efficiency and effectiveness of care coordination and care transitions.
“The great thing was because we had one specific person implementing the pathways, we received a lot of informative feedback and information on how the pathways could be refined,” Raman explains. “We learned which steps were not doable but could be streamlined.”
The APP worked with the team to refine the pathway according to what worked, and to adjust what did not.
“Until you have one person actually looking at a process, it’s impossible to know which parts of the pathway are functional,” Raman says. “If everyone is looking at one specific step, they’ll think, ‘OK, we’re doing that step right,’ but they’re not taking a holistic view of the entire process.”
LOS Shortened for All Surgeries
Allowing for flexibility in the study and the processes, investigators found the intervention worked well. LOS was shortened after all the cancer operations in urology once the nurse practitioner had integrated into the hospital’s workflow. This included both minimally invasive surgeries and more complex procedures in the urologic oncology patients.
“The length of stay decrease in hours depended on the type of operation,” Raman explains. “For example, some minimally invasive surgical operations, where maybe the LOS at baseline was 34 hours — we were able to decrease that by eight hours to 26 hours.”
For more complex operations, after which patients typically stayed in the hospital for as long as a week, they shortened LOS by 1.5 days. “Proportionately, when looking at the LOS decrease from baseline, that percentage change was similar across the board,” Raman adds.
The researchers did not address the financial effect, but since the urology patients were covered under bundled cost payments, any reduction in LOS would be positive for the hospital.
Inpatient APPs coordinating postoperative care for these patients does not generate revenue because all costs are included in the bundled payments. “What we were able to show is in our hospital, they’re not generating revenue, but they’re decreasing length of stay, which is decreasing cost to the hospital,” Raman explains.
The APP worked with the hospital’s discharge staff and patient care team members. “From a patient satisfaction point of view, our hospital is big on team-based, collaborative care rounds,” Raman says. “The entire team — the nurse involved with the patient, someone from social work, therapy, service team, [and others] — did rounds on the patient.”
The APP was the consistent person who helped the team align the care coordination process. This took people out of their silos and into a mindset of working collaboratively to help the patient achieve the best outcomes.
“The APP also helped with co-localization,” Raman says. “Rather than having patients sprinkled throughout the hospital, all patients undergoing a similar operation were to be co-localized in the same unit.”
This tactic helped familiarize nurses and other staff with patients and the particulars of their care. It also ensured each person working with the patients was on the same page and knew about the patient’s operation.
“Rather than the advanced practice provider going over the protocol with a new team on a different floor each week, they were able to focus on co-localized patients on a certain floor and with a set of nurses seeing these patients more often,” Raman explains. “When the APP said, ‘Here is our pathway,’ there was familiarity with staff, and it improved adherence with the patient.”
Co-Localization Challenges
Getting to co-localization, even before the COVID-19 pandemic, was easier said than done. “The most difficult buy-in was at the level of hospital administration recognizing the benefits and bed management of the co-localization concept,” Raman says. “For the staff taking care of patients, it was very appealing.”
Hospital leadership worried about nursing specialization. Their goal was to achieve the greatest amount of flexibility and to cross-train nurses. “But when you get to cancer operations, where there is a higher level of expertise, there’s a lot of value in it,” Raman adds. “It’s hard to teach someone to be facile across the spectrum when you have these complex patients.”
The APP was hired in 2017, and the first year was part of the learning curve. The study period began in 2018 and continued into 2020. A lot of the research observations took place before the pandemic.
“As the hospital became inundated with COVID patients, the co-localization became very difficult,” Raman says.
In 2022, COVID-19 case rates and hospitalizations declined, making co-localization feasible again. “Now, we’re able to revisit the co-localization concept,” Raman says.
The APP’s role included postoperative checks to ensure the patient was recovering, and lab tests were normal. The APP also:
- reinforced the team’s adherence to pathways;
- helped refine the pathways;
- assisted with care coordination during discharge planning;
- involved consultation and integration with consulting services, such as ensuring patients with an irregular heartbeat obtained a cardiology consultation;
- oversaw discharge planning, including medication prescriptions.
“Broadly speaking, care coordination helped identify the patient’s needs,” Raman says. “Do they need physical therapy when they go home? Do they need to go to an inpatient rehabilitation facility?” While patients may be recovering well from the urological surgery perspective, there could be significant physical therapy needs and other issues, he adds.
The hospital has continued the APP model and is refining protocols to further shorten LOS. Also, they are collecting patient satisfaction scores to see if these can be higher.
REFERENCE
- Hull BP, Humphrey MD, Lehman KK, et al. Impact of an inpatient advanced practice provider on hospital length of stay after major urologic oncology procedures. Urol Oncol 2022 Jul 25;S1078-1439(22)00242-3.
A timely hospital discharge is particularly challenging for urologic oncology patients after surgery. But the results of a new study show including case management-style coordinated care with an advanced practice provider can dramatically shorten length of stay.
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