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Critical Path Network
Multi-thronged approach moves patients through continuum
Sticker alerts team to targeted LOS
A series of initiatives that includes on-site screeners for rehabilitation and long-term care, as well as a lounge for patients being discharged has helped Bay Regional Medical Center in Bay City, MI, move patients safely through the continuum of care in a timely manner.
"We take a proactive approach to discharge planning, making sure that the patient's care follows the clinical pathway, and working with ancillary staff to ensure that all of the tests and procedures are performed in a timely manner," says Patricia Valley, RN, case manager on the neuro unit.
For instance, when the hospital's length of stay crept up from an average of 4.24 days during the winter months, the hospital targeted the length of stay for its top four DRGs — pneumonia, chest pain, congestive heart failure, and acute myocardial infarction.
Now, when a patient comes into the emergency department with one of the four diagnoses, the unit or floor case manager puts a sticker on the front of the chart, alerting the treatment team to the targeted length of stay for the patient.
For instance, when a patient with pneumonia is transferred to Valley's unit, she knows by looking at the sticker that the patient is likely to be ready for discharge in four days and works to make sure that whatever tests and procedures he or she needs are conducted in a timely manner.
Another initiative ensures that patients who are admitted in observation status quickly receive the diagnostic studies needed for the physician to make a decision on whether to admit or discharge the patient.
"It alerts the nursing staff that the patient needs to move along. We have only so many hours to decide if this patient should be admitted or discharged," Valley explains.
When a physician puts a patient in observation status, the case manager puts a yellow sticker on the chart, alerting the staff that if anything is ordered, it has to be immediately completed so the patient can be admitted or released in the 24-hour time frame allowed for observation status.
"The physician might order a chest X-ray for a patient in observation. If it's a newly admitted patient, the X-ray can wait, but if the patient is in observation status, it needs to be done immediately," Valley says.
At Bay Regional Medical Center, case managers are assigned by unit. Each unit has an anchor case manager and one who rotates between units.
For instance, Valley is the anchor for the neuro unit, which treats patients with strokes, traumatic brain injuries, cerebral injuries, debilitation, and those who undergo elective neurosurgery or orthopedic surgery, such as lumbar and cervical surgery. The other case manager works in the neuro unit and the orthopedic unit to handle overflow cases.
The unit includes a neuro step-down unit with eight telemetry beds for patients who are transferred out of critical care but still need monitoring and specialized care.
The beds also are for cerebrovascular accident (CVA) or transient ischemic attack (ITA) patients who bypass critical care and are admitted directly to the neuro unit.
Case managers are on-site in the emergency department 10 hours a day from 10 a.m. to 10 p.m. One case manager or social worker is on duty in the hospital every Saturday, doing discharge planning and ensuring that observation cases are either discharged or admitted in a timely manner.
The case management staff rotate on call for evening, Sundays, and holidays.
Case managers handle both the utilization review and discharge planning for their patients, Valley says.
"It works well for us because the physician talks to just one person and we have an opportunity to establish a good working relationship with them," she says.
On the neuro unit, a multidisciplinary team that includes case managers; occupational, physical, and speech therapists; and the rehabilitation screener works together to facilitate discharges and look for opportunities to improve patient care and throughput.
The entire treatment team, including the nursing staff and the case managers, meet every day to review the treatment plan and discharge potential for their patients.
"We meet to brainstorm on the patients. If the plan is for the patient to go home, I know that I need to talk with the family," Valley says.
The nursing staff use the meeting as an opportunity to bring the rest of the team up to speed on any new orders.
When a patient is admitted to her unit, Valley reviews the records to determine that the patient meets inpatient admission criteria.
If the patient is admitted with a diagnosis that has a clinical pathway, such as a stroke patient, she makes sure the clinical pathway is being used and standing orders for each day of the stay are in place. The orders list possible tests, procedures, and consultations with a place for the physician to check off.
"When a patient is admitted to a unit, we immediately start looking at discharge options. For instance, we evaluate the potential for a patient to need ongoing antibiotics after discharge. If the patient's insurance won't pay for IV antibiotics at home, we start looking for other options," Valley reports.
For instance, the case managers work closely with the pharmacy department to keep up with companies that may provide medications for free to indigent patients.
On-site screeners key
On-site screeners from the hospital system's rehabilitation center and long-term acute care hospital (LTAC) are another key to a speedy and safe discharge. Based on the patient's admitting diagnoses, such as stroke, closed-head injury or craniotomy, they frequently evaluate patients on the day of admission, instead of being called in after the physician writes an order for an evaluation.
The screeners work with the case managers, the physical therapists, and occupational therapists to determine which patients are likely candidates for post-acute care and make the arrangements in advance for appropriate patients.
For instance, the rehabilitation screener reviews all stroke admissions for a potential rehabilitation stay and sets up a physiatrist evaluation if it appears that the patient is likely to need inpatient rehabilitation services. She also coordinates transfers to other rehabilitation centers throughout the state if patients from other parts of Michigan want to go to a facility that is near their homes.
Valley alerts the patients and family as far in advance as possible so they can arrange transportation when a patient is being discharged to home.
"It's hard for patients who live outside Bay City to get a ride home when it may be an hour or longer away. We notify them ahead of time so they can make arrangements for their transportation," she says.
She reminds the patients that they can go home later in the day and up until midnight if the person who is taking them home works during the day. The hospital operates a courtesy van, staffed by volunteers who take patients home within the city limits.
Lounge for waiting discharge patients
As part of its initiative to improve patient throughput, the hospital created a hospitality lounge for patients who are waiting for discharge to home. The lounge, created from two patient rooms, is equipped with recliners, a television, movies, food, and beverages. Patients who are able to wait comfortably and independently are moved to the hospitality lounge while they wait for their ride home.
The lounge is operated from 8 a.m. to 8 p.m. Monday through Thursday and from noon to 8 p.m. on Fridays. It is staffed by an admission nurse.
Valley serves on the CVA work group, a multidisciplinary team that was formed eight years ago to develop a clinical pathway and standing orders for stroke.
In recent years, the workgroup has concentrated on meeting the criteria to achieve The Joint Commission's stroke certification.
In addition to Valley, the team includes the neuro floor nurse manager who also serves as the group's chair; the neuroscience nurse clinician; the rehabilitation screener; the nursing director for the neuro and orthopedic floor services; the hospital's stroke champion who is an emergency department physician; and representatives from physical therapy, critical care, the emergency department, and diagnostic imaging. Other ad hoc committee members who come occasionally include representatives from pharmacy and the quality staff.
The hospital's quality and resource management department, of which case management is a part, tracks "opportunity days" — days when discharges were held up pending glitches in the system.
Working the data
The department reviews InterQual data to identify variances and when there is reports to a committee of select medical staff and nursing management. The physician advisor to case management presents the data to the department or physician group responsible for the variances. In addition, each physician receives a confidential report of his or her own length of stay.
The case management team works to come up with solutions. For instance, when data showed that there was a long delay in getting results of MRIs, CT scans, and cardiac stress tests from the hospital's radiology department, the team looked at ways to get a quicker turnaround.
One solution was a contract with Night Hawks, a group of radiologists in Australia who read the tests on-line, giving the clinical staff access to a report 24 hours a day. The hospital radiologists reread the films the next day.
"It's helped us with patient flow. If the results are negative, the patient can go home. It's also helped us provide timely treatment for patients who present with strokes," she says.
For instance, if a patient comes in with symptoms of an ischemic stroke, the hospital has three hours to determine from a CAT scan that the patient did have an ischemic stroke and administer Tissue Plasminogen Activator (TPA), a clot-busting drug.
The team established a neon-green form that includes the date, the time, and what test was performed. "The physicians can look at the form during rounds and let us know when they need the results. If discharge is pending the results, I call the film room and ask them to expedite the results," Valley says.
Before starting the process to gain certification, the CVA workgroup reviewed patient charts to make sure that the hospital is meeting all of the quality indicators for stroke care.
The workgroup created stroke assessment orders, revised the acute ischemic stroke order sets, and updated the clinical pathways for stroke. The team has developed stroke discharge and home care instructions and developed community education projects.
For instance, members of the team conduct education programs at Bay Regional Medical Center's volunteer clinic for people without health insurance.
"Many of the people who come to the clinic are overweight, smoke, and are hypertensive. Health care speakers come on-site monthly and talk to them about healthy lifestyles while they wait for treatment," Valley says.
Members of the workgroup set up booths at health fairs and community events and conduct stroke screenings at an off-site location every year during May, Stroke Awareness Month.