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Noel Thomas, RN, MSN
Yvonne Bernard, RN
Vanderbilt Children’s Hospital
In 1997, it was realized that DRG 108 ("other major cardiothoracic procedures"), which includes many of the surgical repairs for congenital heart disease, was one of the biggest money losers for Vanderbilt Children’s Hospital, resulting in a loss of approximately $1 million per year.
At that time, a multidisciplinary team, including nurses, physicians from intensive care, cardiology, anesthesia and surgery, case managers, utilization manager/diagnoses-related group specialists, a respiratory therapist, and representatives from the quality office, was formed to find ways to standardize care, cut costs, and improve the quality of the care given to this cohort of patients.
Among the many efforts made by this team of care providers, a critical pathway was developed for the care of patients who undergo simple congenital heart surgery. This critical pathway was named "Simple Congenital Heart Defect Open Surgical Repair." (To see pathway, click here.)
A majority of the patients appropriate to this pathway have their preoperative evaluation in the Cardiac and Thoracic Surgery clinic one to two days prior to the operation. A standardized order set for preoperative evaluation with 100% compliance in the clinic eliminates the need to attach the path to the patient’s chart at that time. A subgroup from the operating room, including anesthesia, OR nurses, perfusionists, and case managers, developed a separate OR pathway.
The highlights of the OR pathway are included on the "Simple Congenital Heart Defect Open Surgical Repair" pathway for the purpose of education of the care team. The pediatric critical care nurse attaches the pathway to the patient’s chart on the patient’s arrival to the critical care unit where they are recovered postoperatively. The nurse is required to document progress of the patient on the pathway every 24 hours on the patient flow sheet. Individualized goals, such as those related to comorbidities, can be entered in the individualized goal section on the pathway.
Standardized order sets for admission to the critical care unit after surgery also help with compliance to the pathway. A preoperative order set also has been developed for patients who are in-house preoperatively to maintain compliance to the pathway for these patients. Our care team currently is developing an order set for transfer from critical care to the floor. Currently, our critical care patients are not on computerized order entry. Our eventual goal is to have the patient admitted with the pathway assigned and to have the standardized orders, the hard copy of the pathway and the appropriate teaching material print out automatically.
Among the teaching materials included will be an illustrated patient/family-friendly version of the path that is being developed by the case manager and the child life therapist who work with this patient population in conjunction with The Learning Center at Vanderbilt. The goal of this version of the path is to reduce anxiety for the patient/family by keeping them informed of what to expect, to increase their involvement and control, and potentially to assist us in focusing on compliance to the pathway.
For a variety of reasons, an overall marked decrease in cost has not been realized with the initiation of the pathways to this point. One reason for this is the increased utilization of high-technology and high-cost modalities, such as extracorporeal membrane oxygenation and inhaled nitric oxide, in the complex population. However, increased standardization through improvements in benchmarks such as length of stay, length of critical care stay, number of chest X-rays, number of arterial blood gases, and time to extubation, has been noted.
One additional positive impact of pathway development has been improved communication between care providers. Multiple physician groups, including intensivists, cardiologists, and surgeons, manage these patients along with a number of ancillary services. The process of discussing necessity of treatments has given representatives from each of these groups the opportunity to share their knowledge and come to agreements on what care is needed or not needed for the majority of these patients.
Representatives frequently presented the applicable current research in making these decisions. However, developing pathways never takes away the necessity of assessment and individualizing the care based upon the patient’s clinical condition. Constant revision of the pathway and open minds to opportunities for improvement will hopefully result in continued improvement of quality and reduction of cost.
(Special thanks to Patricia Throop, RN, BSN, Greta Fowinkle, RN, MSN, and the Office of Case Management.)