Measuring the benefits and outcomes of cm: Clinical Pathways Trish White bn mn (dist)

Measuring the benefits and outcomes of CM: Clinical Pathways

• Trish White BN MN (dist)

• Nurse Practitioner: Adult Urology

• Hawke’s Bay DHB

• October 2005

Outcomes

• Defined as the end result of a process, treatment or intervention

• Traditionally mortality and morbidity – measures of clinical outcomes and physiology

• Modern Parameters:

• Physiological
• Psychosocial (attitude, mood)
• Behavioural (motivation)
• Functional (ADL’s)
• QOL (symptom control, well being)
• Knowledge (medications, diet)
• Financial (costs of care)
• Satisfaction (patient, staff) (Kleinpell, 2003)

Why do it?

• Improves standard of care

• How good is the care we are providing?
• Measures the benefit of care
• Benchmarking
• Promotes continuous quality improvements

• Nurses should be critical thinkers

• Clearly illustrates benefits of the role

• Justify role
• Prove impact in a measurable way
• Gatekeepers

How I measure outcomes….

• Monthly report

• Linked to Nursing Council competencies
• Clinical data: number of pts seen in ward, OPD, home
• Referral sources: Nurse, Urologist, GP, Hospice
• Prevented admissions
• Teaching sessions
• Professional activities: presentations, publication, mentoring

• Audits: readmissions, active review, day cases, blood transfusions, returns to OT

• Clinical Pathways: variance monitoring reports

• Research

Clinical Pathways

• “Documentation of variance – key to improving patient outcomes”

• Sheehan, Nursing Management, Feb 2002

Clinical Pathways: process

• IT obtain patient data & enter onto Excel spreadsheet

• Clinical audit of medical records

• Manual input of clinical data into spreadsheet

• Report generated

• Analysis by me

• Feedback to clinicians (nursing and medical) & discussion

• Any changes put in place

Hyperemesis Gravidarum

• Multidisciplinary CP implemented in 1999: input from nursing, dietitian & medical staff

• HBDHB Quality Award, NZ Gynaecology Nurses Conference best paper 2002
• Replaces daily flow chart
• Ability to individualise

HG – Length of Stay

HG – Cost implications

• Pre Clinical Pathway

• $85,367 per annum

• Post Clinical Pathway

• $35 – 47,000 per annum

• At best $50,000 saving per year

Readmissions

• 25% of patients readmitted

• Aggressive management for readmissions

• NG feeding
• Case coordination

Ethnicity: July 03 – Dec 04

HG – Clinical Indicators

• Demographics

• Nausea & Vomiting Day 2

• Ketones Day 2

• Ptyalism

• NG feeding

• CP completion rates: ED & ward

• Potential to be used in PHC

TURP Data

• Implemented as guideline in 1998

• Variance Monitoring 2001

• 2002

• TURP volumes = 18.2% of surgery

• 105 case weights = 28% of total contract

TURP - LOS

Clinical Indicators

• Acute vs Elective

• Admission DOS

• CBI/MBI

• Readmissions

• Operating time

Benchmarking

• Benchmarking – (ACHS) Australian Council Healthcare Standards

• Each variance has between

• 60 – 84 Health Care

• organisations reporting

• figures

• Tissue weight, histology, blood

• transfusions, operating time,

• readmissions

Outcomes – Last report:

• Reduced TURP LOS by 0.5 day

• Plan to reduce readmissions in place

• Frequency of postop blood tests reviewed

• Difference in practice: CBI reviewed

• Rate of DOS admissions discussed

• HBDHB within Australasian benchmarks

Hysterectomy

• Includes: vaginal, abdominal & laparoscopic

• LOS further broken down by type of surgery & gynaecologist

• Benchmarked with ACHS

Hysterectomy - LOS

Clinical Indicators

• Demographics

• Readmission rate

• Admit DOS

• Postop blood work

• Intraoperative injury

• IDC

• Nausea & vomiting

• Fever

• Bowel function

• CP completion rate

Outcomes – last report:

• 2004-2005 for first time Laparoscopic Hysterectomy has shortest length of stay

• IDC removal and patients tolerating diet on Day 1 improved

• Fever rate >38 increased – no trend noted

• HBDHB within ACHS benchmarks

• Length of stay reducing

• Readmission rate reduced

Conclusions

• Clinical indicators selected on potential impact to quality of care and LOS

• Little benefit having clinical pathways without a robust VM system

• Clinical pathway an option even with different techniques between clinicians

• Linking clinical outcomes with data

• Provides a guideline for staff

• Current method labour intensive

• Future link to Trendcare, acuity system

CLINICAL PATHWAYS

• SHOULD NOT REPLACE CLINICAL JUDGEMENT