1995 OPEN FORUM Abstracts
CASE MANAGEMENT APPROACH TO THE CARE OF VENTILATOR DEPENDENT PATIENTS IN A COMMUNITY HOSPITAL
Keith G, Rasmussen MS, RRT, Mary E. Lough RN, MS, CCRN, Sequoia Hospital, Redwood City, CA.
Introduction: Ventilator dependent patients are an expensive sub-category of intensive care patients. Case Management, combined with a multidisciplinary approach, effectively coordinates care and controls costs for these patients. In 1991, patients requiring 10 or more days of mechanical ventilation (Pts >=10) were retrospectively evaluated. Diagnoses were surgical (3) and cardiac (12). The average duration of ventilation per patient (LOV) was 29 days. Average length of hospital stay (LOS) was 47 days. Outcomes were; extubated (7), expired (7) or transferred ventilator dependent (1). In 1992 a Task Force was formed to study and support changes in patient care management. A multidisciplinary approach, coordinated by Case Managers (Clinical Nurse Specialist and Respiratory Care Educator) was implemented in mid 1993. Method: All Pts >=10 are included, without other entry or exclusion criteria. Diagnoses in 1993/1994; surgical (1/1), cardiac (12/6) and medical (4/5). On ventilator day four, the Case Manager contacts the physician and family and sets up a multidisciplinary conference. Conference participants are: Case Manager, Patient and Family, Physician, Nurse, Respiratory Therapist, Dietitian, Pharmacist, Rehabilitation Specialists (PT, OT, Speech), Social Worker, and Discharge Planner. Objectives of the conference: educate family and health professionals about current medical conditions; establish joint goals and plan of care; discuss discharge options; answer family questions. Conferences create an environment where decisions by consensus occur and goals are set to move care progressively forward. Conferences are repeated weekly until the patient is extubated, discharged, transferred or deceased. The Case Manager assures compliance with the established plan of care, and maintains communication with the physician, patient and family members.
Results: When compared to 1991 using the Kruskal-Wallis Multiple Comparison test (non-parametric), LOS and LOV for 1993 and 1994 were significantly reduced (p< .05) for Pts >=10. While LOS for all hospital patients declined in 93/94 (-1%/ -7%), the declines for the Pts >=10 group were substantially greater (see table). Outcomes for 93/94 were; extubated (8/6), expired (7/4) and transferred ventilator dependent (2/2).
LOS / LOV 1991 (n=15)1993 (n=17)1994 (n=12)
Days Days % Change Days%Change
(Range)(Range)from '91(Range) from '91
LOS Pts >=1047 (16-97) 30 (12-88)-36% 22 (14-33)-53%
LOV Pts >=1029 (10-90) 20 (10-86)-31% 16 (10-26)-45%
Average charges per patient, per day, for ventilator dependent patients: in 1993 = $6626; in 1994 = $6937. Estimated savings due to decreased LOS in 1993: $1.9 million; in 1994: $2.1 million. Experience: Decreases in LOS are due to coordination of care and decisions made at conferences for weaning, transfer or withdrawal of life support. Effective case management of even a small group of expensive patients results in substantial cost savings.
Conclusions: Multidisciplinary Case Management approach to ventilator dependent patient care shortens length of stay, on the ventilator and in the hospital, and reduces hospital costs.