1996 OPEN FORUM Abstracts
INTEGRATION OF THERAPIST DRIVEN PROTOCOLS INTO A CLINICAL PATHWAY: THE EFFECT ON COST AND REDUCTION IN LENGTH OF STAY
David R. Wheeler, RRT, Kathryn Hale, MD, Ken Hargett, RRT, Cathy Meents, RRT, The Methodist Hospital, Houston, Texas
Background: Coronary Artery Bypass (CAB) surgery with and without catheterization was a highly utilized service at our institution. In response to managed care issues and cost reduction initiatives, we developed a clinical pathway and evaluated its impact on hospital cost, utilization of services, and length of stay(LOS). Methods: A multidisciplinary work group was formed to define the issues with CAB and develop the pathway. All aspects of patient management during their hospitalization were analyzed and the pathway (PW) developed to streamline pre-op, ICU, and floor care to reduce cost and LOS. Two key components of the pathway were the Respiratory Care Post-Op Weaning/Extubation Protocol and the CAB Oxygen Weaning Protocol. The Extubation Protocol utilized respiratory mechanics, saturation monitoring and f/TV as key indicators for the reduction of ventilator support. The number of blood gases obtained was reduced from non-pathway (NPW). Extubation criteria were incorporated along with FiO2 reduction. After discharge from the ICU, the Oxygen Wean Protocol allowed therapist to reduce FiO2, titrate nasal cannula flows and remove the patient from oxygen. Discharge criteria related to removal of oxygen need. The pathway was implemented and data collected from April 1994-April 1995. 371 patients were enrolled in the PW and 386 were NPW. The two populations were selected by physician preference and comparable in all aspects, i.e. age, ASA score, previous surgery. Results: LOS was reduced in the PW population vs. NPW. (Mean 10.6 vs. 14.5 days, a decrease of 26.8%) PW CAB/cath was mean of 9.3 days, down from 13.2; CAB without cath was mean of 11.9 days, down from 15.8 days. PW ICU LOS was mean of 2.8 days for CAB/cath, down from 4.2 days NPW; 2.0 days for CAB without cath, down from 3.0 NPW. Oxygen utilization after ICU was reduced from 6.8 days NPW to 4.2 days with the PW. Respiratory Department Cost/patient was reduced from mean $1,322 CAB with cath to $792 and from $1230 to $708 CAB without cath. Conclusion: The use of a Clinical Pathway resulted in both fixed (LOS) and variable cost reductions (RT blood gases, oxygen utilization and vent days). The integration of TDP's was a major determinant in these savings. Accelerated discharge from the ICU and reduction in oxygen time allowing discharge home were both positively influenced by utilizing TDP's.