Measuring the Measuring the benefits and benefits and

outcomes of CM: outcomes of CM: Clinical PathwaysClinical Pathways

Trish White BN MN (Trish White BN MN (dist)dist)

Nurse Practitioner: Adult UrologyNurse Practitioner: Adult Urology

Hawke’s Bay DHBHawke’s Bay DHBOctober 2005October 2005

OutcomesOutcomes Defined as the end result of a process, Defined as the end result of a process,

treatment or interventiontreatment or intervention Traditionally mortality and morbidity – Traditionally mortality and morbidity –

measures of clinical outcomes and physiologymeasures of clinical outcomes and physiology Modern Parameters:Modern Parameters:

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

2003)2003)

Why do it?Why do it? Improves standard of careImproves standard of care

How good is the care we are providing?How good is the care we are providing? Measures the benefit of careMeasures the benefit of care BenchmarkingBenchmarking Promotes continuous quality improvementsPromotes continuous quality improvements

Nurses should be critical thinkersNurses should be critical thinkers Clearly illustrates benefits of the roleClearly illustrates benefits of the role

Justify roleJustify role Prove impact in a measurable wayProve impact in a measurable way GatekeepersGatekeepers

How I measure outcomes….How I measure outcomes…. Monthly reportMonthly report

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

mentoringmentoring Audits: readmissions, active review, day cases, Audits: readmissions, active review, day cases,

blood transfusions, returns to OTblood transfusions, returns to OT Clinical Pathways: variance monitoring reports Clinical Pathways: variance monitoring reports ResearchResearch

Clinical Pathways Clinical Pathways

““Documentation of variance – Documentation of variance – key to improving patient key to improving patient

outcomes”outcomes”

Sheehan, Nursing Management, Sheehan, Nursing Management, Feb 2002Feb 2002

Clinical Pathways: processClinical Pathways: process

IT obtain patient data & enter onto IT obtain patient data & enter onto Excel spreadsheetExcel spreadsheet

Clinical audit of medical recordsClinical audit of medical records Manual input of clinical data into Manual input of clinical data into

spreadsheetspreadsheet Report generatedReport generated Analysis by meAnalysis by me Feedback to clinicians (nursing and Feedback to clinicians (nursing and

medical) & discussionmedical) & discussion Any changes put in placeAny changes put in place

Hyperemesis GravidarumHyperemesis Gravidarum

Multidisciplinary CP implemented Multidisciplinary CP implemented in 1999: input from nursing, in 1999: input from nursing, dietitian & medical staffdietitian & medical staff HBDHB Quality Award, NZ HBDHB Quality Award, NZ

Gynaecology Nurses Conference best Gynaecology Nurses Conference best paper 2002paper 2002

Replaces daily flow chart Replaces daily flow chart Ability to individualise Ability to individualise

HG – Length of StayHG – Length of Stay

0

1

2

3

4

5

6

7

98-99 99-00 00-01 01-02 02-03 03-04 04-05

CP CP IntroducedIntroduced

LOS LOS daysdays

Year Year

HG – Cost implicationsHG – Cost implications

Pre Clinical PathwayPre Clinical Pathway$85,367 per annum$85,367 per annum

Post Clinical PathwayPost Clinical Pathway$35 – 47,000 per annum$35 – 47,000 per annum

At best $50,000 saving per yearAt best $50,000 saving per year

ReadmissionsReadmissions

25% of patients readmitted25% of patients readmitted

Aggressive management for Aggressive management for readmissions readmissions NG feeding NG feeding Case coordinationCase coordination

Ethnicity: July 03 – Dec 04Ethnicity: July 03 – Dec 04

0

10

20

30

40

50

60

70

80

NZEuro

PI Maori Other

Admissions2001 census

%%

HG – Clinical IndicatorsHG – Clinical Indicators

DemographicsDemographics Nausea & Vomiting Day 2Nausea & Vomiting Day 2 Ketones Day 2Ketones Day 2 PtyalismPtyalism NG feedingNG feeding CP completion rates: ED & wardCP completion rates: ED & ward Potential to be used in PHCPotential to be used in PHC

TURP Data TURP Data

Implemented as guideline in 1998Implemented as guideline in 1998 Variance Monitoring 2001Variance Monitoring 2001

20022002 TURP volumes = 18.2% of surgeryTURP volumes = 18.2% of surgery 105 case weights = 28% of total 105 case weights = 28% of total

contractcontract

TURP - LOSTURP - LOS

00.5

11.5

22.5

33.5

44.5

5

2001 2002 2003 2004

ITClinical Audit

Clinical IndicatorsClinical Indicators

Acute vs Acute vs ElectiveElective

Admission DOSAdmission DOSCBI/MBICBI/MBIReadmissionsReadmissionsOperating timeOperating time

FeverFeverPostop HbPostop HbTOVTOVLOSLOSHistologyHistology

BenchmarkingBenchmarking Benchmarking – (ACHS) Australian Council Benchmarking – (ACHS) Australian Council

Healthcare StandardsHealthcare Standards Each variance has betweenEach variance has between 60 – 84 Health Care 60 – 84 Health Care organisations reporting organisations reporting figuresfigures Tissue weight, histology, blood Tissue weight, histology, blood transfusions, operating time,transfusions, operating time, readmissionsreadmissions

Outcomes – Last report:Outcomes – Last report:

Reduced TURP LOS by 0.5 dayReduced TURP LOS by 0.5 day Plan to reduce readmissions in place Plan to reduce readmissions in place Frequency of postop blood tests Frequency of postop blood tests

reviewed reviewed Difference in practice: CBI reviewedDifference in practice: CBI reviewed Rate of DOS admissions discussedRate of DOS admissions discussed HBDHB within Australasian HBDHB within Australasian

benchmarks benchmarks

HysterectomyHysterectomy

Includes: vaginal, abdominal & Includes: vaginal, abdominal & laparoscopiclaparoscopic

LOS further broken down by type LOS further broken down by type of surgery & gynaecologistof surgery & gynaecologist

Benchmarked with ACHSBenchmarked with ACHS

Hysterectomy - LOSHysterectomy - LOS

00.5

11.5

22.5

33.5

44.5

5

2000 2001 2002 2003 2004

LOS LOS daysdays

YearYear

Clinical IndicatorsClinical Indicators

DemographicsDemographics Readmission rateReadmission rate Admit DOSAdmit DOS Postop blood workPostop blood work Intraoperative injuryIntraoperative injury IDCIDC Nausea & vomitingNausea & vomiting FeverFever Bowel functionBowel function CP completion rateCP completion rate

Outcomes – last report:Outcomes – last report:

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

IDC removal and patients tolerating diet IDC removal and patients tolerating diet on Day 1 improved on Day 1 improved

Fever rate >38 increased – no trend Fever rate >38 increased – no trend notednoted

HBDHB within ACHS benchmarksHBDHB within ACHS benchmarks Length of stay reducingLength of stay reducing Readmission rate reducedReadmission rate reduced

ConclusionsConclusions Clinical indicators selected on potential Clinical indicators selected on potential

impact to quality of care and LOSimpact to quality of care and LOS Little benefit having clinical pathways Little benefit having clinical pathways

without a robust VM systemwithout a robust VM system Clinical pathway an option even with Clinical pathway an option even with

different techniques between clinicians different techniques between clinicians Linking clinical outcomes with dataLinking clinical outcomes with data Provides a guideline for staffProvides a guideline for staff Current method labour intensive Current method labour intensive

Future link to Trendcare, acuity systemFuture link to Trendcare, acuity system

CLINICAL CLINICAL PATHWAYSPATHWAYS

SHOULD NOT REPLACE SHOULD NOT REPLACE CLINICAL JUDGEMENTCLINICAL JUDGEMENT