Transcript Do Clinical Pathways Influence Outcomes for TURP?

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
7
6
CP Introduced
5
LOS
days
4
3
2
1
0
98-99
99-00
00-01
01-02
Year
02-03
03-04
04-05
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
80
70
60
%
50
40
Admissions
2001 census
30
20
10
0
NZ
Euro
PI
Maori Other
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
5
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
IT
Clinical Audit
2001
2002
2003
2004
Clinical Indicators
 Acute
vs Elective
 Admission DOS
 CBI/MBI
 Readmissions
 Operating time
 Fever
 Postop
Hb
 TOV
 LOS
 Histology
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
LOS
days
5
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
2000
2001
2002
Year
2003
2004
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