MAKING THE BUSINESS CASE FOR THE CNL

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MAKING THE BUSINESS CASE FOR THE CNL

• Linda M. Rusch, MS, RN, APN
• Vice President, Patient Care Services
• January 2008

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The Hunterdon Medical Center Story
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• By the summer of 2008 we will be supporting 6
  CNLs at the cost of approximately 500,000. This
  is a huge commitment.
• Medical Unit 3 CNL (48 beds)
• Step Down 2 CNL (31 beds)
• ICU - 1 (CNS) (12 beds)
• Surgical Unit 1 CNL(31 beds)

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• ROI The CNL must function as stated in the
  White Paper. She/He must be true to the role of
  the safety nurse and lateral integrator.
• Monthly meetings with the CNO to assure role is
  being followed

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THE FOCUS

• CMS End of 2008 CMS will not reimburse for that
  part of the hospital bill related to hospital
  acquired incidents.

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• Examples
• - Falls with injuries ( i.e. fractured hip)
• - UTI
• - Hospital acquired decubiti
• - MRSA/MRO infection
• - Central line infection
• - VAPS

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Also

• Appropriate Care Measures (public reporting)
• SIP
• Flu/pneumonia vaccines
• Discharge Instructions
• CMS Patient Satisfaction (public reporting)

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The Case for Cost AvoidanceMRSA
Results LOS 20 days longer Variable cost
30,000 Mortality rate 1.5 x that of peers
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Measurement

• Measure month to month, year to year the
  decrease in hospital acquired MRSA and other MRO
  infections

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UTI An Opportunity

• Cost - 3,772.00 extra
• (DRG adjusted variable cost)
• - So far a 15 reduction in UTIs over last
• year
• CNLs spearhead this project (Foley monitoring
  includes, leg straps on, working on contaminated
  specimens and removing foleys within 3 days or
  less)

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Central Line Infection

• Each year, an estimated 250,000 cases of central
  line-associated BSIs occur in hospitals in the
  United States, with an estimated attributable
  mortality of 12-25 for each infection.
• The Marginal cost to the healthcare system is
  approximately 25,000 per episode.
• CDC 2002

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VAP (Ventilator
Associated Pneumonia)

• The mean added stay was calculated at 10.13 days
  at an extra cost of 14,253
• I. Kappstein
• Springer Science 2005

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Hospital Acquired Decubiti

• The Cost
• The estimated cost of managing a single full
  thickness pressure ulcer is as high as 70,000
  per patient.
• Jama 2006296974-984

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Other Factors Effecting LOSThings falling
through the cracks found by the CNL

• Referral to Wound Care consult
• Referral to Cardio Pulmonary Rehab
• Referrals to Physical Therapy
• Consults missed MD puts thoughts in progress
  note, does not order

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• DVT Prophylaxis missing
• Medication reconciliation not done
• Delays in transfer due to doc to doc
  communication
• No glucoscan orders ordered on new DM patient

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• Blood orders not completed from the ED
• Delay with Psych consult
• Patient on isolation, no sign outside door
• OOB one day for an elderly patient in bed takes
  7 days to recover

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• Missed red dot protocol
• Missing weights and BMI
• HPs not done (not on charts especially over
  weekend, typing delay)

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• Nutrition trigger missing for failure to thrive
  patient
• Chart found with orders not picked up for type
  and cross match

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• MDs not flagging chart CNL picks up Coumadin
  order, lab work, consult to oncology and
  neurology
• Latex allergy patient missed
• Numerous medication orders not ordered by MDs
  (forgetting human error/pressure)

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Proactive Influence on LOS and Quality of Life

• CNL influencing the changing of the level of care
  (LOS)
• Palliative Care Consult (LOS)
• Hospice referrals (LOS and Revenue for Hospice)
• (80 of healthcare costs spent on last 10 days
  of hospital care)

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Other Systems Influence

• Transport issues
• SBAR between Nursing and Radiology

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Last But Not Least

• Geriatrics
• Huge focus on the Medicare population
• (working with MD Geriatrician) focus is on
  quality care, decrease LOS by avoiding
  complications
• - Physical
• - Health maintenance
• - Medications

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• - Social
• - Functional
• - Psychological
• - Cognition
• (OOB, safety for falls, breakdown, UTI, proper
  drugs for the elderly i.e. not using Haldol)

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New Grads

• A wonderful group of young, hopeful and energized
  nurses, but huge concern for their competency and
  functioning as safe practitioners
• (CNL extremely valuable as ongoing mentor and
  support, and a resource nurse)