Measuring the benefits and outcomes of CM: Clinical Pathways

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Measuring the benefits and outcomes of CM
Clinical Pathways

• Trish White BN MN (dist)
• Nurse Practitioner Adult Urology
• Hawkes Bay DHB
• October 2005

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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 (ADLs)
• QOL (symptom control, well being)
• Knowledge (medications, diet)
• Financial (costs of care)
• Satisfaction (patient, staff)
  (Kleinpell, 2003)

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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

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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

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Clinical Pathways

• Documentation of variance key to improving
  patient outcomes
• Sheehan, Nursing Management, Feb 2002

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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

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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

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HG Length of Stay
CP Introduced
LOS days
Year
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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

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Readmissions

• 25 of patients readmitted
• Aggressive management for readmissions
• NG feeding
• Case coordination

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Ethnicity July 03 Dec 04

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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

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TURP Data

• Implemented as guideline in 1998
• Variance Monitoring 2001
• 2002
• TURP volumes 18.2 of surgery
• 105 case weights 28 of total contract

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TURP - LOS
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Clinical Indicators

• Acute vs Elective
• Admission DOS
• CBI/MBI
• Readmissions
• Operating time

• Fever
• Postop Hb
• TOV
• LOS
• Histology

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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

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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

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Hysterectomy

• Includes vaginal, abdominal laparoscopic
• LOS further broken down by type of surgery
  gynaecologist
• Benchmarked with ACHS

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Hysterectomy - LOS
LOS days
Year
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Clinical Indicators

• Demographics
• Readmission rate
• Admit DOS
• Postop blood work
• Intraoperative injury
• IDC
• Nausea vomiting
• Fever
• Bowel function
• CP completion rate

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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 gt38 increased no trend noted
• HBDHB within ACHS benchmarks
• Length of stay reducing
• Readmission rate reduced

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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

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CLINICAL PATHWAYS

• SHOULD NOT REPLACE CLINICAL JUDGEMENT