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
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 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
Pre Clinical Pathway Post Clinical Pathway 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
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
Clinical Indicators Acute vs Elective Admission DOS CBI/MBI Readmissions Operating time
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
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 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
SHOULD NOT REPLACE CLINICAL JUDGEMENT
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