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Measuring the benefits and outcomes of CM: Clinical Pathways

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

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Measuring the benefits and outcomes of CM: Clinical Pathways

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  1. Measuring the benefits and outcomes of CM: Clinical Pathways Trish White BN MN (dist) Nurse Practitioner: Adult Urology Hawke’s Bay DHB October 2005

  2. 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)

  3. 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

  4. 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

  5. Clinical Pathways “Documentation of variance – key to improving patient outcomes” Sheehan, Nursing Management, Feb 2002

  6. 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

  7. 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

  8. HG – Length of Stay CP Introduced LOS days Year

  9. 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

  10. Readmissions • 25% of patients readmitted • Aggressive management for readmissions • NG feeding • Case coordination

  11. Ethnicity: July 03 – Dec 04 %

  12. 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

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

  14. TURP - LOS

  15. Acute vs Elective Admission DOS CBI/MBI Readmissions Operating time Fever Postop Hb TOV LOS Histology Clinical Indicators

  16. 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

  17. 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

  18. Hysterectomy • Includes: vaginal, abdominal & laparoscopic • LOS further broken down by type of surgery & gynaecologist • Benchmarked with ACHS

  19. Hysterectomy - LOS LOS days Year

  20. Clinical Indicators • Demographics • Readmission rate • Admit DOS • Postop blood work • Intraoperative injury • IDC • Nausea & vomiting • Fever • Bowel function • CP completion rate

  21. 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

  22. 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

  23. CLINICAL PATHWAYS SHOULD NOT REPLACE CLINICAL JUDGEMENT

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