The Gynecologic Oncology group at University of Colorado Hospital is changing the way patients receive care, both before they enter the hospital and during their stays – and showing that doing so can get them home sooner.
A team of inpatient and outpatient staff and providers from Gynecologic Oncology (aka Gyn Onc) joined forces last year to develop a process improvement project with the Institute for Healthcare Quality, Safety and Efficiency (IHQSE). Their broad goal was to streamline the care patients receive, from pre-admission, through their hospital stay, to their post-discharge care.
It wasn’t an easy assignment, said Jamie Nordhagen, RN, nurse manager of the hospital’s Oncology/Gynecologic Oncology/Medicine Unit.
“We wanted to unite inpatient and outpatient care into one service line,” she said. “But we realized we were pretty siloed.”
The work is still underway, but the IHQSE project has helped to break down some of those walls. For example, the team is meeting a goal of implementing and integrating inpatient education into teaching before patients are admitted to the hospital, Nordhagen said.
Post-surgery, providers follow a clinical pathway – embodied in an evidence-based order set – that includes advancing patients’ diets, getting them up and moving earlier, titrating their supplemental oxygen, following steps to prevent deep-vein thromboses, and removing indwelling catheters as soon as it is safe to do so.
Consults for social work and case management are also embedded in the order set to address post-discharge needs, such as home health, depression treatment, substance abuse, palliative care and the like, and improve patients’ transitions of care, Nordhagen said.
It’s working: Recent data from the IHQSE show that the clinical pathway, which rolled out last October, has helped to reduce the average length of stay for Gyn Onc inpatients by a day and a half.
Eyes on the unit
The project sprung from daily observations of life on the unit, said Georgina Cheng, MD, PhD, a fellow with the Gyn Onc service. Cheng said she, Nordhagen, and Barbara Wenger, RN, MS, a clinical nurse specialist with Nursing Professional Development, noticed inconsistencies in implementing orders for patients on the unit.
For example, in rounding on patients, Wenger noticed variations in care, such as catheters retained longer than necessary, Cheng said. Wenger would relay the information back to nurses, but the need for standardizing practice was clear. With input and consensus from attending physicians, the team created the clinical pathway and order set. It is now being integrated into the Epic electronic health record to ensure the standardized care is delivered to patients consistently.
The work has created predictable milestones for patients treated for conditions such as endometrial cancer, Cheng said. “There will always be exceptions,” she said, “but we are able also to identify barriers to moving patients to the next step in their care.”
The direction is important for Gyn Onc’s staff of more than 100 nurses, as well as for the certified nursing assistants (CNAs) and advanced care partners who work the floor, Nordhagen noted.
“They need structure and consistency in providing care,” she said. “We’ve empowered nurses and allowed them to function at a higher scope in their jobs.”
Getting in and getting out
Cheng said the team has also concentrated on consistently “setting patients’ expectations” with pre-operative education about preparations for procedures, such as cleansing to prevent infections; expected length of stay; pain levels; medications; contacts for providers and more.
The effort also helps to prepare patients for discharge, where they frequently get large amounts of information in a short period of time.
“The pre-op education decreases the load of discharge preparation,” Cheng said. “Repetition is important.”
The work to build a continuum of care continues. Inpatient and outpatient representatives now meet to strengthen communication with patients after they leave the hospital. The goals: increase patient satisfaction and head off complications that could lead to readmissions. Nordhagen said the plan could also include post-discharge phone calls, possibly by the end of the first quarter of this year.
“We’re trying to bridge transitions of care to the outpatient setting,” Nordhagen said.
“The challenge is developing a unifying message and defining the information that patients receive,” Cheng added. “We improve satisfaction when patients know what to expect.”
Reducing average length of stay and improving the patient experience are important payoffs from the IHQSE project, said Nordhagen, but she highlighted an additional benefit.
“Perhaps the most beneficial outcome has been improved collegiality and collaboration between our unit’s leadership and Gyn Onc providers,” she said. “We’ve laid a strong foundation to move ahead.”