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Reducing Complications and Hospitalizations Through an Innovative Catheter Care Clinic for Percutaneous Nephrostomy Catheter Patients
Journal of Radiology Nursing 35 (2016) 275e280
Contents lists available at ScienceDirect
Journal of Radiology Nursing journal homepage: www.radiologynursing.org
Reducing Complications and Hospitalizations Through an Innovative Catheter Care Clinic for Percutaneous Nephrostomy Catheter Patients Vivienne Ganter Ritz, BSN, RN-BC, CRN a, *, Karen Gabel Speroni, PhD, MHSA, BSN, RN b, Diane Walbridge, MSN, RN, NEA-BC c a
Interventional Radiology, University of Maryland Shore Regional Health, Easton, MD Nursing Administration, Research, University of Maryland Shore Regional Health, Easton, MD c Nursing Administration, Clinical and Financial Nursing Resources, University of Maryland Shore Regional Health, Easton, MD b
a b s t r a c t Keywords: Percutaneous nephrostomy catheter Complications Quality improvement Innovation Clinic Health care costs
This quality improvement activity implemented by the hospital's interventional radiology (IR) department, including an interprofessional team of physicians, IR registered nurses (RNs), and technologists, evaluated best practices for reducing complications that would result in emergency department (ED) and/or inpatient hospitalizations and associated charges for patients with percutaneous nephrostomy (PCN) catheters. A catheter care clinic (CCC) was established that focused on patient and caregiver education by an RN and 24/7 access to the team for patients with complications or PCN-related questions. Pre-CCC implementation, 15 of the 32 (46.9%) adult (age range ¼ 45e92) patients with PCNs required hospitalizations, with 34 hospitalizations (ED ¼ 16; inpatient ¼ 18), totaling $183,750 (ED ¼ $30,799; inpatient ¼ $152,951). Post-CCC, 2 of 47 (4.3%) patients required hospitalizations (ED ¼ 2; inpatient ¼ 0), totaling $704. This was a hospitalization reduction of 43.5%, saving $183,046. Five of 16 (31.3%) patients not participating in the CCC post-CCC implementation required six hospitalizations (ED ¼ 4; inpatient ¼ 2), totaling $38,312 (ED ¼ $1,879; inpatient ¼ $36,433). Those participating had a 27.0% hospitalization reduction, saving $37,608. As a result of the innovative CCC, there were improved PCN patient outcomes demonstrated by lower hospitalization rates and total charges, when compared by preCCC and post-CCC implementation and by patient participation in the CCC. Driving the success of the program is consistent availability of the IR RN and an interprofessional team that provides patient and caregiver education in the CCC. Ideally, other facilities with IR departments or those who treat patients with catheters can consider a CCC. Copyright © 2016 by the Association for Radiologic & Imaging Nursing.
Introduction Key features of the Patient Protection and Affordable Care Act (ACA) of 2010 include a focus on delivering high-quality and costefficient health care (U.S. Department of Health & Human Services (HHS), hhs.gov, 2014). The ACA established the Hospital Readmissions Reduction Program, which requires Centers for Medicare and Medicaid Services (CMS) to reduce payments to hospitals with excess readmissions (CMS, 2016). The emphasis on reducing complications that may cause readmissions, and the focus on patient satisfaction and quality of care, resulted in an
Funding/grant support: None to report. * Corresponding author: Vivienne Ganter Ritz, University of Maryland Shore Regional Health, 219 S. Washington Street, Easton, MD 21601-2912. E-mail address: [email protected] (V. Ganter Ritz).
interventional radiology (IR) department developing through planned and coordinated activities, a follow-up clinic for patients with percutaneous nephrostomy (PCN) catheters. Background The IR department is part of a rural health system with three hospitals located in the mid-Atlantic region of the United States. The hospital system's IR department performs approximately 75 cases per year that involve percutaneous drainage catheters. The most common drainage catheter that is placed by the interventional radiologist is a PCN catheter. PCN catheters are required for obstruction of the ureter, usually secondary to malignancy; however, other causes such as interstitial cystitis and traumatic injury to ureters would warrant a PCN tube (Farrel & Hicks, 1997). Approximately 55% of PCN cases performed in the IR department are for
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long-term use. Long-term use is defined as PCN placement required for more than 2 weeks in duration. Placement of PCN catheters in an outpatient setting has been commonplace and generally regarded as safe for more than 20 years (Gray et al., 1996). Minor complications occur in approximately 15% of patients, whereas major complications occur in approximately 4% with mortality rates <0.2% (Ferral, Stockhouse, Bjarnason, Hunter, & Casteneda-Zuniga, 1994). The hospital system's patient population is diverse, with varying socioeconomic, cultural, and linguistic needs. The challenges associated with teaching and engaging patients and their family and/or caregiver to participate in the management of their condition frequently presents problems. These are generally related to a lack of understanding in the care required for maintenance of PCN catheters. Patients who do not have the resources or skills to effectively manage their condition are subject to resulting complications, which include, but not limited to, obstructed flow, skin breakdown, local infection, catheter dislodgment, and in severe cases, sepsis. Historically, many long-term PCN patients have come into the emergency department (ED) to be seen for complications, such as infection, back pain, and changes in urine output. Although these complications were often considered common, the IR team, consisting of the IR physician, nurses, and technologists, questioned whether they could be prevented. The point case was a skilled nursing facility (SNF) patient who presented to the ED with a partially dislodged catheter. At the time of insertion, the IR department used an external fixation device that anchors the catheter to the skin to prevent dislodging. The device in this case had become soiled and ineffective. No new device or dressing had been applied since the patient's catheter exchange 3 months before. As a result, the patient was subsequently admitted to the hospital because of urinary tract infection. The problem was obvious, as was the need for more consistent follow-up. Based on this case and others, a way to enact quality improvement (QI), optimize care, and decrease complications in the PCN patient population arose from a brainstorming session held by the IR team. The IR team reviews each case in a daily huddle. During one huddle, a patient who had a history of previous complications related to the PCN catheter was scheduled for a routine catheter change. The team decided it would be beneficial to have the patient return in 1 week for follow-up care. The primary IR nurse on the case contacted the SNF responsible for the patients care. It was agreed that the patient would return in 1 week for follow-up care. At the time of the patient's followup visit, it was noted that the dressing was moist and not adhering to the skin allowing for risk of PCN catheter dislodgment and potential infection. Proper catheter care was performed, including cleansing the area, flushing the catheter, and reapplying the fixation device and the cover dressing. The SNF agreed to have the patient return weekly for catheter checks and dressing changes. At that time, the IR team agreed that all the long-term PCN patients could benefit from weekly follow-ups. With this first patient, the innovative catheter care clinic (CCC) that focused on patient and caregiver education by a registered nurse (RN) and 24/7 access to the team for patients with complications or PCN-related questions was initiated.
collected on the number of patients with PCN catheters, the number who received care from the clinic and who did not, and the number of complications experienced that resulted in an ED visit within the health care system where the QI activity was completed. Data were compared for the preclinic period (2009 to March 2011; the first patient was seen in the CCC March 2011) to the postclinic period thereafter through 2015. Data were also collected on charges associated with complications for ED visits or hospitalizations. Charges for PCN patients who had ED or inpatient admissions within the hospital system where this QI activity was conducted were obtained from the system's database. QI processes The hospital system uses find a process, organize a team, clarify, understand variation, and select process (i.e., FOCUS)/plan, do, study, act (i.e., PDSA) as the QI process model (Langley et al., 2009). The process to improve was driven by the ACA, which requires CMS to fund the aggregate hospital value-based purchasing incentive payments by reducing the base operating diagnosis-related group payment amounts. The interprofessional team involved in the QI activity included members who were physicians, nurses, and technologists from the IR department. They clarified the current knowledge about PCN patient numbers pre-CCC and post-CCC implementation, including resulting complications requiring hospitalization (ED or inpatient) and hospitalization charges. Post-CCC implementation, they also clarified the number of patients who participated in the CCC and those who did not participate in the CCC. For those patients receiving hospitalizations within the hospital system performing this QI activity, total charges billed for each hospitalization (ED and inpatient) were quantified. As a result of this data collection, the team was able to understand the variations in practice resulting in patients having a greater number of hospitalizations. They attributed the variation to a lack of not only access to IR teams after hours but also patient and caregiver education or knowledge attributed to PCN catheter care. Herewith, programs developed around access to care and education are described. Access to care Patients and caregivers alike are encouraged to contact the IR RN with any PCN issues. This maintains a lifeline for patients and their caregivers. Often it is just shared information via a call that can resolve a problem such as a kinked catheter, thus eliminating the need for an ED visit. The on-call RN (who is available 24/7) will, if necessary, meet with the patient in the ED department or IR department during nonbusiness hours. Most of these calls also prevent undesirable ED visits. For complex problems, the IR physician is called to evaluate the patients and their condition. This may include site infection, urinary tract infection, bleeding, or PCN complications requiring IR procedures or replacement.
Purpose CCC patient and caregiver education program This QI activity implemented by the hospital's IR department evaluated best practices for reducing complications that would result in ED and/or inpatient hospitalizations and associated charges for patients with PCN catheters. Methods This QI activity was reviewed by the hospital system's institutional review board and determined to be exempt. Data were
After a PCN procedure, while the patient is still hospitalized, either in an outpatient or an inpatient setting, the IR RN meets with the patient, performs a dressing change, and reviews with the patient and caregiver the common PCN problems that may arise. It is noted that because of the posterior location of most PCN catheters, it is ideal for patients to have their caregiver involved in the education process associated with the CCC. Written standard instructions regarding care of PCNs from the IR department are
V. Ganter Ritz et al. / Journal of Radiology Nursing 35 (2016) 275e280
Antiseptic Sponge
Fixaation device
Saline Flussh
4x44 gauuze
Figure 1. Care of percutaneous nephrostomy tube.
Moisture resistant dressing
277
Clear occlusive o dressinng
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V. Ganter Ritz et al. / Journal of Radiology Nursing 35 (2016) 275e280
provided to the patient on discharge from the hospital. These address activity and follow-up care. Additional instructions, as provided in Figure 1, are also provided to all patients, as part of the CCC. It is noted that when the CCC began use of the instructions for patients earlier, evidence-based practice instructions were provided. The evidence-based practice instructions in Figure 1 demonstrate the inclusion of updated guidelines and other sources (Lippincott's Nursing Procedures, 2013; NIH Clinical Catheter Education, 2015). For patients with long-term catheters, defined as >2 weeks, the IR RN also ensures that a 30-minute follow-up appointment is scheduled within a 1-week period. The IR RN responsibilities at the postprocedure 1-week follow-up appointment are as follows: (1) evaluate for general PCN complications, including evaluating the insertion site for signs or symptoms of infection; (2) evaluate for bleeding as evidenced in the drainage bag; (3) perform a dressing change, evaluate skin integrity, and provide dressing change supplies as needed; (4) assess patient and caregiver ability to care for the PCN; (5) provide contact information for the CCC oncall RN and when to call (Figure 1); and (6) evaluate timing for the return visit. General complications included drainage at the insertion site, new swelling at the site, urine issues (bloody, foul smelling, decreased output, cloudy, and/or sediment), and/or flank, bladder, or lower abdomen pain (Figure 1). Regarding the 1-week follow-up assessment for the patient and caregiver, it is noted that the education program developed as part of the CCC is based on adult learning principles (Knowles, 1980). This instructional and observational visit is conducted in a friendly and informal climate. The IR RN provides thorough hands-on teaching, with a focus on the caregiver. A second follow-up visit is scheduled a week later, and at this time, the dressing is done by the caregiver while the IR RN observes, thus basing readiness for assuming care on direct observation and return demonstration. It is also at that time that the RN assesses both the patient's and the caregiver's understanding of common PCN problems. A review of the PCN care instructions serve as the education format. It is important to note that for patients who return to a SNF, an interorganization collaborative is encouraged. The IR RN requests that the patient's primary SNF nurse attend the initial 1-week follow-up appointment. The purpose of this request is to facilitate the SNF nurse's comfort with PCN care instructions, including identification of complications and management of complications that may arise (Figure 1). This is intended to facilitate unnecessary ED visits for SNF patients. When a nurse from the SNF is not available, alternate communication between the SNF nurse and the IR RN should occur to address patient care. Patients that require a home health nurse to assist in care are given supplies and information for home health to contact CCC for additional information or clarification regarding care. Regarding timing for the return visit, the frequency is contingent on whether patients have a caregiver. For long-term PCN catheter patients with a caregiver and no complications, the patient returns for approximately two consecutive weekly visits and is provided enough supplies for a 3-month period. For long-term PCN catheter patients with no complications and no caregiver, the patient returns for approximately four to six consecutive weekly visits, followed by every other week visits for dressing changes until the PCN catheter is changed at approximately 3 months postinsertion. Short-term PCN catheter patients, or those having the PCN catheter 2 weeks, are not included in the CCC. Patients in this category underwent PCN catheter insertion for access for endurologic procedures such as percutaneous nephrolithotomy. These patients received postprocedural care by the ordering urologist.
Hospitalization (ED and inpatient) charges To determine the cost savings as a result of the CCC, the total number of ED visits and inpatient hospitalizations and charges were quantified for the period of time pre-CCC implementation (i.e., 2009, 2010, and 2011 from January 1 to March 27, 2011) and the period of time post-CCC implementation (i.e., March 28, 2011 to December 31, 2011, and 2012, 2013, 2014, and 2015). It is noted that charges were not included for the period in 2011 when the CCC processes were being tested and revised after the initiation. Results Pre-CCC implementation, 15 of the 32 (46.9%) adult (age range ¼ 45e92) patients with PCNs experienced complications requiring hospitalization (Table 1). Of these patients, there were a total of 34 hospitalizations (ED ¼ 16; inpatient ¼ 18), resulting in total charges of $183,750 (ED ¼ $30,799; inpatient ¼ $152,951). The pre-CCC period for which data were available was 27 months; there were on average 1.2 PCN patients per month. Post-CCC implementation, 2 of the 47 (4.3%) PCN catheter patients experienced complications requiring hospitalization (ED ¼ 2; inpatient ¼ 0), resulting in total charges of $704 (Table 2). The post-CCC period for which data were available was 57 months; there were on average 82 PCN patients per month. As a result of the CCC, there has been a reduction in hospitalization rates by 43.5% and total charge savings of $183,046. Of note, although all patients receiving catheters in the health system are provided the same information about the CCC, not all patients in the health system choose to receive care in the CCC for various reasons, including patient preference, convenience, and personal barriers. Post-CCC implementation, it is noted that not all patients who received PCNs received care in the CCC (Table 3). A total of 5 of the 16 (31.3%) patients not participating in the CCC, during the post-CCC implementation period, experienced complications requiring hospitalization. Of these patients, there were a total of six hospitalizations (ED ¼ 4; inpatient ¼ 2), resulting in total charges of $38,312 (ED ¼ $1,879; inpatient ¼ $36,433). The post-CCC period for PCN patients choosing not to participate in the CCC for which data were available was 57 months; there were on average 28 PCN patients per month. The PCN catheter patients participating in the CCC had 27.0% lower hospitalization rate than patients who chose not to participate in the CCC during the post-CCC period. Accordingly, there were total savings of $37,608 realized in decreased hospital charges as well for the PCN catheter patients participating in the CCC as compared with those not participating. Discussion The innovation of a CCC resulted in improved outcomes for patients with PCNs as measured by fewer ED and inpatient hospitalizations and cost savings realized through decreased hospital charges. This was demonstrated when compared both by pre-CCC and post-CCC implementation periods and for the post-CCC implementation period when compared by patients participating in the CCC and those not participating in the CCC. Although all patients receiving PCNs in the health system are provided the information about their participation in the CCC, not all patients choose to participate. Similar to the pre-CCC period, those PCN patients who did not participate postimplementation continued to have higher hospitalization rates and total charges than PCN
V. Ganter Ritz et al. / Journal of Radiology Nursing 35 (2016) 275e280 Table 1 Hospitalization frequencies and total charges before CCC implementation Pre-CCC implementation (years 2009e2011a)
2009
Total number of long-term catheter patients Total number of patients with hospitalizations, n (%) ED Inpatient Total hospitalization charges, $ ED Inpatient
2011a
2010
Table 3 Patients not receiving care post-CCC implementation for years 2011a to 2015 Outcomes of PCN patients not participating in CCC
Total
15
14
3
7 (47)
6 (43)
2 (67)
15 (46.9)
11 6 70,952 4,474 66,478
4 8 75,781 25,741 50,040
1 4 37,017 584 36,433
16 18 183,750 30,799 152,951
32
CCC ¼ catheter care clinic; ED ¼ emergency department. a January 1, 2011 to March 27, 2011.
patients who participated in the CCC. Exploration is warranted to identify facilitators and barriers for PCN patient participation in the CCC. It is noted that National Institutes of Health Clinical Center (NIH, 2015) provides patient education material that suggest dressing changes to be done weekly. During the first year of CCC operation, patients returned on a weekly basis. The rural area of this health care system forces some patients to travel long distances for followup. Based on the foundation of relationship-based care (Koloroutis, 2004) where decision regarding care is a collaborative between the health care workers, patient, and their support systems after evaluating the condition of the dressing and site and noting that many returned with a clean intact dressing without any loss of integrity, that follow-up could extend to 2 weeks. The standard process followed for the CCC to include every other week dressing changes for those that maintained integrity of site. Research may be warranted to determine the best standard of practice of dressing change frequency. The patient population served by the CCC originally was intended to be only PCN patients. As a result of the improved patient outcomes and reduced related charges associated with PCN patients, the patient population served by the CCC has been expanded to include patients with abscess drain catheters. Additional evaluation is warranted to determine the effect on patient outcomes for this population as well. Finally, additional evaluation is warranted comparing patient outcomes, including cost savings between CCC versus home care/SNF care.
Conclusions As a result of the innovative CCC, there were improved PCN patient outcomes demonstrated by lower hospitalization rates and
Table 2 Hospitalization frequencies and total charges after CCC implementation Post-CCC implementation (years 2011ae2015)
2011a
2012
Total number of long-term catheter patients Total number of patients with hospitalizations, n (%) ED Inpatient Total hospitalization charges, $ ED Inpatient
10
7
0
0
1 (14.3)
0
1 (9.1)
2 (4.3)
0 0 0
0 0 0
1 0 455
0 0 0
1 0 249
2 0 704
0 0
0 0
455 0
0 0
249 0
704 0
2013 7
CCC ¼ catheter care clinic; ED ¼ emergency department. a March 28, 2011 to December 31, 2011.
2014 12
279
2015
Total
11
47
Total number of long-term catheter patients Total number of patients with hospitalizations, n (%) ED Inpatient Total hospitalization charges, $ ED Inpatient
2011a 6
2012
2013
2014
2015
Total
4
1
1
4
16
2 (33.3)
2 (50)
0
1 (100)
0
5 (31.3)
1 2 37,018
2 0 841
0 0 0
1 0 453
0 0 0
4 2 38,312
585 36,433
841 0
0 0
453 0
0 0
1,879 36,433
CCC ¼ catheter care clinic; ED ¼ emergency department. a March 28, 2011 to December 31, 2011.
total charges, for both pre-CCC and post-CCC implementation periods and for the post-CCC implementation period when compared by patients participating in the CCC and those not participating in the CCC. Driving the success of the program is an interprofessional team that provides patient and caregiver education in the CCC and IR RN consistently. Implications and expanding practice As a result of this QI process, an innovative CCC was developed and tested. For patients with long-term PCNs, as a result of the patient and caregiver education program of CCC and the IR RN consecutively staffed, improved patient outcomes were realized by fewer ED and inpatient hospitalizations and thus decreased costs. Subsequently, the CCC has been expanded to include all percutaneous drains and catheters placed by IR. These additional catheters include, but are not limited to, percutaneous cholecystomies and abscess drains. The IR department currently documents placement of all catheters and tracks these patients as well. During weekly huddles, the IR team identifies patients due for catheter changes and ensures visits are scheduled. They also review and discuss problems or concerns regarding catheter care. This continuous QI process ensures that patients with catheters replaced by IR continue to undergo the best processes for follow-up care that can reduce the potential for complications, unnecessary ED visits, and/or hospitalization, and that is cost effective. Additional considerations for organizations implementing CCC would be evaluation of operating expenses including charges potentially billed for patient CCC visits and RN salary. It is noted that variable reimbursement rates result in variances for CCC visits.
Acknowledgments The authors thank Frank Brennan, MD, Mary Mahoney, RN, CRN, and Eva Smorzaniuk, MD, for their dedication in development and implementation of the CCC. They also thank Edison Bowens for illustrations.
References CMS.gov Center for Medicare & Medicaid Services. Readmissions Reduction Program (HRRP). 2016. Retrieved from www.cms.gov/Medicare/Medicare-Fee-forService-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html. Accessed April 18, 2016.
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Farrell, T.A., & Hicks, M.E. (1997). A review of radiologically guided percutaneous nephrostomies in 303 patients. Journal of Vascular Interventional Radiology, 8(5), 769-774. Ferral, H., Stackhouse, D.J., Bjarnason, H., Hunter, D.W., & Castaneda-Zuniga, W.R. (1994). Complications of percutaneous nephrostomy catheter placement. Seminars in Interventional Radiology, 11, 198-206. Gray, R.R., So, C.B., Mcloughlin, R.F., Pugash, R.A., Saliken, J.C., & Macklin, N.I. (1996). Outpatient percutaneous nephrostomy. Radiology, 198(1), 85-88. Knowles, M. (1980). The modern practice of adult education: From Pedagogy to Andragogy (2nd ed.). Cambridge, NY: Cambridge Books. Koloroutis, M. (2004). Relationship-based care: A model for transforming practice. Minneapolis, MN: Creative Health Care Management.
Langley, G.L., Moen, R., Nolan, K.M., Nolan, T.W., Norman, C.L., & Provost, L.P. (2009). The improvement guide: A practical approach to enhancing organizational performance (2nd ed.). San Francisco, CA: Jossey-Bass Publishers. Lippincott's nursing procedures (7th ed.). (2013). Philadelphia, PA: Lippincott, Williams and Wilkins. NIH Clinical Catheter Education 2015. Retrieved from http://clinicalcenter.nih.gov/ ccc/patient_education/procdiag/percutaneous_nephrostomy.pdf. Accessed October 31, 2016. U.S. Department of Health & Human Services (hhs.gov). Key features of the Affordable Care Act. 2014. Retrieved from http://www.hhs.gov/ healthcare/facts-and-features/key-features-of-aca/. Accessed November 18, 2014.
Contents lists available at ScienceDirect
Journal of Radiology Nursing journal homepage: www.radiologynursing.org
Reducing Complications and Hospitalizations Through an Innovative Catheter Care Clinic for Percutaneous Nephrostomy Catheter Patients Vivienne Ganter Ritz, BSN, RN-BC, CRN a, *, Karen Gabel Speroni, PhD, MHSA, BSN, RN b, Diane Walbridge, MSN, RN, NEA-BC c a
Interventional Radiology, University of Maryland Shore Regional Health, Easton, MD Nursing Administration, Research, University of Maryland Shore Regional Health, Easton, MD c Nursing Administration, Clinical and Financial Nursing Resources, University of Maryland Shore Regional Health, Easton, MD b
a b s t r a c t Keywords: Percutaneous nephrostomy catheter Complications Quality improvement Innovation Clinic Health care costs
This quality improvement activity implemented by the hospital's interventional radiology (IR) department, including an interprofessional team of physicians, IR registered nurses (RNs), and technologists, evaluated best practices for reducing complications that would result in emergency department (ED) and/or inpatient hospitalizations and associated charges for patients with percutaneous nephrostomy (PCN) catheters. A catheter care clinic (CCC) was established that focused on patient and caregiver education by an RN and 24/7 access to the team for patients with complications or PCN-related questions. Pre-CCC implementation, 15 of the 32 (46.9%) adult (age range ¼ 45e92) patients with PCNs required hospitalizations, with 34 hospitalizations (ED ¼ 16; inpatient ¼ 18), totaling $183,750 (ED ¼ $30,799; inpatient ¼ $152,951). Post-CCC, 2 of 47 (4.3%) patients required hospitalizations (ED ¼ 2; inpatient ¼ 0), totaling $704. This was a hospitalization reduction of 43.5%, saving $183,046. Five of 16 (31.3%) patients not participating in the CCC post-CCC implementation required six hospitalizations (ED ¼ 4; inpatient ¼ 2), totaling $38,312 (ED ¼ $1,879; inpatient ¼ $36,433). Those participating had a 27.0% hospitalization reduction, saving $37,608. As a result of the innovative CCC, there were improved PCN patient outcomes demonstrated by lower hospitalization rates and total charges, when compared by preCCC and post-CCC implementation and by patient participation in the CCC. Driving the success of the program is consistent availability of the IR RN and an interprofessional team that provides patient and caregiver education in the CCC. Ideally, other facilities with IR departments or those who treat patients with catheters can consider a CCC. Copyright © 2016 by the Association for Radiologic & Imaging Nursing.
Introduction Key features of the Patient Protection and Affordable Care Act (ACA) of 2010 include a focus on delivering high-quality and costefficient health care (U.S. Department of Health & Human Services (HHS), hhs.gov, 2014). The ACA established the Hospital Readmissions Reduction Program, which requires Centers for Medicare and Medicaid Services (CMS) to reduce payments to hospitals with excess readmissions (CMS, 2016). The emphasis on reducing complications that may cause readmissions, and the focus on patient satisfaction and quality of care, resulted in an
Funding/grant support: None to report. * Corresponding author: Vivienne Ganter Ritz, University of Maryland Shore Regional Health, 219 S. Washington Street, Easton, MD 21601-2912. E-mail address: [email protected] (V. Ganter Ritz).
interventional radiology (IR) department developing through planned and coordinated activities, a follow-up clinic for patients with percutaneous nephrostomy (PCN) catheters. Background The IR department is part of a rural health system with three hospitals located in the mid-Atlantic region of the United States. The hospital system's IR department performs approximately 75 cases per year that involve percutaneous drainage catheters. The most common drainage catheter that is placed by the interventional radiologist is a PCN catheter. PCN catheters are required for obstruction of the ureter, usually secondary to malignancy; however, other causes such as interstitial cystitis and traumatic injury to ureters would warrant a PCN tube (Farrel & Hicks, 1997). Approximately 55% of PCN cases performed in the IR department are for
http://dx.doi.org/10.1016/j.jradnu.2016.09.006 1546-0843/$36.00/Copyright © 2016 by the Association for Radiologic & Imaging Nursing.
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long-term use. Long-term use is defined as PCN placement required for more than 2 weeks in duration. Placement of PCN catheters in an outpatient setting has been commonplace and generally regarded as safe for more than 20 years (Gray et al., 1996). Minor complications occur in approximately 15% of patients, whereas major complications occur in approximately 4% with mortality rates <0.2% (Ferral, Stockhouse, Bjarnason, Hunter, & Casteneda-Zuniga, 1994). The hospital system's patient population is diverse, with varying socioeconomic, cultural, and linguistic needs. The challenges associated with teaching and engaging patients and their family and/or caregiver to participate in the management of their condition frequently presents problems. These are generally related to a lack of understanding in the care required for maintenance of PCN catheters. Patients who do not have the resources or skills to effectively manage their condition are subject to resulting complications, which include, but not limited to, obstructed flow, skin breakdown, local infection, catheter dislodgment, and in severe cases, sepsis. Historically, many long-term PCN patients have come into the emergency department (ED) to be seen for complications, such as infection, back pain, and changes in urine output. Although these complications were often considered common, the IR team, consisting of the IR physician, nurses, and technologists, questioned whether they could be prevented. The point case was a skilled nursing facility (SNF) patient who presented to the ED with a partially dislodged catheter. At the time of insertion, the IR department used an external fixation device that anchors the catheter to the skin to prevent dislodging. The device in this case had become soiled and ineffective. No new device or dressing had been applied since the patient's catheter exchange 3 months before. As a result, the patient was subsequently admitted to the hospital because of urinary tract infection. The problem was obvious, as was the need for more consistent follow-up. Based on this case and others, a way to enact quality improvement (QI), optimize care, and decrease complications in the PCN patient population arose from a brainstorming session held by the IR team. The IR team reviews each case in a daily huddle. During one huddle, a patient who had a history of previous complications related to the PCN catheter was scheduled for a routine catheter change. The team decided it would be beneficial to have the patient return in 1 week for follow-up care. The primary IR nurse on the case contacted the SNF responsible for the patients care. It was agreed that the patient would return in 1 week for follow-up care. At the time of the patient's followup visit, it was noted that the dressing was moist and not adhering to the skin allowing for risk of PCN catheter dislodgment and potential infection. Proper catheter care was performed, including cleansing the area, flushing the catheter, and reapplying the fixation device and the cover dressing. The SNF agreed to have the patient return weekly for catheter checks and dressing changes. At that time, the IR team agreed that all the long-term PCN patients could benefit from weekly follow-ups. With this first patient, the innovative catheter care clinic (CCC) that focused on patient and caregiver education by a registered nurse (RN) and 24/7 access to the team for patients with complications or PCN-related questions was initiated.
collected on the number of patients with PCN catheters, the number who received care from the clinic and who did not, and the number of complications experienced that resulted in an ED visit within the health care system where the QI activity was completed. Data were compared for the preclinic period (2009 to March 2011; the first patient was seen in the CCC March 2011) to the postclinic period thereafter through 2015. Data were also collected on charges associated with complications for ED visits or hospitalizations. Charges for PCN patients who had ED or inpatient admissions within the hospital system where this QI activity was conducted were obtained from the system's database. QI processes The hospital system uses find a process, organize a team, clarify, understand variation, and select process (i.e., FOCUS)/plan, do, study, act (i.e., PDSA) as the QI process model (Langley et al., 2009). The process to improve was driven by the ACA, which requires CMS to fund the aggregate hospital value-based purchasing incentive payments by reducing the base operating diagnosis-related group payment amounts. The interprofessional team involved in the QI activity included members who were physicians, nurses, and technologists from the IR department. They clarified the current knowledge about PCN patient numbers pre-CCC and post-CCC implementation, including resulting complications requiring hospitalization (ED or inpatient) and hospitalization charges. Post-CCC implementation, they also clarified the number of patients who participated in the CCC and those who did not participate in the CCC. For those patients receiving hospitalizations within the hospital system performing this QI activity, total charges billed for each hospitalization (ED and inpatient) were quantified. As a result of this data collection, the team was able to understand the variations in practice resulting in patients having a greater number of hospitalizations. They attributed the variation to a lack of not only access to IR teams after hours but also patient and caregiver education or knowledge attributed to PCN catheter care. Herewith, programs developed around access to care and education are described. Access to care Patients and caregivers alike are encouraged to contact the IR RN with any PCN issues. This maintains a lifeline for patients and their caregivers. Often it is just shared information via a call that can resolve a problem such as a kinked catheter, thus eliminating the need for an ED visit. The on-call RN (who is available 24/7) will, if necessary, meet with the patient in the ED department or IR department during nonbusiness hours. Most of these calls also prevent undesirable ED visits. For complex problems, the IR physician is called to evaluate the patients and their condition. This may include site infection, urinary tract infection, bleeding, or PCN complications requiring IR procedures or replacement.
Purpose CCC patient and caregiver education program This QI activity implemented by the hospital's IR department evaluated best practices for reducing complications that would result in ED and/or inpatient hospitalizations and associated charges for patients with PCN catheters. Methods This QI activity was reviewed by the hospital system's institutional review board and determined to be exempt. Data were
After a PCN procedure, while the patient is still hospitalized, either in an outpatient or an inpatient setting, the IR RN meets with the patient, performs a dressing change, and reviews with the patient and caregiver the common PCN problems that may arise. It is noted that because of the posterior location of most PCN catheters, it is ideal for patients to have their caregiver involved in the education process associated with the CCC. Written standard instructions regarding care of PCNs from the IR department are
V. Ganter Ritz et al. / Journal of Radiology Nursing 35 (2016) 275e280
Antiseptic Sponge
Fixaation device
Saline Flussh
4x44 gauuze
Figure 1. Care of percutaneous nephrostomy tube.
Moisture resistant dressing
277
Clear occlusive o dressinng
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provided to the patient on discharge from the hospital. These address activity and follow-up care. Additional instructions, as provided in Figure 1, are also provided to all patients, as part of the CCC. It is noted that when the CCC began use of the instructions for patients earlier, evidence-based practice instructions were provided. The evidence-based practice instructions in Figure 1 demonstrate the inclusion of updated guidelines and other sources (Lippincott's Nursing Procedures, 2013; NIH Clinical Catheter Education, 2015). For patients with long-term catheters, defined as >2 weeks, the IR RN also ensures that a 30-minute follow-up appointment is scheduled within a 1-week period. The IR RN responsibilities at the postprocedure 1-week follow-up appointment are as follows: (1) evaluate for general PCN complications, including evaluating the insertion site for signs or symptoms of infection; (2) evaluate for bleeding as evidenced in the drainage bag; (3) perform a dressing change, evaluate skin integrity, and provide dressing change supplies as needed; (4) assess patient and caregiver ability to care for the PCN; (5) provide contact information for the CCC oncall RN and when to call (Figure 1); and (6) evaluate timing for the return visit. General complications included drainage at the insertion site, new swelling at the site, urine issues (bloody, foul smelling, decreased output, cloudy, and/or sediment), and/or flank, bladder, or lower abdomen pain (Figure 1). Regarding the 1-week follow-up assessment for the patient and caregiver, it is noted that the education program developed as part of the CCC is based on adult learning principles (Knowles, 1980). This instructional and observational visit is conducted in a friendly and informal climate. The IR RN provides thorough hands-on teaching, with a focus on the caregiver. A second follow-up visit is scheduled a week later, and at this time, the dressing is done by the caregiver while the IR RN observes, thus basing readiness for assuming care on direct observation and return demonstration. It is also at that time that the RN assesses both the patient's and the caregiver's understanding of common PCN problems. A review of the PCN care instructions serve as the education format. It is important to note that for patients who return to a SNF, an interorganization collaborative is encouraged. The IR RN requests that the patient's primary SNF nurse attend the initial 1-week follow-up appointment. The purpose of this request is to facilitate the SNF nurse's comfort with PCN care instructions, including identification of complications and management of complications that may arise (Figure 1). This is intended to facilitate unnecessary ED visits for SNF patients. When a nurse from the SNF is not available, alternate communication between the SNF nurse and the IR RN should occur to address patient care. Patients that require a home health nurse to assist in care are given supplies and information for home health to contact CCC for additional information or clarification regarding care. Regarding timing for the return visit, the frequency is contingent on whether patients have a caregiver. For long-term PCN catheter patients with a caregiver and no complications, the patient returns for approximately two consecutive weekly visits and is provided enough supplies for a 3-month period. For long-term PCN catheter patients with no complications and no caregiver, the patient returns for approximately four to six consecutive weekly visits, followed by every other week visits for dressing changes until the PCN catheter is changed at approximately 3 months postinsertion. Short-term PCN catheter patients, or those having the PCN catheter 2 weeks, are not included in the CCC. Patients in this category underwent PCN catheter insertion for access for endurologic procedures such as percutaneous nephrolithotomy. These patients received postprocedural care by the ordering urologist.
Hospitalization (ED and inpatient) charges To determine the cost savings as a result of the CCC, the total number of ED visits and inpatient hospitalizations and charges were quantified for the period of time pre-CCC implementation (i.e., 2009, 2010, and 2011 from January 1 to March 27, 2011) and the period of time post-CCC implementation (i.e., March 28, 2011 to December 31, 2011, and 2012, 2013, 2014, and 2015). It is noted that charges were not included for the period in 2011 when the CCC processes were being tested and revised after the initiation. Results Pre-CCC implementation, 15 of the 32 (46.9%) adult (age range ¼ 45e92) patients with PCNs experienced complications requiring hospitalization (Table 1). Of these patients, there were a total of 34 hospitalizations (ED ¼ 16; inpatient ¼ 18), resulting in total charges of $183,750 (ED ¼ $30,799; inpatient ¼ $152,951). The pre-CCC period for which data were available was 27 months; there were on average 1.2 PCN patients per month. Post-CCC implementation, 2 of the 47 (4.3%) PCN catheter patients experienced complications requiring hospitalization (ED ¼ 2; inpatient ¼ 0), resulting in total charges of $704 (Table 2). The post-CCC period for which data were available was 57 months; there were on average 82 PCN patients per month. As a result of the CCC, there has been a reduction in hospitalization rates by 43.5% and total charge savings of $183,046. Of note, although all patients receiving catheters in the health system are provided the same information about the CCC, not all patients in the health system choose to receive care in the CCC for various reasons, including patient preference, convenience, and personal barriers. Post-CCC implementation, it is noted that not all patients who received PCNs received care in the CCC (Table 3). A total of 5 of the 16 (31.3%) patients not participating in the CCC, during the post-CCC implementation period, experienced complications requiring hospitalization. Of these patients, there were a total of six hospitalizations (ED ¼ 4; inpatient ¼ 2), resulting in total charges of $38,312 (ED ¼ $1,879; inpatient ¼ $36,433). The post-CCC period for PCN patients choosing not to participate in the CCC for which data were available was 57 months; there were on average 28 PCN patients per month. The PCN catheter patients participating in the CCC had 27.0% lower hospitalization rate than patients who chose not to participate in the CCC during the post-CCC period. Accordingly, there were total savings of $37,608 realized in decreased hospital charges as well for the PCN catheter patients participating in the CCC as compared with those not participating. Discussion The innovation of a CCC resulted in improved outcomes for patients with PCNs as measured by fewer ED and inpatient hospitalizations and cost savings realized through decreased hospital charges. This was demonstrated when compared both by pre-CCC and post-CCC implementation periods and for the post-CCC implementation period when compared by patients participating in the CCC and those not participating in the CCC. Although all patients receiving PCNs in the health system are provided the information about their participation in the CCC, not all patients choose to participate. Similar to the pre-CCC period, those PCN patients who did not participate postimplementation continued to have higher hospitalization rates and total charges than PCN
V. Ganter Ritz et al. / Journal of Radiology Nursing 35 (2016) 275e280 Table 1 Hospitalization frequencies and total charges before CCC implementation Pre-CCC implementation (years 2009e2011a)
2009
Total number of long-term catheter patients Total number of patients with hospitalizations, n (%) ED Inpatient Total hospitalization charges, $ ED Inpatient
2011a
2010
Table 3 Patients not receiving care post-CCC implementation for years 2011a to 2015 Outcomes of PCN patients not participating in CCC
Total
15
14
3
7 (47)
6 (43)
2 (67)
15 (46.9)
11 6 70,952 4,474 66,478
4 8 75,781 25,741 50,040
1 4 37,017 584 36,433
16 18 183,750 30,799 152,951
32
CCC ¼ catheter care clinic; ED ¼ emergency department. a January 1, 2011 to March 27, 2011.
patients who participated in the CCC. Exploration is warranted to identify facilitators and barriers for PCN patient participation in the CCC. It is noted that National Institutes of Health Clinical Center (NIH, 2015) provides patient education material that suggest dressing changes to be done weekly. During the first year of CCC operation, patients returned on a weekly basis. The rural area of this health care system forces some patients to travel long distances for followup. Based on the foundation of relationship-based care (Koloroutis, 2004) where decision regarding care is a collaborative between the health care workers, patient, and their support systems after evaluating the condition of the dressing and site and noting that many returned with a clean intact dressing without any loss of integrity, that follow-up could extend to 2 weeks. The standard process followed for the CCC to include every other week dressing changes for those that maintained integrity of site. Research may be warranted to determine the best standard of practice of dressing change frequency. The patient population served by the CCC originally was intended to be only PCN patients. As a result of the improved patient outcomes and reduced related charges associated with PCN patients, the patient population served by the CCC has been expanded to include patients with abscess drain catheters. Additional evaluation is warranted to determine the effect on patient outcomes for this population as well. Finally, additional evaluation is warranted comparing patient outcomes, including cost savings between CCC versus home care/SNF care.
Conclusions As a result of the innovative CCC, there were improved PCN patient outcomes demonstrated by lower hospitalization rates and
Table 2 Hospitalization frequencies and total charges after CCC implementation Post-CCC implementation (years 2011ae2015)
2011a
2012
Total number of long-term catheter patients Total number of patients with hospitalizations, n (%) ED Inpatient Total hospitalization charges, $ ED Inpatient
10
7
0
0
1 (14.3)
0
1 (9.1)
2 (4.3)
0 0 0
0 0 0
1 0 455
0 0 0
1 0 249
2 0 704
0 0
0 0
455 0
0 0
249 0
704 0
2013 7
CCC ¼ catheter care clinic; ED ¼ emergency department. a March 28, 2011 to December 31, 2011.
2014 12
279
2015
Total
11
47
Total number of long-term catheter patients Total number of patients with hospitalizations, n (%) ED Inpatient Total hospitalization charges, $ ED Inpatient
2011a 6
2012
2013
2014
2015
Total
4
1
1
4
16
2 (33.3)
2 (50)
0
1 (100)
0
5 (31.3)
1 2 37,018
2 0 841
0 0 0
1 0 453
0 0 0
4 2 38,312
585 36,433
841 0
0 0
453 0
0 0
1,879 36,433
CCC ¼ catheter care clinic; ED ¼ emergency department. a March 28, 2011 to December 31, 2011.
total charges, for both pre-CCC and post-CCC implementation periods and for the post-CCC implementation period when compared by patients participating in the CCC and those not participating in the CCC. Driving the success of the program is an interprofessional team that provides patient and caregiver education in the CCC and IR RN consistently. Implications and expanding practice As a result of this QI process, an innovative CCC was developed and tested. For patients with long-term PCNs, as a result of the patient and caregiver education program of CCC and the IR RN consecutively staffed, improved patient outcomes were realized by fewer ED and inpatient hospitalizations and thus decreased costs. Subsequently, the CCC has been expanded to include all percutaneous drains and catheters placed by IR. These additional catheters include, but are not limited to, percutaneous cholecystomies and abscess drains. The IR department currently documents placement of all catheters and tracks these patients as well. During weekly huddles, the IR team identifies patients due for catheter changes and ensures visits are scheduled. They also review and discuss problems or concerns regarding catheter care. This continuous QI process ensures that patients with catheters replaced by IR continue to undergo the best processes for follow-up care that can reduce the potential for complications, unnecessary ED visits, and/or hospitalization, and that is cost effective. Additional considerations for organizations implementing CCC would be evaluation of operating expenses including charges potentially billed for patient CCC visits and RN salary. It is noted that variable reimbursement rates result in variances for CCC visits.
Acknowledgments The authors thank Frank Brennan, MD, Mary Mahoney, RN, CRN, and Eva Smorzaniuk, MD, for their dedication in development and implementation of the CCC. They also thank Edison Bowens for illustrations.
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