- Email: [email protected]
The impact of DRGs on OR nursing
vv
The impact of DRGs on OR nursing Sharon Bird Claire Mailhot, RN
idespread concern over sky‘rocketinghealth care costs is forcing nurses to consider the roles they will have in the health care system. The changing environment presents a potential threat to nursing as well as a potential for tremendous growth and diversification. The use of diagnosis-related groups (DRGs) to reimburse hospitals for the care of Medicare patients will create strong incentives for hospitals to cut their budgets wherever possible. Under this system, hospitals will be reimbursed a predetermined amount for treating patients based on the patients’ diagnoses regardless of the actual amount of resources used in providing care. Therefore, hospitals will want to use as few resources as possible. Although the DRG system applies only to Medicare patients, this type of fmed reimbursement is the wave of the future for all payers including the various Medicaid programs, Blue Cross, and other private insurance companies. Consequently, even hospitals without significant numbers of Medicare patients are beginning to evaluate the costs of the care they pr0vide.l All aspects of hospital operations will be affected by this belt tightening. Nursing costs account for substantial portions of all hospital budgets, and as a result they will be prime candidates for careful scrutiny and possible budget cuts. The impact of these budget cuts will probably be greater than anything nurses have had to deal with in the past. Nurses will have to concern themselves with the costs associated with nursing. One reason for this is that physicians’ services aren’t included under the DRG system. They will continue to be reimbursed based on the bilk they submit. Consequently physicians, who control most high cost items (diagnostic tests, operative procedures, and length of pa-
AORN Journal, November 1983, Vol38, No 5
N
urses will have to interact with patients who expect “Cadillac” service.
tient stay, for example), will not have incentives to cut the costs of patient care. Since most hospitals generally don’t significantly influence physician behavior, the burden for cutting costs will fall on other shoulders. Nursing feels the pressure. There are several areas where nurses will feel the pinch of budget cuts in their daily practice. For example, overall staffing levels may drop. In the OR this could mean that, in simpler cases, a scrub nurse might set up the instruments and sterile supplies and then scrub out and serve as the circulator. Two examples of procedureswell suited to this are D & Cs (dilation and curettage) and certain endoscopic procedures. This prospect appears to be a more likely possibility in teaching hospitals where surgical teams have several members due to the presence of residents, interns, and medical students. The percentage of registered nurses on staff may decrease. Many hospital ORs already employ surgical technicians, and this trend may continue since technicians are less expensive to hire than registered nurses. The lack of nursing research to validate that patient outcomes are improved under registered nurse care in the OR makes the move away from registered nurse staffing a possibility. In larger hospitals, OR nurses may be forced to become more specialized. Training personnel to be competent in
several services is expensive, particularly as medicine becomes more technological. In smaller hospitals, on the other hand, there will probably be more generalists because there is not enough volume to justig extensive specialization. In either case, some patient care is likely to be compromised. In a larger hospital, for example, volume in a specific service might experience a temporary drop, and a nurse specialist would be assigned to cases outside of hisher area of expertise. Furthermore, staff development programs may be severely restricted. Unfortunately for OR managers, lack of orientation may lead t o higher equipment repair bills. Staff members unfamiliar with the correct procedures for handling sophisticated equipment and instruments are more likely to cause damage. There may be an increase in the nurse’s involvement in nonnursing tasks to cut ancillary personnel expenses. In the OR this could mean that registered nurses will be more involved in patient transport, room cleaning, and instrument packing and reprocessing. This would be particularly true on offshifts where nurses are scheduled for emergency cases but may not be routinely busy. In the past, the high cost of acquiring ultramodern equipment has been shared by all patients regardless of whether they actually use it. Costs were
AORN Journal, November 1983, Vol38, No 5
779
urses interested and trained in management will be in more demand.
N
reflected in higher room rates and OR charges. Under DRGs and other furedrate systems of reimbursement, hospitals may not be able to justify spending $100,000 on equipment that may only be used by one or two patients a week. The high revenue generated by operating rooms has led many hospitals to buy the latest technology to cater to surgeons who bring in considerable business. Some surgeons have come to expect that their requests for expensive equipment will be routinely granted. As hospitals stop this practice, OR nurses will have to compensate for older, less sophisticated equipment. In addition, they may be a captive audience for surgeons venting their anger at these restrictions. Nurses will also have to interact with patients and families who expect “Cadillac”service. Amenities like valet service, extensive menus, and lwruriously furnished rooms that have been instituted in some hospitals to attract patients will no longer be financially viable.2 The government, Blue Cross, and other private insurance companies will no longer subsidize these services. The fixed rates will cover only necessary medical and nursing care and minimal support services. This belt tightening is likely to affect the perioperative nursing practice. hoperative patient education by OR nurses has improved patients’ surgical experiences. In addition, OR nurses 780
have felt their practice has been validated by postoperative patient evaluations. Unfortunately, perioperative nursing involves expenditures for nursing time without any corresponding revenue. Lastly, increases in nurses’ salaries probably will become smaller. Over the past ten years, nurses have received good raises to correct historical underpayment. The new pressures that hospitals are feeling may end this trend. Opportunities for diversifiation. It is expected that hospitals and patients will change radically from the way they are today. The high costs of inpatient hospitalizationare causing more care to be provided on an outpatient basis. This will lead to more acutely ill hospital patient populations as well as more opportunities for nurses to work in alternative settings. Operating room nurses who want to remain in a surgical environment will find an increase in ambulatory surgery centers and clinics. These will be freestanding facilities not affiliated with hospitals as well as outpatient units administered by hospitals. Other options will include emergency care and family medicine clinics opening up in such locations as shopping malls. Home health care will also continue to grow because it is a low-cost alternative to hospitalization that also keeps the patient in a comfortable and familiar environment. Nurses interested in more involvement in patient
AORN Journal, November 1983, Vol38, No 5
erioperative nursing expends nursing time without corresponding revenue.
P
education and the psychosocial aspects of nursing will find this particularly attractive. Hospices are also experiencing growth. These facilities for the terminally ill provide a home-like environment, and family members are encouraged to help care for the patients. Nurses’roles will also expand. Nurses interested and trained in management will be more in demand. Nurse managers with clinical competency as well as administrative skills will be ideal candidates to manage emergency centers, ambulatory surgery clinics, and other facilities. Another nursing role that will increase is the nurse practitioner. Many clinics already rely on nurse practitioners. The lower costs associated with nurse practitioners in comparison with physicians make them attractive to administrators. Many patients prefer nurse practitioners because of the personalized nature of the care they receive from these health care professional^.^ A cull to action. Although the basic changes in the reimbursement system have been formulated already, there are several areas where nurses can work together to insure that high quality nursing care remains a n important priority. Nursing departments will need to defend their budgets in terms of the specific amounts of resources needed to care for their patients. Patient classification systems based on DRGs would be
invaluable because hospital administrators will be familiar with those categories. A patient classification system, however, requires the development of standards of care. This would require research to validate the relationship between any proposed standards and patient outcomes.4 One possible application of this in the OR would be assignment of three registered nurses in cases where the patient is given a local anesthetic. If it is shown that the presence of a third registered nurse to observe the patient improves patient outcomes, an allowance for the extra personnel could be justified in the OR budget. Another area where nurses can take action to preserve and strengthen their roles is to document the time spent on nonnursing tasks such as patient transport and room cleaning. Inefficient use of registered nurse resources where ancillary personnel are more appropriate must be documented because this may be an area where hospitals will have costs above the DRG-reimbursement level. Nurses need to consider the precise scope of their responsibilities.The question, “What is nursing,” has a multitude of answers. There is no universally accepted definition, which means nursing is vulnerable as hospital departments compete for scarce budget dollars. In recent years, some traditional nursing responsibilities have been
AORN Journal, November 1983, Vol38, No 5
781
taken over by other departments. These include n u t r i t i o n education, now done by dieticians, and intravenous medicat i o n preparation, n o w h a n d l e d by pharmacists. If nurses don’t work together t~ consolidate their profession, other health care disciplines w i l l chip away at the nursing role until nurses are l i t t l e more than patient care coordinators rather than actual care-givers. The challenge. Indeed, these are challenging times for nurses. The profession can take a stand and take advantage o f the opportunities for growth and diversification presented by changes in the reimbursement system. The other road w i l l lead to fragmentation of the profes-
sion and could result in compromises in patient care. Above all, nursing must continue its key role as a patient advocate and help keep the health care syst e m focused o n t h e primary goal of providing high quality patient care. Notes 1. A Trafford, C Work, “Soaring hospital costs,” US News and World Report (Aug 22,1983) 39-42. 2. “Pleasing the patient,” Hospitals 57 (Aug 1, 1983) 53-72. 3. S Taller, R Feldrnan, “The training and utilization of nurse practitioners in adult health appraisal,” Medical Care (January 1974) 40-48. 4. P Giovannetti,“Understandingpatient classification systems,” Journal of Nursing Administration 9 (February 1979) 4-9.
Hormone strengthens patients with ALS The muscle strength of patients with amyotrophic lateral sclerosis (ALS) improved after high dosages of an established peptide hormone were administered intravenously. W King Engel, MD, director of the University of Southern California neuromuscular center, Los Angeles, reported in Lancet that 12 patients have received temporary benefit from thyrotropin-releasing hormone (TRH). The 12 patients receiving this experimental therapy received as much as 500 mg of TRH during an eight-hour period. The dosage was varied as was the benefit to the patients. Some of the patients experienced dramatic increases in muscle strength and decreases in muscle spasticity, but others had minimal improvements. The benefit occurs quickly, and it is attributed to TRH being a neurotransmitter. TRH is found in the motor nerve cells in the spinal column. Dr Engel said, “The improvement is rapid, evident as early as a half minute after the drug infusion is started.” At this stage of the study, however, the achieved benefit is temporary. Dr Engel concludes that in ALS patients, the dead motor cells are not as numerous
782
as thought from the patient‘s degree of weakness. While the motor nerve cells are not functioning, it seems they are viable and with appropriate therapy can function again. “Right now we can say that TRH makes the ALS patients stronger. But we can’t as yet say that the treatment rescues nerve cells from eventual death.” Dr Engel is studying how the nerve cells could be rescued. This is an experimental treatment and has only been used in a clinical research setting for less than 24 hours. Dr Engel said, “The next step is to infuse TRH over a longer period-a number of days-and then longer.” The cause and cure for ALS are unknown. ALS is diagnosed in 5,000 people annually in the United States, but it is often mistaken for another condition. The most common early symptoms include muscle weakness, fatigue, or difficulty with speech or swallowing. The onset is gradual, and victims lead productive lives while the disease progresses. Most of the victims are in their 40s to 60s, and about one and a half times as many men as women are affected.
AORN Journal, November 1983, Vol38, No 5
The impact of DRGs on OR nursing Sharon Bird Claire Mailhot, RN
idespread concern over sky‘rocketinghealth care costs is forcing nurses to consider the roles they will have in the health care system. The changing environment presents a potential threat to nursing as well as a potential for tremendous growth and diversification. The use of diagnosis-related groups (DRGs) to reimburse hospitals for the care of Medicare patients will create strong incentives for hospitals to cut their budgets wherever possible. Under this system, hospitals will be reimbursed a predetermined amount for treating patients based on the patients’ diagnoses regardless of the actual amount of resources used in providing care. Therefore, hospitals will want to use as few resources as possible. Although the DRG system applies only to Medicare patients, this type of fmed reimbursement is the wave of the future for all payers including the various Medicaid programs, Blue Cross, and other private insurance companies. Consequently, even hospitals without significant numbers of Medicare patients are beginning to evaluate the costs of the care they pr0vide.l All aspects of hospital operations will be affected by this belt tightening. Nursing costs account for substantial portions of all hospital budgets, and as a result they will be prime candidates for careful scrutiny and possible budget cuts. The impact of these budget cuts will probably be greater than anything nurses have had to deal with in the past. Nurses will have to concern themselves with the costs associated with nursing. One reason for this is that physicians’ services aren’t included under the DRG system. They will continue to be reimbursed based on the bilk they submit. Consequently physicians, who control most high cost items (diagnostic tests, operative procedures, and length of pa-
AORN Journal, November 1983, Vol38, No 5
N
urses will have to interact with patients who expect “Cadillac” service.
tient stay, for example), will not have incentives to cut the costs of patient care. Since most hospitals generally don’t significantly influence physician behavior, the burden for cutting costs will fall on other shoulders. Nursing feels the pressure. There are several areas where nurses will feel the pinch of budget cuts in their daily practice. For example, overall staffing levels may drop. In the OR this could mean that, in simpler cases, a scrub nurse might set up the instruments and sterile supplies and then scrub out and serve as the circulator. Two examples of procedureswell suited to this are D & Cs (dilation and curettage) and certain endoscopic procedures. This prospect appears to be a more likely possibility in teaching hospitals where surgical teams have several members due to the presence of residents, interns, and medical students. The percentage of registered nurses on staff may decrease. Many hospital ORs already employ surgical technicians, and this trend may continue since technicians are less expensive to hire than registered nurses. The lack of nursing research to validate that patient outcomes are improved under registered nurse care in the OR makes the move away from registered nurse staffing a possibility. In larger hospitals, OR nurses may be forced to become more specialized. Training personnel to be competent in
several services is expensive, particularly as medicine becomes more technological. In smaller hospitals, on the other hand, there will probably be more generalists because there is not enough volume to justig extensive specialization. In either case, some patient care is likely to be compromised. In a larger hospital, for example, volume in a specific service might experience a temporary drop, and a nurse specialist would be assigned to cases outside of hisher area of expertise. Furthermore, staff development programs may be severely restricted. Unfortunately for OR managers, lack of orientation may lead t o higher equipment repair bills. Staff members unfamiliar with the correct procedures for handling sophisticated equipment and instruments are more likely to cause damage. There may be an increase in the nurse’s involvement in nonnursing tasks to cut ancillary personnel expenses. In the OR this could mean that registered nurses will be more involved in patient transport, room cleaning, and instrument packing and reprocessing. This would be particularly true on offshifts where nurses are scheduled for emergency cases but may not be routinely busy. In the past, the high cost of acquiring ultramodern equipment has been shared by all patients regardless of whether they actually use it. Costs were
AORN Journal, November 1983, Vol38, No 5
779
urses interested and trained in management will be in more demand.
N
reflected in higher room rates and OR charges. Under DRGs and other furedrate systems of reimbursement, hospitals may not be able to justify spending $100,000 on equipment that may only be used by one or two patients a week. The high revenue generated by operating rooms has led many hospitals to buy the latest technology to cater to surgeons who bring in considerable business. Some surgeons have come to expect that their requests for expensive equipment will be routinely granted. As hospitals stop this practice, OR nurses will have to compensate for older, less sophisticated equipment. In addition, they may be a captive audience for surgeons venting their anger at these restrictions. Nurses will also have to interact with patients and families who expect “Cadillac”service. Amenities like valet service, extensive menus, and lwruriously furnished rooms that have been instituted in some hospitals to attract patients will no longer be financially viable.2 The government, Blue Cross, and other private insurance companies will no longer subsidize these services. The fixed rates will cover only necessary medical and nursing care and minimal support services. This belt tightening is likely to affect the perioperative nursing practice. hoperative patient education by OR nurses has improved patients’ surgical experiences. In addition, OR nurses 780
have felt their practice has been validated by postoperative patient evaluations. Unfortunately, perioperative nursing involves expenditures for nursing time without any corresponding revenue. Lastly, increases in nurses’ salaries probably will become smaller. Over the past ten years, nurses have received good raises to correct historical underpayment. The new pressures that hospitals are feeling may end this trend. Opportunities for diversifiation. It is expected that hospitals and patients will change radically from the way they are today. The high costs of inpatient hospitalizationare causing more care to be provided on an outpatient basis. This will lead to more acutely ill hospital patient populations as well as more opportunities for nurses to work in alternative settings. Operating room nurses who want to remain in a surgical environment will find an increase in ambulatory surgery centers and clinics. These will be freestanding facilities not affiliated with hospitals as well as outpatient units administered by hospitals. Other options will include emergency care and family medicine clinics opening up in such locations as shopping malls. Home health care will also continue to grow because it is a low-cost alternative to hospitalization that also keeps the patient in a comfortable and familiar environment. Nurses interested in more involvement in patient
AORN Journal, November 1983, Vol38, No 5
erioperative nursing expends nursing time without corresponding revenue.
P
education and the psychosocial aspects of nursing will find this particularly attractive. Hospices are also experiencing growth. These facilities for the terminally ill provide a home-like environment, and family members are encouraged to help care for the patients. Nurses’roles will also expand. Nurses interested and trained in management will be more in demand. Nurse managers with clinical competency as well as administrative skills will be ideal candidates to manage emergency centers, ambulatory surgery clinics, and other facilities. Another nursing role that will increase is the nurse practitioner. Many clinics already rely on nurse practitioners. The lower costs associated with nurse practitioners in comparison with physicians make them attractive to administrators. Many patients prefer nurse practitioners because of the personalized nature of the care they receive from these health care professional^.^ A cull to action. Although the basic changes in the reimbursement system have been formulated already, there are several areas where nurses can work together to insure that high quality nursing care remains a n important priority. Nursing departments will need to defend their budgets in terms of the specific amounts of resources needed to care for their patients. Patient classification systems based on DRGs would be
invaluable because hospital administrators will be familiar with those categories. A patient classification system, however, requires the development of standards of care. This would require research to validate the relationship between any proposed standards and patient outcomes.4 One possible application of this in the OR would be assignment of three registered nurses in cases where the patient is given a local anesthetic. If it is shown that the presence of a third registered nurse to observe the patient improves patient outcomes, an allowance for the extra personnel could be justified in the OR budget. Another area where nurses can take action to preserve and strengthen their roles is to document the time spent on nonnursing tasks such as patient transport and room cleaning. Inefficient use of registered nurse resources where ancillary personnel are more appropriate must be documented because this may be an area where hospitals will have costs above the DRG-reimbursement level. Nurses need to consider the precise scope of their responsibilities.The question, “What is nursing,” has a multitude of answers. There is no universally accepted definition, which means nursing is vulnerable as hospital departments compete for scarce budget dollars. In recent years, some traditional nursing responsibilities have been
AORN Journal, November 1983, Vol38, No 5
781
taken over by other departments. These include n u t r i t i o n education, now done by dieticians, and intravenous medicat i o n preparation, n o w h a n d l e d by pharmacists. If nurses don’t work together t~ consolidate their profession, other health care disciplines w i l l chip away at the nursing role until nurses are l i t t l e more than patient care coordinators rather than actual care-givers. The challenge. Indeed, these are challenging times for nurses. The profession can take a stand and take advantage o f the opportunities for growth and diversification presented by changes in the reimbursement system. The other road w i l l lead to fragmentation of the profes-
sion and could result in compromises in patient care. Above all, nursing must continue its key role as a patient advocate and help keep the health care syst e m focused o n t h e primary goal of providing high quality patient care. Notes 1. A Trafford, C Work, “Soaring hospital costs,” US News and World Report (Aug 22,1983) 39-42. 2. “Pleasing the patient,” Hospitals 57 (Aug 1, 1983) 53-72. 3. S Taller, R Feldrnan, “The training and utilization of nurse practitioners in adult health appraisal,” Medical Care (January 1974) 40-48. 4. P Giovannetti,“Understandingpatient classification systems,” Journal of Nursing Administration 9 (February 1979) 4-9.
Hormone strengthens patients with ALS The muscle strength of patients with amyotrophic lateral sclerosis (ALS) improved after high dosages of an established peptide hormone were administered intravenously. W King Engel, MD, director of the University of Southern California neuromuscular center, Los Angeles, reported in Lancet that 12 patients have received temporary benefit from thyrotropin-releasing hormone (TRH). The 12 patients receiving this experimental therapy received as much as 500 mg of TRH during an eight-hour period. The dosage was varied as was the benefit to the patients. Some of the patients experienced dramatic increases in muscle strength and decreases in muscle spasticity, but others had minimal improvements. The benefit occurs quickly, and it is attributed to TRH being a neurotransmitter. TRH is found in the motor nerve cells in the spinal column. Dr Engel said, “The improvement is rapid, evident as early as a half minute after the drug infusion is started.” At this stage of the study, however, the achieved benefit is temporary. Dr Engel concludes that in ALS patients, the dead motor cells are not as numerous
782
as thought from the patient‘s degree of weakness. While the motor nerve cells are not functioning, it seems they are viable and with appropriate therapy can function again. “Right now we can say that TRH makes the ALS patients stronger. But we can’t as yet say that the treatment rescues nerve cells from eventual death.” Dr Engel is studying how the nerve cells could be rescued. This is an experimental treatment and has only been used in a clinical research setting for less than 24 hours. Dr Engel said, “The next step is to infuse TRH over a longer period-a number of days-and then longer.” The cause and cure for ALS are unknown. ALS is diagnosed in 5,000 people annually in the United States, but it is often mistaken for another condition. The most common early symptoms include muscle weakness, fatigue, or difficulty with speech or swallowing. The onset is gradual, and victims lead productive lives while the disease progresses. Most of the victims are in their 40s to 60s, and about one and a half times as many men as women are affected.
AORN Journal, November 1983, Vol38, No 5