- Email: [email protected]
The vascular project: Using data to improve processes and outcomes
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The vascular project: Using data to improve processes and outcomes Anne Aquila, APRN Fiscal accountability by health care providers has become a theme in health care delivery systems; however, evaluation of outcomes on the basis of cost alone may minimize the importance of patient needs and the quality of the care delivered. Mechanisms related to resource identification and allocation has to be driven by internal data and information systems that consider clinical, financial, administrative, and patient satisfaction data. This article will define processes, outcomes and outcomes measurement, and management. Various nursing-sensitive outcomes will be presented and their establishment, tracking, interpretation, and effect on the delivery of patient care in a newly opened vascular unit will be highlighted. (J Vasc Nurs 2001;19:80-6)
Hospitals are redesigning their physical space to meet the changing health care needs that face them in the new millennium. Care providers are also redefining ways to deliver health care to populations of patients. Care delivered to patients with vascular disease is no exception. Terms such as resource allocation, resource utilization, implementation of clinical pathways, reducing costs and length of stay (LOS) while maintaining quality are discussed in the vascular literature. Several authors have reported the selective use of intensive care for patients undergoing carotid surgery.1,2 Clinical pathways have been used to reduce costs, decrease LOS, improve processes, and increase patient satisfaction.3 Use of a case management approach to deliver care to vascular patients has been shown to improve the coordination of care, streamline processes, and allow care to be delivered in a timely and efficient manner.4
BACKGROUND Data from the Apache III system was reviewed at the Hospital of Saint Raphael. This system identifies high-risk and lowrisk patients requiring an intensive care unit (ICU) stay. It was determined that patients in the ICU accounted for approximately 20% of the hospital’s current inpatient census and were consuming more than 30% of the hospital’s resources. Within the surgical intensive care unit (SICU), patients considered low-risk monitor (LRM) comprised 49.7% of SICU admissions with an average LOS of 2.6 days. For the calendar year 1998, these figures represented 763 patients and 1947 ICU days. The Apache best practice demonstrated LRM admission rates for similar
Anne Aquila, APRN, is a Vascular Program Coordinator, Hospital of St Raphael, New Haven, Connecticut. Address reprint requests to Anne Aquila, APRN, Vascular Program Coordinator, Hospital of St Raphael, 1450 Chapel St, New Haven, CT 06511. Copyright © 2001 by the Society for Vascular Nursing, Inc. 1062-0303/2001/$35.00 + 0 40/1/117986 doi:10.1067/mvn.2001.117986
SICUs to be 20%. If we could reduce the LRM patients to 30%, it would represent a reduction of 778 ICU days. Patients considered LRM fell into several groups. Of the 763 patients considered LRM, 264 patients fell into the cardiovascular disease group (Table I), 150 patients fell into the neurologic postoperative group, 139 patients fell into the respiratory postoperative group, and the remaining 210 patients fell into miscellaneous categories. With this data and data from a Clinical Value Enhancement Project conducted at the hospital from July 1997 through June 1998, a team began to explore the selective use of ICU for carotid and lower extremity patients, as these patients compromised many of those in the cardiovascular disease LRM group. A pilot project began in the SICU, whereby criteria were developed and used to triage patients to acute versus subacute sections of the SICU. During the pilot project, specific patient outcomes were identified and monitored and group differences and procedural complications were documented. Although the driving force for this project was the reduction in the number of LRM patients being cared for in the SICU, thereby allowing for more critically ill patients to be admitted, the section of vascular surgery saw this as an opportunity to transition populations of vascular patients to a subacute unit and still provide quality care. Having a dedicated unit for care delivery might also allow for an improvement in processes and outcomes already in place and for the implementation of new projects and procedures to enhance the care delivered to patients with vascular disease.
DEFINING PROCESSES AND OUTCOMES The Oxford American Dictionary5 defines a process as “a series of actions or operations used in making or manufacturing or achieving something.” The Centers for Disease Control and Prevention6 (CDC) defines outcomes as “the end results of care, desirable or undesirable changes in individuals and populations that can be attributed to services provided.” Donabedian7 suggests that outcomes are changes in the actual or potential health status of individual patients, groups, or communities. Outcomes measurement is the ultimate definition of effectiveness and efficiency. It involves determining the indicators, gathering the necessary data, analyzing that data, interpreting the
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TABLE I
TABLE II
LOW-RISK MONITOR (LRM) PATIENTS
NURSING-SENSITIVE OUTCOMES
264/763 LRM patients
• Use of services
264 in the cardiovascular disease group 99 Carotid Endarterectomy, carotid 57 Peripheral ischemia Dilatation (with or without general anesthesia) Embolectomy (with or without general anesthesia)
• ICU versus VCU • Patient transfers • Patient readmissions • Cost • VCU utilization • Patient satisfaction
Grafts, all renal bypass
• Patient’s opinion of care received
Graft, all other
• Satisfaction with nursing care
55 Femoral bypass Graft, aorto-iliac Graft, femoral-popliteal 53 Other
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• Satisfaction with educational information before and after surgery • Satisfaction with overall care • Clinical status of patient population • Documentation on clinical pathway outcomes • Complication rates
results, making necessary changes in care or perhaps processes, and finally, evaluating effectiveness. Through outcomes studies, specific nursing interventions and treatment protocols can be examined and relevant questions can be asked.8 Outcomes management uses the information collected by measuring patient outcomes to improve patient care and how that care is delivered to a given population. This involves many departments, including nursing, medicine, physical therapy, dietary, and pharmacy. Performance improvement is an inherent goal of this process.8 Nurse researcher Karen Dorman Marek9 categorized several types of nursing-sensitive outcomes. They include outcomes allowing for the measurement of physiologic status, psychosocial status, functional status, behavior, knowledge, safety, symptom control, quality of life, goal attainment, patient satisfaction, use of services, and resolution of nursing diagnoses. Table II lists the outcomes identified and measured to determine the effectiveness of the Vascular Project and the impact that the opening of the vascular care unit (VCU) has had on processes and identified outcomes.
THE VCU The pilot project that began as a result of the review of the Apache III data led to the opening of the VCU in June 1999. The VCU is a 4-bed subacute unit located on the cardiothoracic stepdown unit. When the unit opened, it was primarily used to care for patients after carotid artery surgery and lower extremity bypass surgery. Patients were admitted to the VCU after a 4-hour stay in the postanesthesia care unit (PACU). Staff members on the unit are trained in cardiac monitors and rhythm interpretation and have attended Phase I of the hospital’s critical care course. In reviewing the data from the pilot project, the decision was made to accept arterial lines and vasoactive
TABLE III VASCULAR CARE UNIT EDUCATION • Vasoactive medications • Hemodynamic monitoring • Practice and case studies • Carotid artery surgery and clinical pathway documentation tool • Endovascular repair of abdominal aortic aneurysms • Thoracic surgery • Arterial blood gas interpretation • Lower extremity procedures and use of the clinical path ways and order sets • Thrombolytic therapy in the peripheral circulation • Patient education • Epidural review and practice session
medications, including phenylepherine (Neosynepherine) and sodium nitroprusside (Nipride), in the unit. Initial critical care staff education was performed approximately 1 month before the opening of the unit. The cardiothoracic clinical nurse specialist focused on arterial line monitoring and vasoactive medication initiation and titration. The nurses were given time to practice calculating drug dosages and setting up arterial lines. Staff also spent time in the cardiothoracic ICU where they monitored and discontinued arterial lines. Although they did not titrate medications independently while in the ICU, they became familiar with the medications and titration techniques. A competency checklist was used to document staff performance.
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Vascular education initially focused on the care of patients after carotid artery surgery and lower extremity bypass procedures. Clinical pathways and preprinted order sets were in effect for these 2 populations and were used to guide the education. These pathways are not used for documentation at the hospital. Before the opening of the VCU, the carotid clinical pathway was transformed into a documentation tool that would allow for documentation of all the care provided to the patient after carotid endarterectomy. Implementation of this tool streamlined documentation. Time was also spent reviewing available patient education materials, including teaching protocols and lesson plans, patient pathways, and educational booklets and brochures. The emphasis was on providing consistent patient education to the 2 patient populations targeted for admission to the VCU. As the population of patients in the unit expanded, additional education was provided (Table III). Presently, 76% of the staff working on the cardiothoracic step-down unit are also trained to work in the VCU. Through better timing in getting newer staff to the critical care course, we have been able to streamline education so that the same content is taught in fewer hours.
OUTCOME 1: USE OF SERVICES
ICU versus VCU Data from July 1999 through March 2001 demonstrated that 371 out of 400 (93%) patients undergoing carotid surgery were admitted directly to the VCU, and 29 (7%) patients were admitted to the ICU. Reasons for ICU admission included suspicion of a myocardial infarction, severe hypotension, and a neurologic event in the PACU (necessitating a return to the operating room and then admission to the ICU), combined procedures, and the need for isolation. Four beds are available in the VCU and bed availability may also be a problem, particularly on heavy volume operative vascular days. Relocating these patients to the VCU reduced ICU days by 371 for this population alone and allowed more critically ill patients to be admitted to the ICUs. Before the opening of the VCU, the average ICU LOS for these patients was 1 day. For the same time frame noted previously, 228 out of 306 (75%) patients undergoing lower extremity procedures were admitted to the VCU. The majority of these patients fall into ICD 9-CM procedure code 39.29. Here the reasons for ICU admission included the need for additional hemodynamic monitoring (Swan-Ganz catheters), continued intubation postoperatively, a significant patient history that the vascular surgeon deemed needed closer monitoring then the VCU can provide, the need for peritoneal dialysis, combined procedures, and the need for isolation. As with the carotid population, bed availability can be a problem on select days. Before the opening of the VCU, all of these patients were admitted to the ICU with an average LOS of 1.2 days. Presently, only 25% of these patients are treated in the ICU and a reduction of at least 228 ICU days has been realized.
Patient transfers and readmissions Transfer of patients to a level of higher acuity is rare. From July 1999 through March 2001, 9 patients required transfer to an ICU. In addition, 4 patients undergoing carotid endarterectomy
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required a return to the OR for reexploration because of wound hematoma and were readmitted to the VCU after recovering. Thirty-day readmissions and operative complications were being tracked via several mechanisms. Beginning in late 1998, a vascular registry was initiated at the hospital. Its inception has allowed for improved tracking of the patient transfers and readmissions. Data from the registry show no dramatic increases in readmissions or complications for either patient population since care has transitioned to a new unit.
Cost We have not seen dramatic cost savings for either population initially targeted for admission to the VCU. Patients undergoing carotid surgery are now classified as 23-hour holds, which is essentially an outpatient classification. This patient designation has influenced reimbursement. On average our cost per case has decrease by $300. Average LOS is 1.5 days, slightly lower than when the VCU opened. Our real improvements with this population have been seen in patient education and patient satisfaction. For the lower extremity population, primarily ICD 9-CM procedure code 39.29, no significant reduction in costs occurred, and the longer-than-desirable LOS continued, particularly for those patients presenting with limb-threatening ischemia. Although prior efforts have been made to address several issues regarding this patient population, the gains have not been held and more focused attention is required to address the needs of this patient population. Although the majority of these patients are initially cared for in the VCU, it is not VCU LOS that is problematic, it is the LOS on the floor. Data from the vascular registry have been used to identify characteristics of this group and will be used to determine future vascular section activities.
VCU utilization Data on utilization of the unit continues to be reviewed monthly. Daily unit census is tracked as well as census by day of the week. After the VCU was open for 3 months, changes were made on the basis of vascular registry and census data. First, PACU time was decreased from 4 hours to 2 hours. Data on patient outcomes was presented to the vascular surgeons and it was evident that during the first 3 months the VCU was open, LOS remained consistent and no increase in complications related to a change in patient location occurred. Furthermore, patients were not transferred from the VCU to the ICU because of instability; in fact, the surgeons wanted their patients admitted to the “new unit.” Two new populations of patients were added to the VCU mix in December 1999: patients undergoing thrombolysis and thoracic surgery, primarily lobectomy. Patients undergoing thoracotomy were another LRM patient population identified by the Apache III data. Presently, 50% of the patients undergoing thoracotomy for benign tumor, lung cancer, or other malignancy in the chest are admitted to the VCU. This transition has further reduced ICU days. In February 2000, the hospital performed its first endovascular abdominal aortic aneurysm repair. These patients are also presently receiving care in the VCU. In February 2001, the PACU LOS for patients undergoing thoracotomy was decreased from 4 hours to 2 hours. Data on clinical patient
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Figure 1. Carotid endarterectomy telephone callback record 24-48 hour telephone follow-up I. This section to be completed before discharge: Telephone number:_____________________________Surgery date:___________________Call back on:__________________ Surgeon:______________________________Primary nurse:______________________________ Anesthesiologist:___________________________Nurse anesthetist:_________________________________ Type of anesthesia: Cervical plexus block General Local by surgeon Do you recall having pain during your surgery? Yes No (If response is YES, ask next question) If YES, what was your pain level? 0 1 2 3 4 5 6 7 8 9 10 Questions specific to preoperative teaching 1a. Did you receive the preoperative informational folder (aqua in color) from your surgeon or someone in his office? Yes No If response to 1a is yes, how well did the information prepare you for your hospital stay and your surgery? 1. Not well at all 2. Fairly well 3. Well 4. Very well 5. Extremely well 1b. Did you view the preoperative video? Yes No If yes, was it at preadmission testing or on a nursing unit before surgery? (circle location) 1c. How well did the information prepare you for your hospital stay and your surgery? 1. Not well at all 2. Fairly well 3. Well 4. Very well 5. Extremely well If you do not feel the information prepared you for your hospital say, what could have been improved? Upon discharge did the patient have: Dressing? Yes No Drain? Yes No Neuro Deficit? Yes (Type)________________________________________ No Pain Medication? Yes (Type)________________________________________ No What was pain level at discharge? 0 1 2 3 4 5 6 7 8 9 10 Was “Home Care Guidelines after CEA” instruction sheet provided? Yes No II. Follow-up questions to be completed during phone conversation 1. How are you feeling? Excellent Good Fair Poor ——Patient’s response unfavorable, referred to MD 2. How are you managing at home? Excellent Good Fair Poor 3. What is your present pain level? 0 1 2 3 4 5 6 7 4. How helpful did you find the information you received upon discharge? 1. Not helpful 2. Fairly helpful 3. Helpful 4. Very helpful Care of Incision 1 2 3 4 5 Activity/Restriction Level 1 2 3 4 5 When to call MD 1 2 3 4 5 5. How satisfied were you with the care you received in the Vascular Care Unit? 1. Very dissatisfied 2. Dissatisfied 3. Slightly dissatisfied 4. Slightly satisfied 6. Is there any additional information you would have found helpful?
Signature Referred to: MRC Approval: 10/96 Revised: 6/99, 5/00, 6/00
RN
Date
8
9
10
5. Extremely helpful
5. Satisfied
6. Very satisfied
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Figure 2.
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HOSPITAL OF SAINT RAPHAEL, A MEMBER OF THE SAINT RAPHAEL HEALTHCARE SYSTEM: HOME CARE GUIDELINES AFTER CAROTID ARTERY SURGERY
The carotid arteries are blood vessels in your neck. They carry the major supply of blood to your head and brain. Carotid artery disease results from the build up of cholesterol and fat deposits (plaque) in the inner lining of the carotid artery. During your hospital stay, your doctor performed a carotid endarterectomy in order to remove the plaque that had built up inside your artery. Now that you are going home, there are a few things you should know. How to take care of your incision line
The area where the operation was done (incision line) may have staples in it. These will stay in until your follow-up visit. At that time, your doctor will take them out. Until then keep that area clean and dry. Your doctor or nurse will tell you when you may shower or bathe. If the staples were taken out in the hospital, you will probably have “steri-strips” on your incision line. Steri-strips are similar to small bandages and look like little pieces of tape. Do not remove the steri-strips. They will gradually dry up and fall off by themselves. If, however, they don’t fall off in about a week, then you may peel them off. Each day, gently wash (shower) your incision line with warm water and mild soap; gently pat dry. Do not put any lotions, creams or powders on the incision line unless prescribed by your doctor. Numbness and/or tingling at the incision site is common after carotid surgery. You may also experience some incisional swelling, which should decrease over the next several days.
Your activity level You should move your neck as you would normally. Expect that you may feel a little weaker and more tired at home. This is normal, and it may take a few weeks to feel like yourself again. Some rules to remember: • Get enough rest. Rest in between activities. Remember that rest does not always mean sleeping; it may include sitting quietly for 20 to 30 minutes. • Stop any activity when you begin to feel tired. Don’t let yourself become overtired. • Pace your activities, spreading them out during the day. Don’t try to do too many things all at one time. • At your first follow-up visit, you can discuss any changes in your activity level with your doctor. If you have any specific questions, write them down so you’ll remember them.
Activity limitations While your incision line is healing, you need to be careful about putting too much strain on it. This means you should take the following precautions: • Do not drive for at least two weeks or until you can move your neck as freely as you did prior to surgery. • Until your first follow-up visit, do not lift or carry objects heavier than five pounds. This includes carrying children, lifting or carrying bags of groceries or carrying a suitcase. • You may shower on . Once again, plan to discuss any changes in your activities with your doctor and write down any specific questions you may have.
When to call your doctor If you have any questions or problems at home, feel free to contact your doctor or nurse between checkups. Slight dizziness or a mild headache are not uncommon after carotid surgery. However, do report any new or recurring symptoms, such as weakness or numbness of your arm or leg, difficulty walking, changes in your vision, severe headaches, difficulty swallowing, or difficulty talking. Also call your doctor if you notice any of the following: • You have a temperature greater than 100 degrees Fahrenheit. • Your incision line gets redder. • Your incision line starts to drain. • Your incision line becomes more painful or tender. If you have any questions you want to ask your doctor or nurse, write them down so you’ll remember them. The information contained in this material should not be used to replace the regular medical advice of your physician. 6/95; revised 6/97, 6/99, 4/00
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outcomes was presented to the thoracic surgeons allowing for the change in PACU recovery time. Although the focus is, and will remain, on the care of patients undergoing vascular or thoracic surgery, additional patient populations have been cared for in the VCU, particularly on days when vascular surgical volume is low. This includes general surgery, trauma, urology, and other patients considered LRM, including neurosurgery. Admission of these patients has saved additional ICU days.
OUTCOME 2: PATIENT SATISFACTION Various outcomes are assessed with regard to patient satisfaction and include satisfaction with nursing care, satisfaction with educational information before and after surgery, and satisfaction with overall care. Before the opening of the VCU, available educational materials were packaged for completeness and new educational materials were developed. Educational folders were put together and delivered to the surgeon’s offices. Again, the 2 groups targeted were the patients undergoing carotid surgery or lower extremity bypass surgery. The goal is for the patients to receive information before the scheduled surgery. The same materials available in the physician offices are available in the VCU and on the general vascular floor. Procedure-specific teaching protocols and lesson plans are also readily available to staff. A video, “Your Carotid Surgery,” was filmed before the opening of the VCU and is available for patient viewing before surgery. Presently, the VCU staff evaluates patient and family satisfaction for patients undergoing carotid artery surgery. Satisfaction is documented via a phone call to patients 24 to 48 hours after discharge (Figure 1). While the callback record was available before the opening of the VCU, its use was inconsistent primarily because these patients were being discharged from 4 different units in the hospital. Phone calls were placed to patients approximately 30% of the time. Since the opening of the VCU, the callback record has undergone revisions on the basis of information received from patients. The most recent revision was in July 2000. Data from July 2000 to March 2001 demonstrated that the average callback day was 3, slightly ahead of our goal of 24 to 48 hours. Eighty-seven percent of patients responded to the phone call, which is excellent considering that 93% of the patients having carotid procedures performed are admitted to the VCU. With regard to preoperative teaching, 74% of patients received the education materials preoperatively, and 80% of patients who received the information found it helpful or extremely helpful. Physician offices were contacted reminding them about the available educational materials and encouraging their use before the planned surgery. Only 40% of patients were viewing the carotid surgery teaching video. The reasons for this seem to be multifactorial and include limited space in the preadmission testing area or patients undergoing preadmission testing outside the hospital. To address this, the video is now available on closed circuit hospital television 3 times a day. Although this is not ideal, it provides an additional means to present the information postoperatively, if not preoperatively. The viewing of the video will continue to be monitored.
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With regard to postoperative education, 100% of patients received the preprinted discharge instruction sheet (Figure 2) and 100% thought the information prepared them for their discharge. The instruction sheet discusses the procedure performed, wound care, activity and limitations, and when to call the doctor. Revisions were made in the instruction sheet on the basis of patient feedback. All callback data is reviewed monthly and summarized every 3 months. With the most recent version of the callback tool, questions were added related to pain management because some patients were reporting pain during their surgery. Information related to intraoperative pain scores has been shared with anesthesia departments for their thoughts and review. Pain level at discharge from the hospital was <3 (scale: 0, no pain, 10, worst pain imaginable) in 93% of patients, and was <3 in 92% of patients at the time of the call. Overall, 94% of patients were feeling good or excellent on the day they were telephoned and 98% were managing well at home. Ninety-nine percent of patients were satisfied or very satisfied with the care in the VCU. A callback for patients having undergone lower extremity bypass was recently developed and the tool is being piloted on the vascular floor. Callback data will be summarized, and modifications in the tool will be made before its implementation.
OUTCOME 3: CLINICAL STATUS OF PATIENT POPULATION For patients undergoing carotid surgery, documentation on the clinical pathway tool is 100%. All patient outcomes are documented and variances are charted. From July 1999 to March 2001, 298 (75%) patients were discharged on postoperative day (POD) 1, an additional 46 (12%) by POD 2, and 20 (5%) patients on POD 3. The clinical pathway is written for a 1-day LOS and thus, 75% of patients are following it. Stroke rate and other additional complications for this patient population are tracked via the vascular registry, reported on, and evaluated to determine possible areas for improvement. For patients undergoing lower extremity bypass procedures, there is 100% follow-through of all required patient outcomes while the patient is in the VCU. This includes initiation of teaching, mobilization, placement of physical therapy consultation, and discontinuation of tubes, drains, and lines as appropriate. Average stay in the VCU is 1 day. Review of the LOS data demonstrates that for patients undergoing procedures for claudication, the clinical pathway is followed consistently, with patient discharge at or below our mark of 4 days. For patients who require interventions for limb-threatening ischemia, LOS remains higher than desirable with only 18% to 32% of patients discharged by POD 4 and an additional 12% to 22% discharged by POD 5 and 6. As mentioned, these data are being reviewed and discussed with the vascular section.
ADDITIONAL UNIT ACTIVITIES FOCUSING ON PATIENT OUTCOMES A heel assessment and monitoring program was implemented as a multiunit quality improvement project involving the
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PACU, VCU, and vascular floor. Peer review was also implemented in the unit in January 2000. The peer review tool allows for evaluation of staff performance in areas such as completeness of nursing documentation, frequency and completeness of patient assessments and initiation, and documentation of patient education. Each staff member is required to review 2 peer charts per quarter. Results are summarized and shared with each staff member.
THE VCU TEAM Although quality is about technical excellence—the provision of care efficiently, effectively, and skillfully—it is also about relationships, care providers with each other and care providers with the patient. Since the VCU opened, the team concept has been emphasized. The staff met and continue to meet informally to discuss how things were going and to determine if any problems or issues need immediate attention. For the first 18 months, we held formal staff meetings every other month to review unit census data, discuss unit activities, review challenging patients, and identify whether we could be doing things differently or better. Meeting minutes were posted in the VCU for staff review. Presently, VCU data are presented at the floor staff meetings. Staff members have always viewed themselves as part of the unit development and they actively seek solutions to problems, rather then have problems solved for them. A mostly positive atmosphere has been maintained in the VCU despite staffing issues and a heavy workload. This is a testament to the nursing staff and their commitment to provide excellent, coordinated, and comprehensive care to their patients.
CONCLUSIONS In conclusion, use of service outcome is being met as the selective use of ICU for vascular, thoracic, and other patient populations has occurred. There has been a reduction in ICU days,
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approaching the 30% targeted. There has been no increase in patient complications and no dramatic increase in transfer of patients out of the VCU because of problems or complications. Care provided to patients targeted for admission to the VCU has been enhanced as demonstrated by patient satisfaction and clinical outcomes. Clinical outcomes are being consistently met for the carotid surgery population. Patients undergoing lower extremity infrainguinal bypass need more focused attention.
REFERENCES 1. O’Brien M, Ricotta J. Conserving resources after carotid endarterectomy: selective use of the intensive care unit. J Vasc Surg 1991;14:796-802. 2. Lipsett P, Tierney S, Gordon T, et al. Carotid endarterectomy—is intensive care unit care necessary? J Vasc Surg 1994;20:403-10. 3. Collier PE, Friend SZ, Gentile C, et al. Carotid endarterectomy clinical pathway: an innovative approach. J Med Qual 1995;10:38-47. 4. Roddy SP, O’Donnell TF, Iafrati MD, et al. Reduction of hospital resources utilization in vascular surgery: a four-year experience. J Vasc Surg 1998;27:1066-77. 5. Oxford American Dictionary. New York: Avon Books; 1986. Process; p. 713. 6. Position papers from the Third National Injury Control Conference: Setting the National Agenda for Injury Control in the 1990s. 1991 Apr 22-25; Denver, Colorado. MMWR Morb Mortal Wkly Rep 1992:41(RR-6):1-38. 7. Donabedian A. The methods and findings of quality assessment and monitoring: an illustrated analysis. Ann Arbor (MI): Health Administration Press; 1985. 8. Oerman MH, Huber D. Patient outcomes: a measure of nursing’s value. Am J Nurs 1999;99(9):40-7. 9. Marek KD. Measuring the effectiveness of nursing care [quiz 13]. Outcomes Manag Nurs Pract 1997;1:8-12.
WRITING AWARD The Journal of Vascular Nursing Article Award honors nurse authors for their efforts to create a publishable manuscript. Manuscripts will be judged for accuracy of content, relevance to vascular nursing practice, and excellence of writing style. All feature articles published in the Journal of Vascular Nursing during the calendar year will be considered for the JVN Article Award. The award recipient will be given a plaque commemorating the award and a cash prize donated by Mosby. The award and cash prize will presented at the annual symposium. Annoucement of the award recipient will appear in the Journal of Vascular Nursing and in SVN...prn.
JOURNAL OF VASCULAR NURSING
SEPTEMBER 2001
The vascular project: Using data to improve processes and outcomes Anne Aquila, APRN Fiscal accountability by health care providers has become a theme in health care delivery systems; however, evaluation of outcomes on the basis of cost alone may minimize the importance of patient needs and the quality of the care delivered. Mechanisms related to resource identification and allocation has to be driven by internal data and information systems that consider clinical, financial, administrative, and patient satisfaction data. This article will define processes, outcomes and outcomes measurement, and management. Various nursing-sensitive outcomes will be presented and their establishment, tracking, interpretation, and effect on the delivery of patient care in a newly opened vascular unit will be highlighted. (J Vasc Nurs 2001;19:80-6)
Hospitals are redesigning their physical space to meet the changing health care needs that face them in the new millennium. Care providers are also redefining ways to deliver health care to populations of patients. Care delivered to patients with vascular disease is no exception. Terms such as resource allocation, resource utilization, implementation of clinical pathways, reducing costs and length of stay (LOS) while maintaining quality are discussed in the vascular literature. Several authors have reported the selective use of intensive care for patients undergoing carotid surgery.1,2 Clinical pathways have been used to reduce costs, decrease LOS, improve processes, and increase patient satisfaction.3 Use of a case management approach to deliver care to vascular patients has been shown to improve the coordination of care, streamline processes, and allow care to be delivered in a timely and efficient manner.4
BACKGROUND Data from the Apache III system was reviewed at the Hospital of Saint Raphael. This system identifies high-risk and lowrisk patients requiring an intensive care unit (ICU) stay. It was determined that patients in the ICU accounted for approximately 20% of the hospital’s current inpatient census and were consuming more than 30% of the hospital’s resources. Within the surgical intensive care unit (SICU), patients considered low-risk monitor (LRM) comprised 49.7% of SICU admissions with an average LOS of 2.6 days. For the calendar year 1998, these figures represented 763 patients and 1947 ICU days. The Apache best practice demonstrated LRM admission rates for similar
Anne Aquila, APRN, is a Vascular Program Coordinator, Hospital of St Raphael, New Haven, Connecticut. Address reprint requests to Anne Aquila, APRN, Vascular Program Coordinator, Hospital of St Raphael, 1450 Chapel St, New Haven, CT 06511. Copyright © 2001 by the Society for Vascular Nursing, Inc. 1062-0303/2001/$35.00 + 0 40/1/117986 doi:10.1067/mvn.2001.117986
SICUs to be 20%. If we could reduce the LRM patients to 30%, it would represent a reduction of 778 ICU days. Patients considered LRM fell into several groups. Of the 763 patients considered LRM, 264 patients fell into the cardiovascular disease group (Table I), 150 patients fell into the neurologic postoperative group, 139 patients fell into the respiratory postoperative group, and the remaining 210 patients fell into miscellaneous categories. With this data and data from a Clinical Value Enhancement Project conducted at the hospital from July 1997 through June 1998, a team began to explore the selective use of ICU for carotid and lower extremity patients, as these patients compromised many of those in the cardiovascular disease LRM group. A pilot project began in the SICU, whereby criteria were developed and used to triage patients to acute versus subacute sections of the SICU. During the pilot project, specific patient outcomes were identified and monitored and group differences and procedural complications were documented. Although the driving force for this project was the reduction in the number of LRM patients being cared for in the SICU, thereby allowing for more critically ill patients to be admitted, the section of vascular surgery saw this as an opportunity to transition populations of vascular patients to a subacute unit and still provide quality care. Having a dedicated unit for care delivery might also allow for an improvement in processes and outcomes already in place and for the implementation of new projects and procedures to enhance the care delivered to patients with vascular disease.
DEFINING PROCESSES AND OUTCOMES The Oxford American Dictionary5 defines a process as “a series of actions or operations used in making or manufacturing or achieving something.” The Centers for Disease Control and Prevention6 (CDC) defines outcomes as “the end results of care, desirable or undesirable changes in individuals and populations that can be attributed to services provided.” Donabedian7 suggests that outcomes are changes in the actual or potential health status of individual patients, groups, or communities. Outcomes measurement is the ultimate definition of effectiveness and efficiency. It involves determining the indicators, gathering the necessary data, analyzing that data, interpreting the
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TABLE I
TABLE II
LOW-RISK MONITOR (LRM) PATIENTS
NURSING-SENSITIVE OUTCOMES
264/763 LRM patients
• Use of services
264 in the cardiovascular disease group 99 Carotid Endarterectomy, carotid 57 Peripheral ischemia Dilatation (with or without general anesthesia) Embolectomy (with or without general anesthesia)
• ICU versus VCU • Patient transfers • Patient readmissions • Cost • VCU utilization • Patient satisfaction
Grafts, all renal bypass
• Patient’s opinion of care received
Graft, all other
• Satisfaction with nursing care
55 Femoral bypass Graft, aorto-iliac Graft, femoral-popliteal 53 Other
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• Satisfaction with educational information before and after surgery • Satisfaction with overall care • Clinical status of patient population • Documentation on clinical pathway outcomes • Complication rates
results, making necessary changes in care or perhaps processes, and finally, evaluating effectiveness. Through outcomes studies, specific nursing interventions and treatment protocols can be examined and relevant questions can be asked.8 Outcomes management uses the information collected by measuring patient outcomes to improve patient care and how that care is delivered to a given population. This involves many departments, including nursing, medicine, physical therapy, dietary, and pharmacy. Performance improvement is an inherent goal of this process.8 Nurse researcher Karen Dorman Marek9 categorized several types of nursing-sensitive outcomes. They include outcomes allowing for the measurement of physiologic status, psychosocial status, functional status, behavior, knowledge, safety, symptom control, quality of life, goal attainment, patient satisfaction, use of services, and resolution of nursing diagnoses. Table II lists the outcomes identified and measured to determine the effectiveness of the Vascular Project and the impact that the opening of the vascular care unit (VCU) has had on processes and identified outcomes.
THE VCU The pilot project that began as a result of the review of the Apache III data led to the opening of the VCU in June 1999. The VCU is a 4-bed subacute unit located on the cardiothoracic stepdown unit. When the unit opened, it was primarily used to care for patients after carotid artery surgery and lower extremity bypass surgery. Patients were admitted to the VCU after a 4-hour stay in the postanesthesia care unit (PACU). Staff members on the unit are trained in cardiac monitors and rhythm interpretation and have attended Phase I of the hospital’s critical care course. In reviewing the data from the pilot project, the decision was made to accept arterial lines and vasoactive
TABLE III VASCULAR CARE UNIT EDUCATION • Vasoactive medications • Hemodynamic monitoring • Practice and case studies • Carotid artery surgery and clinical pathway documentation tool • Endovascular repair of abdominal aortic aneurysms • Thoracic surgery • Arterial blood gas interpretation • Lower extremity procedures and use of the clinical path ways and order sets • Thrombolytic therapy in the peripheral circulation • Patient education • Epidural review and practice session
medications, including phenylepherine (Neosynepherine) and sodium nitroprusside (Nipride), in the unit. Initial critical care staff education was performed approximately 1 month before the opening of the unit. The cardiothoracic clinical nurse specialist focused on arterial line monitoring and vasoactive medication initiation and titration. The nurses were given time to practice calculating drug dosages and setting up arterial lines. Staff also spent time in the cardiothoracic ICU where they monitored and discontinued arterial lines. Although they did not titrate medications independently while in the ICU, they became familiar with the medications and titration techniques. A competency checklist was used to document staff performance.
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Vascular education initially focused on the care of patients after carotid artery surgery and lower extremity bypass procedures. Clinical pathways and preprinted order sets were in effect for these 2 populations and were used to guide the education. These pathways are not used for documentation at the hospital. Before the opening of the VCU, the carotid clinical pathway was transformed into a documentation tool that would allow for documentation of all the care provided to the patient after carotid endarterectomy. Implementation of this tool streamlined documentation. Time was also spent reviewing available patient education materials, including teaching protocols and lesson plans, patient pathways, and educational booklets and brochures. The emphasis was on providing consistent patient education to the 2 patient populations targeted for admission to the VCU. As the population of patients in the unit expanded, additional education was provided (Table III). Presently, 76% of the staff working on the cardiothoracic step-down unit are also trained to work in the VCU. Through better timing in getting newer staff to the critical care course, we have been able to streamline education so that the same content is taught in fewer hours.
OUTCOME 1: USE OF SERVICES
ICU versus VCU Data from July 1999 through March 2001 demonstrated that 371 out of 400 (93%) patients undergoing carotid surgery were admitted directly to the VCU, and 29 (7%) patients were admitted to the ICU. Reasons for ICU admission included suspicion of a myocardial infarction, severe hypotension, and a neurologic event in the PACU (necessitating a return to the operating room and then admission to the ICU), combined procedures, and the need for isolation. Four beds are available in the VCU and bed availability may also be a problem, particularly on heavy volume operative vascular days. Relocating these patients to the VCU reduced ICU days by 371 for this population alone and allowed more critically ill patients to be admitted to the ICUs. Before the opening of the VCU, the average ICU LOS for these patients was 1 day. For the same time frame noted previously, 228 out of 306 (75%) patients undergoing lower extremity procedures were admitted to the VCU. The majority of these patients fall into ICD 9-CM procedure code 39.29. Here the reasons for ICU admission included the need for additional hemodynamic monitoring (Swan-Ganz catheters), continued intubation postoperatively, a significant patient history that the vascular surgeon deemed needed closer monitoring then the VCU can provide, the need for peritoneal dialysis, combined procedures, and the need for isolation. As with the carotid population, bed availability can be a problem on select days. Before the opening of the VCU, all of these patients were admitted to the ICU with an average LOS of 1.2 days. Presently, only 25% of these patients are treated in the ICU and a reduction of at least 228 ICU days has been realized.
Patient transfers and readmissions Transfer of patients to a level of higher acuity is rare. From July 1999 through March 2001, 9 patients required transfer to an ICU. In addition, 4 patients undergoing carotid endarterectomy
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required a return to the OR for reexploration because of wound hematoma and were readmitted to the VCU after recovering. Thirty-day readmissions and operative complications were being tracked via several mechanisms. Beginning in late 1998, a vascular registry was initiated at the hospital. Its inception has allowed for improved tracking of the patient transfers and readmissions. Data from the registry show no dramatic increases in readmissions or complications for either patient population since care has transitioned to a new unit.
Cost We have not seen dramatic cost savings for either population initially targeted for admission to the VCU. Patients undergoing carotid surgery are now classified as 23-hour holds, which is essentially an outpatient classification. This patient designation has influenced reimbursement. On average our cost per case has decrease by $300. Average LOS is 1.5 days, slightly lower than when the VCU opened. Our real improvements with this population have been seen in patient education and patient satisfaction. For the lower extremity population, primarily ICD 9-CM procedure code 39.29, no significant reduction in costs occurred, and the longer-than-desirable LOS continued, particularly for those patients presenting with limb-threatening ischemia. Although prior efforts have been made to address several issues regarding this patient population, the gains have not been held and more focused attention is required to address the needs of this patient population. Although the majority of these patients are initially cared for in the VCU, it is not VCU LOS that is problematic, it is the LOS on the floor. Data from the vascular registry have been used to identify characteristics of this group and will be used to determine future vascular section activities.
VCU utilization Data on utilization of the unit continues to be reviewed monthly. Daily unit census is tracked as well as census by day of the week. After the VCU was open for 3 months, changes were made on the basis of vascular registry and census data. First, PACU time was decreased from 4 hours to 2 hours. Data on patient outcomes was presented to the vascular surgeons and it was evident that during the first 3 months the VCU was open, LOS remained consistent and no increase in complications related to a change in patient location occurred. Furthermore, patients were not transferred from the VCU to the ICU because of instability; in fact, the surgeons wanted their patients admitted to the “new unit.” Two new populations of patients were added to the VCU mix in December 1999: patients undergoing thrombolysis and thoracic surgery, primarily lobectomy. Patients undergoing thoracotomy were another LRM patient population identified by the Apache III data. Presently, 50% of the patients undergoing thoracotomy for benign tumor, lung cancer, or other malignancy in the chest are admitted to the VCU. This transition has further reduced ICU days. In February 2000, the hospital performed its first endovascular abdominal aortic aneurysm repair. These patients are also presently receiving care in the VCU. In February 2001, the PACU LOS for patients undergoing thoracotomy was decreased from 4 hours to 2 hours. Data on clinical patient
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Figure 1. Carotid endarterectomy telephone callback record 24-48 hour telephone follow-up I. This section to be completed before discharge: Telephone number:_____________________________Surgery date:___________________Call back on:__________________ Surgeon:______________________________Primary nurse:______________________________ Anesthesiologist:___________________________Nurse anesthetist:_________________________________ Type of anesthesia: Cervical plexus block General Local by surgeon Do you recall having pain during your surgery? Yes No (If response is YES, ask next question) If YES, what was your pain level? 0 1 2 3 4 5 6 7 8 9 10 Questions specific to preoperative teaching 1a. Did you receive the preoperative informational folder (aqua in color) from your surgeon or someone in his office? Yes No If response to 1a is yes, how well did the information prepare you for your hospital stay and your surgery? 1. Not well at all 2. Fairly well 3. Well 4. Very well 5. Extremely well 1b. Did you view the preoperative video? Yes No If yes, was it at preadmission testing or on a nursing unit before surgery? (circle location) 1c. How well did the information prepare you for your hospital stay and your surgery? 1. Not well at all 2. Fairly well 3. Well 4. Very well 5. Extremely well If you do not feel the information prepared you for your hospital say, what could have been improved? Upon discharge did the patient have: Dressing? Yes No Drain? Yes No Neuro Deficit? Yes (Type)________________________________________ No Pain Medication? Yes (Type)________________________________________ No What was pain level at discharge? 0 1 2 3 4 5 6 7 8 9 10 Was “Home Care Guidelines after CEA” instruction sheet provided? Yes No II. Follow-up questions to be completed during phone conversation 1. How are you feeling? Excellent Good Fair Poor ——Patient’s response unfavorable, referred to MD 2. How are you managing at home? Excellent Good Fair Poor 3. What is your present pain level? 0 1 2 3 4 5 6 7 4. How helpful did you find the information you received upon discharge? 1. Not helpful 2. Fairly helpful 3. Helpful 4. Very helpful Care of Incision 1 2 3 4 5 Activity/Restriction Level 1 2 3 4 5 When to call MD 1 2 3 4 5 5. How satisfied were you with the care you received in the Vascular Care Unit? 1. Very dissatisfied 2. Dissatisfied 3. Slightly dissatisfied 4. Slightly satisfied 6. Is there any additional information you would have found helpful?
Signature Referred to: MRC Approval: 10/96 Revised: 6/99, 5/00, 6/00
RN
Date
8
9
10
5. Extremely helpful
5. Satisfied
6. Very satisfied
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Figure 2.
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HOSPITAL OF SAINT RAPHAEL, A MEMBER OF THE SAINT RAPHAEL HEALTHCARE SYSTEM: HOME CARE GUIDELINES AFTER CAROTID ARTERY SURGERY
The carotid arteries are blood vessels in your neck. They carry the major supply of blood to your head and brain. Carotid artery disease results from the build up of cholesterol and fat deposits (plaque) in the inner lining of the carotid artery. During your hospital stay, your doctor performed a carotid endarterectomy in order to remove the plaque that had built up inside your artery. Now that you are going home, there are a few things you should know. How to take care of your incision line
The area where the operation was done (incision line) may have staples in it. These will stay in until your follow-up visit. At that time, your doctor will take them out. Until then keep that area clean and dry. Your doctor or nurse will tell you when you may shower or bathe. If the staples were taken out in the hospital, you will probably have “steri-strips” on your incision line. Steri-strips are similar to small bandages and look like little pieces of tape. Do not remove the steri-strips. They will gradually dry up and fall off by themselves. If, however, they don’t fall off in about a week, then you may peel them off. Each day, gently wash (shower) your incision line with warm water and mild soap; gently pat dry. Do not put any lotions, creams or powders on the incision line unless prescribed by your doctor. Numbness and/or tingling at the incision site is common after carotid surgery. You may also experience some incisional swelling, which should decrease over the next several days.
Your activity level You should move your neck as you would normally. Expect that you may feel a little weaker and more tired at home. This is normal, and it may take a few weeks to feel like yourself again. Some rules to remember: • Get enough rest. Rest in between activities. Remember that rest does not always mean sleeping; it may include sitting quietly for 20 to 30 minutes. • Stop any activity when you begin to feel tired. Don’t let yourself become overtired. • Pace your activities, spreading them out during the day. Don’t try to do too many things all at one time. • At your first follow-up visit, you can discuss any changes in your activity level with your doctor. If you have any specific questions, write them down so you’ll remember them.
Activity limitations While your incision line is healing, you need to be careful about putting too much strain on it. This means you should take the following precautions: • Do not drive for at least two weeks or until you can move your neck as freely as you did prior to surgery. • Until your first follow-up visit, do not lift or carry objects heavier than five pounds. This includes carrying children, lifting or carrying bags of groceries or carrying a suitcase. • You may shower on . Once again, plan to discuss any changes in your activities with your doctor and write down any specific questions you may have.
When to call your doctor If you have any questions or problems at home, feel free to contact your doctor or nurse between checkups. Slight dizziness or a mild headache are not uncommon after carotid surgery. However, do report any new or recurring symptoms, such as weakness or numbness of your arm or leg, difficulty walking, changes in your vision, severe headaches, difficulty swallowing, or difficulty talking. Also call your doctor if you notice any of the following: • You have a temperature greater than 100 degrees Fahrenheit. • Your incision line gets redder. • Your incision line starts to drain. • Your incision line becomes more painful or tender. If you have any questions you want to ask your doctor or nurse, write them down so you’ll remember them. The information contained in this material should not be used to replace the regular medical advice of your physician. 6/95; revised 6/97, 6/99, 4/00
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outcomes was presented to the thoracic surgeons allowing for the change in PACU recovery time. Although the focus is, and will remain, on the care of patients undergoing vascular or thoracic surgery, additional patient populations have been cared for in the VCU, particularly on days when vascular surgical volume is low. This includes general surgery, trauma, urology, and other patients considered LRM, including neurosurgery. Admission of these patients has saved additional ICU days.
OUTCOME 2: PATIENT SATISFACTION Various outcomes are assessed with regard to patient satisfaction and include satisfaction with nursing care, satisfaction with educational information before and after surgery, and satisfaction with overall care. Before the opening of the VCU, available educational materials were packaged for completeness and new educational materials were developed. Educational folders were put together and delivered to the surgeon’s offices. Again, the 2 groups targeted were the patients undergoing carotid surgery or lower extremity bypass surgery. The goal is for the patients to receive information before the scheduled surgery. The same materials available in the physician offices are available in the VCU and on the general vascular floor. Procedure-specific teaching protocols and lesson plans are also readily available to staff. A video, “Your Carotid Surgery,” was filmed before the opening of the VCU and is available for patient viewing before surgery. Presently, the VCU staff evaluates patient and family satisfaction for patients undergoing carotid artery surgery. Satisfaction is documented via a phone call to patients 24 to 48 hours after discharge (Figure 1). While the callback record was available before the opening of the VCU, its use was inconsistent primarily because these patients were being discharged from 4 different units in the hospital. Phone calls were placed to patients approximately 30% of the time. Since the opening of the VCU, the callback record has undergone revisions on the basis of information received from patients. The most recent revision was in July 2000. Data from July 2000 to March 2001 demonstrated that the average callback day was 3, slightly ahead of our goal of 24 to 48 hours. Eighty-seven percent of patients responded to the phone call, which is excellent considering that 93% of the patients having carotid procedures performed are admitted to the VCU. With regard to preoperative teaching, 74% of patients received the education materials preoperatively, and 80% of patients who received the information found it helpful or extremely helpful. Physician offices were contacted reminding them about the available educational materials and encouraging their use before the planned surgery. Only 40% of patients were viewing the carotid surgery teaching video. The reasons for this seem to be multifactorial and include limited space in the preadmission testing area or patients undergoing preadmission testing outside the hospital. To address this, the video is now available on closed circuit hospital television 3 times a day. Although this is not ideal, it provides an additional means to present the information postoperatively, if not preoperatively. The viewing of the video will continue to be monitored.
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With regard to postoperative education, 100% of patients received the preprinted discharge instruction sheet (Figure 2) and 100% thought the information prepared them for their discharge. The instruction sheet discusses the procedure performed, wound care, activity and limitations, and when to call the doctor. Revisions were made in the instruction sheet on the basis of patient feedback. All callback data is reviewed monthly and summarized every 3 months. With the most recent version of the callback tool, questions were added related to pain management because some patients were reporting pain during their surgery. Information related to intraoperative pain scores has been shared with anesthesia departments for their thoughts and review. Pain level at discharge from the hospital was <3 (scale: 0, no pain, 10, worst pain imaginable) in 93% of patients, and was <3 in 92% of patients at the time of the call. Overall, 94% of patients were feeling good or excellent on the day they were telephoned and 98% were managing well at home. Ninety-nine percent of patients were satisfied or very satisfied with the care in the VCU. A callback for patients having undergone lower extremity bypass was recently developed and the tool is being piloted on the vascular floor. Callback data will be summarized, and modifications in the tool will be made before its implementation.
OUTCOME 3: CLINICAL STATUS OF PATIENT POPULATION For patients undergoing carotid surgery, documentation on the clinical pathway tool is 100%. All patient outcomes are documented and variances are charted. From July 1999 to March 2001, 298 (75%) patients were discharged on postoperative day (POD) 1, an additional 46 (12%) by POD 2, and 20 (5%) patients on POD 3. The clinical pathway is written for a 1-day LOS and thus, 75% of patients are following it. Stroke rate and other additional complications for this patient population are tracked via the vascular registry, reported on, and evaluated to determine possible areas for improvement. For patients undergoing lower extremity bypass procedures, there is 100% follow-through of all required patient outcomes while the patient is in the VCU. This includes initiation of teaching, mobilization, placement of physical therapy consultation, and discontinuation of tubes, drains, and lines as appropriate. Average stay in the VCU is 1 day. Review of the LOS data demonstrates that for patients undergoing procedures for claudication, the clinical pathway is followed consistently, with patient discharge at or below our mark of 4 days. For patients who require interventions for limb-threatening ischemia, LOS remains higher than desirable with only 18% to 32% of patients discharged by POD 4 and an additional 12% to 22% discharged by POD 5 and 6. As mentioned, these data are being reviewed and discussed with the vascular section.
ADDITIONAL UNIT ACTIVITIES FOCUSING ON PATIENT OUTCOMES A heel assessment and monitoring program was implemented as a multiunit quality improvement project involving the
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PACU, VCU, and vascular floor. Peer review was also implemented in the unit in January 2000. The peer review tool allows for evaluation of staff performance in areas such as completeness of nursing documentation, frequency and completeness of patient assessments and initiation, and documentation of patient education. Each staff member is required to review 2 peer charts per quarter. Results are summarized and shared with each staff member.
THE VCU TEAM Although quality is about technical excellence—the provision of care efficiently, effectively, and skillfully—it is also about relationships, care providers with each other and care providers with the patient. Since the VCU opened, the team concept has been emphasized. The staff met and continue to meet informally to discuss how things were going and to determine if any problems or issues need immediate attention. For the first 18 months, we held formal staff meetings every other month to review unit census data, discuss unit activities, review challenging patients, and identify whether we could be doing things differently or better. Meeting minutes were posted in the VCU for staff review. Presently, VCU data are presented at the floor staff meetings. Staff members have always viewed themselves as part of the unit development and they actively seek solutions to problems, rather then have problems solved for them. A mostly positive atmosphere has been maintained in the VCU despite staffing issues and a heavy workload. This is a testament to the nursing staff and their commitment to provide excellent, coordinated, and comprehensive care to their patients.
CONCLUSIONS In conclusion, use of service outcome is being met as the selective use of ICU for vascular, thoracic, and other patient populations has occurred. There has been a reduction in ICU days,
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approaching the 30% targeted. There has been no increase in patient complications and no dramatic increase in transfer of patients out of the VCU because of problems or complications. Care provided to patients targeted for admission to the VCU has been enhanced as demonstrated by patient satisfaction and clinical outcomes. Clinical outcomes are being consistently met for the carotid surgery population. Patients undergoing lower extremity infrainguinal bypass need more focused attention.
REFERENCES 1. O’Brien M, Ricotta J. Conserving resources after carotid endarterectomy: selective use of the intensive care unit. J Vasc Surg 1991;14:796-802. 2. Lipsett P, Tierney S, Gordon T, et al. Carotid endarterectomy—is intensive care unit care necessary? J Vasc Surg 1994;20:403-10. 3. Collier PE, Friend SZ, Gentile C, et al. Carotid endarterectomy clinical pathway: an innovative approach. J Med Qual 1995;10:38-47. 4. Roddy SP, O’Donnell TF, Iafrati MD, et al. Reduction of hospital resources utilization in vascular surgery: a four-year experience. J Vasc Surg 1998;27:1066-77. 5. Oxford American Dictionary. New York: Avon Books; 1986. Process; p. 713. 6. Position papers from the Third National Injury Control Conference: Setting the National Agenda for Injury Control in the 1990s. 1991 Apr 22-25; Denver, Colorado. MMWR Morb Mortal Wkly Rep 1992:41(RR-6):1-38. 7. Donabedian A. The methods and findings of quality assessment and monitoring: an illustrated analysis. Ann Arbor (MI): Health Administration Press; 1985. 8. Oerman MH, Huber D. Patient outcomes: a measure of nursing’s value. Am J Nurs 1999;99(9):40-7. 9. Marek KD. Measuring the effectiveness of nursing care [quiz 13]. Outcomes Manag Nurs Pract 1997;1:8-12.
WRITING AWARD The Journal of Vascular Nursing Article Award honors nurse authors for their efforts to create a publishable manuscript. Manuscripts will be judged for accuracy of content, relevance to vascular nursing practice, and excellence of writing style. All feature articles published in the Journal of Vascular Nursing during the calendar year will be considered for the JVN Article Award. The award recipient will be given a plaque commemorating the award and a cash prize donated by Mosby. The award and cash prize will presented at the annual symposium. Annoucement of the award recipient will appear in the Journal of Vascular Nursing and in SVN...prn.