By Marissa Schwartz
As a result of growing scrutiny over short-stay admissions from payers and regulators, CV programs across the country feel the pressure to move more procedures to outpatient classification. Yet while procedures are increasingly classified as 'outpatient'—and thus reimbursed at the lower payment—the vast majority of PCI outpatients stay overnight.
In 2013-2014, only 10% of programs discharged PCI patients in an average of 8 hours or less, which has significant financial implications. An unnecessary overnight stay for an outpatient PCI could result in $500 or more in losses for the program.
There are several reasons for adopting same-day discharge (SDD) beyond optimizing reimbursement: streamlining patient throughput, freeing inpatient bed capacity for higher-acuity patients, and improving patient experience. In fact, 89% of patients report satisfaction with SDD for PCI. While clinical protocols and operator acceptance are critical to adopting SDD, these efforts can be for naught if there isn't an operational infrastructure to support SDD.
Park Nicollet in St. Louis Park, Minnesota identified SDD as a top priority to drive value to its patients and its program. Though it performed an average of three outpatient PCIs a day, ingrained scheduling and operational practices disrupted its ability to promptly discharge patients.
In response, Park Nicollet took a multi-pronged approach to revamp its scheduling processes for PCI. We spoke with Kathy Westensee, Interventional Labs Manager at Park Nicollet, to learn more, and as this example demonstrates, adopting SDD requires much more than clinical protocols. It also necessitates team effort, comprehensive education, and support for disciplined scheduling.
Is SDD worth the effort? Many programs think so, as it offers the opportunity for enhanced value for the patient and the hospital.
Read on to learn how Park Nicollet achieved its goals, and how you can too.
Start with the schedule
1. All outpatients interventions are now scheduled during reserved morning time slots
Previously, Park Nicollet did not have a defined protocol for scheduling outpatient cases. Therefore, cases were often scheduled based on patient preference—typically meaning afternoon appointments. Not only did this prohibit SDD for many otherwise eligible patients, but it also led to unwanted variation in daily staffing needs.
To address this, Park Nicollet implemented assigned morning time slots for outpatients at 8, 9, and 10 a.m. Schedulers can only schedule outpatient interventions at these times, and require explicit permission or a physician order to schedule outpatients later in the day, which ensures that the time of procedure will not prevent an eligible patient from being discharged the same day.
This scheduling approach has an added benefit: More efficient staffing, which allows for more consistent staffing needs from day-to-day. The result? Park Nicollet reduced its cath lab shifts from three to two, reduced daily staffing need by two team members, and reduced overtime staffing.
2. Schedulers were fully engaged and accountable for adhering to the new scheduling protocol
In the face of patient requests for later appointments, schedulers may be resistant to adopting the new time slots. By assigning a scheduler champion who understood the long-term benefit of earlier scheduling to lead the charge, Park Nicollet was able to overcome this problem.
This champion provided peer education on the benefits of SDD, so the schedulers were more engaged to support the change, and offered recommendations for how to respond to patient pushback. Additionally, Park Nicollet requires schedulers to document justification whenever they schedule an outpatient in a different time slot, with program leaders providing feedback to outliers.
Communication is key
3. Patient education is provided early and often to ensure they are prepared for SDD
As soon as a patient is identified as an SDD candidate and scheduled for their procedure, the team informs them that they are likely to be discharged the day of the procedure, and ensures they have adequate transportation and home support. A cardiac resource nurse then calls patients prior to their procedure to review instructions, answer questions, and reiterate the SDD message. Finally, when patients are consented for their procedure, the discussion around SDD is repeated.
How the procedure is positioned is important, too: Park Nicollet has changed the phrasing from "if things go well" to "when things go well," to align patient expectations for early discharge.
4. SDD requires a change in mindset for recovery staff
Nurses are often accustomed to admitting post-procedure patients, so they may feel like they are doing a disservice to patients by discharging them earlier than in the past. Therefore, before rolling out the schedule changes, Park Nicollet empowered recovery nurses to support SDD by educating them about the benefits to patients.
It takes a village
5. A strong physician champion and one employed physician group smoothed the scheduling change for Park Nicollet
Medical Director Thomas Davis, MD, of Park Nicollet led the charge to change cath lab scheduling. Physicians are highly collaborative and supportive of SDD, stepping in to take on additional cases and altering schedules when necessary.
For programs lacking this structure, a strong medical director who can bring physicians together and reinforce the benefits of SDD can be helpful, as can dashboard tracking and incentive metrics. Programs with multiple physician groups might also consider rotating who has the earliest morning slots.
6. APPs are empowered to discharge same-day PCI patients
Park Nicollet’s pre/post unit hours are 5:30 a.m. to 7 p.m., with APPs staffing until 5 p.m. They can write conditional discharge orders based upon patient disposition. As long as a patient is done by about 1 p.m., SDD is feasible.
Length of Stay