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Rosemary Sullivan, Nursing Unit Manager, Orthopaedic Ward, St. Vincent's Hospital Sydney. |
Over the last 20 years at St. Vincent's Hospital, Sydney, a variety of models for delivering nursing care have been used. These have included Task Allocation, Team-Nursing, Patient Allocation and more recently Primary Nursing.
In February 1992, another model, Case Management was commenced on Cahill 16, a 36 bed Orthopaedic Ward. Of the patients admitted to the ward approximately 70% are classified as trauma and 30% are elective admissions.
The trauma admissions range from simple presentations such as fractured fingers to complicated multi trauma cases.
Most of the patients admitted are elderly with fractured neck of femurs who very often become confused post operatively, have fluid and electrolyte imbalances and are quite frail.
The elective procedures include total joint replacements, mainly hips and knees, as well as a wide range of orthopaedic conditions such as ankle arthrodesis, fore foot corrections and laminectomy's.
With six orthopaedic surgeons and operating lists each day including night time and weekend it is a very busy ward.
The catalyst for the commencement of Case Management was to improve patient outcomes. This was brought on by an adverse complication suffered by a patient which resulted in substantially increasing this patient's length of stay.
Other reasons for the commencement included:
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According to Zander's definition, Case Management is a model of patient care delivery which restructures and streamlines the clinical production process so that it is outcome based (Zander 1988: 23). As a process Nursing Case Management mobilises, monitors and rationalises the resources that a patient uses over the course of an illness. In so doing, managed care aims at a controlled balance between quality and cost (Giuliano and Poirier, 1991: 52).
Giuliano and Poirier identified five objectives for Case Management. These have been adopted and modified by St. Vincent's, and are to;
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In Case Management the Nursing Unit Manager is responsible for managing the ward. Additional functions include;
This role is a new one. These registered nurses are Clinical Nurse Specialists and their job entails such functions as:-
All Case Managers have adjusted very well to their new role and have stated that they have learnt from the experience.
Registered Nurses, Enrolled Nurses and Trainee Enrolled Nurses
These nursing staff are still directly responsible for the delivery of patient care. They have been assigned to one of two groups since the start of Case Management. This means that the group cares for the patients from admission to discharge and therefore ensure continuity of care of the patient. These groups consult with the Case Manager about the patients' status. They are accountable to the Case Manager for the standard of care they deliver.
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When Case Management commenced in February 1992, we started with three groups each with a Case Manager and caring for a group of 12 patients. This proved to be unworkable as it required a larger nursing establishment than was available. The 36 patients were then grouped into two. Each group consists of 18 patients assigned three nursing staff each morning and evening shift plus a Case Manager for each group Monday to Friday morning shifts. This has proved to be more successful.
The implementation of Case Management was supported by both nursing and hospital management. The implementation was a special Nursing Quality Assurance project, which was facilitated by the Quality Assurance ADN who researched and prepared the documentation and devised a plan for the introduction, education, implementation and evaluation of Case Management.
Initially, there was some resistance from nursing staff to the idea of their team approach. There was also some resistance to the concept of Case Management by allied Health professionals but this was soon overcome by including them in decision making.
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Critical Pathways are the main "tools" of Case Management. They show the critical or key incidents that must occur in a predictable and timely fashion to achieve an appropriate length of stay. The key incidents of a critical pathway are categorised according to consults, diagnostic tests, activity, treatments, diet, medications, discharge planning and teaching (Woldum 1988: 1).
At St. Vincent's so far we have developed ten critical pathways for orthopaedic procedures for inpatient stay. We have developed these for the most commonly occurring patients diagnosis.
These critical pathways have been developed by a multi-disciplinary team consisting of: Community Liaison Clinical Nurse Consultant, Physiotherapist, Occupational Therapist, Social Worker, Nursing Unit Manager and Case Managers who have been meeting weekly. These critical pathways have been based on existing clinical protocols.
Attachment A is an example of a critical pathway for a Total Knee Replacement. The top of Page 1 gives the diagnosis or the procedure, the appropriate DRG and the average expected length of stay for the procedure at St. Vincent's Hospital.
The rest of the page is then divided into major events which are likely to happen within the patients' stay in hospital and on what days these may happen. As these events occur, a tick is placed in the appropriate column.
If patients stray from the critical pathways, for example, if a complication such as wound infection or pulmonary emboli develops or their recovery is slower than expected and events do not occur on the day they should, then this is called a variance and is coded on the variance chart - see Attachment B. As can be seen variances can be separated into four main categories and isolated to see if this particular area can be improved.
With the use of critical pathways, variances should be detected promptly and appropriate action taken. The critical pathway is individualised and is reviewed by the Case Manager and staff looking after the patient each 24 hours. The Case Manager signs the appropriate box everyday.
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Cahill 16 has been using Case Management for nine months. The system now requires evaluation. A Staff Satisfaction Survey has been developed and distributed to all Nursing staff as well as Allied Health and Doctors.
We intend to compare patient outcomes, that is, Falls, Pressure areas and Infection rates and to compare length of stay per DRG's for patient episodes before and after the implementation of Case Management.
The next step will be to ratify and implement the developed critical pathways. This will involve close collaboration with the six Visiting Medical Officers.
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Figure 1: Critical Pathway: Total Knee Replacement (Elective) (Page 1)
Figure 2: Critical Pathway: Total Knee Replacement (Elective) (Page 2)
Figure 3: Critical Pathway: Total Knee Replacement (Elective) (Page3)
Figure 4: Critical Pathway: Total Knee Replacement (Elective) (Page 4)
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