By: Shernaz Dossabhoy, MD, MBA
Team Members: Jocelyn Morta, NP, Carolyn King, RN; Lauran Miklosey, RN; Thelma Flores, RN; Tara Lahiji-Neary, MBA, Sudip Nag (ad-hoc PFP)
Team Sponsors: Ronald L. Dalman, MD and Sridhar Seshadri
As healthcare providers, one of our main goals is to provide quality care for our patients while minimizing their hospital stay. Length of stay (LOS) after a surgical procedure is a significant indicator of the quality of care provided. Shorter LOS has been associated with improved patient satisfaction and decreased healthcare costs. However, in April 2022, we were alerted to a change in our typical LOS metrics. Between Jan 1 and Dec 31, 2021, our institution experienced increased LOS rates for two types of vascular surgery procedures: asymptomatic carotid endarterectomy (CEA) and endovascular aortic aneurysm repair (EVAR).
We next began a several month-long deep dive into our data to better define and understand the problem. Our analysis showed that 67% of SHC patients who underwent asymptomatic CEA had a postoperative LOS >1 day, while 36% of patients undergoing EVAR had a postoperative LOS >2 days. These rates were above the regional and national benchmarks set by the Vascular Quality Initiative (VQI) and had increased from prior years at SHC. As a team, we recognized the need to address this problem and focused on reducing LOS for these two procedures to meet our quality standards.
One of the strengths of our team was our strong cohesiveness, which fostered an environment of open communication and idea sharing. Our group consisted of a resident, APP, nursing educator, patient care manager, and case manager, providing a diverse set of perspectives. We spent a significant amount of time analyzing the data from the past two years and reviewing the system breakdowns before implementing interventions.
During our analysis, we discovered a breakdown in the system that contributed to the increased LOS rates. We targeted these gaps and implemented interventions to improve discharge planning moving forward. However, what surprised us was that the data analysis for our most recent patients showed that our “problem” may have slowly fixed itself. Nevertheless, we continued to implement interventions to sustain this positive change.
Our weekly Friday team meetings kept us accountable, and each team member took the initiative to research and implement interventions after the team had discussed them. Below are some examples of the changes to the discharge planning process that our team implemented:
- Including an expected discharge time and date in the surgery scheduling letter that is mailed to patients ahead of surgery (similar to a “discharge appointment”)
- Instituting a discharge screening tool the morning of surgery and documenting the results in the patient’s Epic chart, allows all providers to see if there are potential barriers to discharge before surgery starts.
- Educating all key patient stakeholders including nurses, physicians, APPs, case managers, and PT on expected discharge procedures and length of stay.
Through these interventions, we were able to reduce the LOS for CEA and EVAR. Accordingly, the percent of patients with LOS >1 day for CEA decreased from 50% to 43%, and LOS >2 days for EVAR decreased from 26% to 0%.
In conclusion, our project aimed to reduce LOS for elective CEA and EVAR patients at our institution. We recognized the need to address this problem and worked together as a team to analyze the data, identify system breakdowns, and implement interventions to improve the discharge process for our patients and providers. Our efforts paid off, and we were able to sustain a positive change. As healthcare providers, it is important to monitor both our patient outcomes and existing systems and workflows to identify areas for future improvement.