It’s a common but not required practice for hospitals to follow clinical pathways to standardize care, control cost and reduce variation in outcomes. Pathways are valuable because they contribute to consistent hospital performance, including meeting length of stay (LOS) and excess days recommendations.
Recognizing the value of pathways, Dell Children’s Medical Center of Central Texas created a collaborative process to standardize treatments through pathways, which led to successful management of LOS and excess days.
According to data in the Pediatric Health Information System® (PHIS), Dell Children’s is in the top five with the lowest percentage of excess days in 2018 for:
- Asthma
- Pneumonia
- Ear, nose and throat infections
- Gastrointenstinal
- Dehydration
- Cellulitis
- Seizure
Excess days can occur because of delays in testing or treatment, standard errors delaying discharge, incorrect coding or incomplete documentation. Hospitals use clinical documentation improvement and quality initiatives to standardize and streamline processes to ensure appropriate management and minimize the setbacks which lead to excess days of stay.
While some PHIS hospitals recorded as high as 50% for excess days with asthma cases, Dell Children’s had substantially lower asthma-related excess days at 0.4%. Here’s how PHIS showed the analysts where Dell Children’s compared.
Excess days defined
Here’s what goes into determining what qualifies as an excess day.
- An expected LOS is established based on the 3M APR DRG and the severity of illness system and national pediatric datasets.
- Any patient LOS past the expected LOS is considered an excess day.
Focus on managing treatments
When Dell Children’s decided to focus on asthma and bronchiolitis management, it involved all stakeholders to help support acceptance and adherence of changes or added practices.
A multidisciplinary workgroup of content experts, including representatives from quality, nursing, medical staff, respiratory therapy, pharmacy and education, met monthly. The group developed an order set, accompanying guidelines and a pathway to standardize key care steps for asthma and bronchiolitis patients.
Jorge Ganem, M.D., is a member of the Hospital Medicine group at Dell Children’s and works with the utilization review and readmission groups to identify ways to improve LOS and decrease excess days.
Understanding the structure of how an organization manages care is an important element to planning improvement.
“We are a team,” says Ganem. “Working together is critical to a successful improvement effort. We collaborated and standardized management of common conditions to decrease variation in outcomes, including LOS and excess days.”
Dell Children’s routinely reviews metrics for LOS, readmissions, delays in discharge and adherence to the pathway.
Positive results
Project management staff from the hospital’s Evidence-Based Outcomes Center supported the work to develop asthma and bronchiolitis pathways. They established a formal structure ensuring the workgroups had a clear scope, defined goals and used evidence-based literature to support the guidelines they developed.
Following the pathways contributed to successful alignment with excess days recommendations. Here's how Dell Children’s ranked against hospitals that participate in PHIS and Inpatient Essentials data comparison.
The asthma bronchiolitis group at Dell Children’s operates on a long-term basis. Members continually review best practices from literature, conferences and lectures, as well as hospital performance data.
“We look for opportunities to align our practice with evidence and decrease variability and then formalize the decision in a guideline or pathway,” says Teresa Stanley, D.N.P., RN, REBC, director, Quality and Patient Safety.
The Evidence-Based Outcomes Center leadership team and steering committee oversee the production of all evidence-based guidelines and pathways. Staff review guidelines every three years and suggest updates if new research emerges. Identification of new knowledge, operational issues or process barriers trigger the development of new guidelines or pathways.
