Nursing study focuses on at-risk patients
An advanced practice nursing program with a DM component has been shown to reduce the number of readmission hospital days for chronically critically ill patients, according to a recent study released by Case Western Reserve University in the American Journal of Critical Care.
The idea behind the program, which was funded by the National Institute of Nursing Research (one of the 27 Institutes and Centers at the National Institutes of Health) is to allow an individual advanced practice nurse (APN) to communicate with caregivers, physicians, and facilities; follow a chronically critically ill patient through the healthcare system; and serve as an advocate for the patient and caregiver.
“The number one cost of caring for these patients once they are discharged from their initial stay was readmission to the hospital,” says Sara L. Douglas, RN, PhD, who authored the study with Barbara J. Daly, RN, PhD, FAAN, at Case Western Reserve University in Cleveland. “If we can do something that can in some way reduce the cost of readmission we would have a significant impact.”
The study was the investigators’ third exploring the chronically critically ill patient population. The authors sought to determine whether the high costs of care and poor outcomes for patients who require prolonged mechanical ventilation and ICU stays could benefit from
a posthospital DM program. These patients are often some of the most complicated and costly cases in a healthcare system.
Douglas says chronically critically ill patients and their caregivers have specific needs that are often not met.
“We thought maybe we could apply some lessons learned from our in-hospital intervention study plus what we know about disease management programs and apply it to this patient population postdischarge,” says Douglas.
In what the study’s authors say is the first outpatient DM intervention in chronically critically ill patients with multiple comorbid conditions, Case Western Reserve University researchers found that establishing an advanced practice nursing program with a DM component for chronically critically ill patients reduces the number of readmission days for those patients readmitted to the hospital—though it didn’t provide overall cost savings for all patients who stayed in the ICU for prolonged periods of time. “We really felt that the communication and coordination activities of the advanced practice nurses were instrumental factors in reducing days of readmission,” says Douglas.
Clareen Wiencek, RN, ANP, along with Helen Foley, RN, took part as one of the intervention nurses. She says the study reinforced the need for communication to help caregivers and patients travel through a “fragmented” healthcare system, especially when chronic critical illness and prolonged dependency on technology and nursing care are involved.
The study found the DM program meant on average 5.77 fewer hospital days per patient following hospital readmission, a savings of nearly $20,000 per patient when using a mean hospital charge of $3,415 per day. If the savings are spread out over all 93 patients in the study who were readmitted, the total savings would have been more than $1.8 million, according to the study authors.
The cost of the program amounted to $486,442, which accounted for the two APNs and 25% of the project director’s salary and benefits.
The study included 335 intensive care patients who received more than three days of mechanical ventilation at University Hospitals of Cleveland. The majority of those who took part were older, female, and white.
The stress level is great for both high-risk patients and their caregivers, and Douglas says the reason some caregivers declined the service was because many felt overwhelmed and didn’t want any further burden.
“We provided a great deal of family support because so many times the patients weren’t able to interact or act as their own decision-maker. Thus, we helped the patients’ outcomes through the families,” says Wiencek.
The healthcare maze is often difficult to steer through for a patient or caregiver, which is complicated when a high-risk patient is involved. Many of the caregivers involved in the experimental group were elderly and found it difficult to handle care of a loved one.
“Families reported on a consistent basis the strong feeling of support when having advanced practice nurses advocate for them,” says Douglas.
“We helped the family member navigate the healthcare system. We were kind of their guide and helped them with their appointments, sometimes going with them to their physician appointments, reminded them what they had to talk about, and sometimes even helped them arrange transportation because getting to appointments was often an issue,” says Wiencek.
For those who agreed to take part, APNs provided an intervention that focused on case management and interdisciplinary communication for eight weeks after hospital discharge regardless of where the patient was residing (home, nursing home, etc.).
The nurse placed in charge of the individual patient provided guidance during the transition period between the hospital and postdischarge locations (80% of the experimental group and 73% of the control group were discharged to an extended care facility).
Those who were able to go home directly were younger and experienced fewer days of mechanical ventilation and fewer comorbid conditions before admission. Of the five independent variables included as covariates, the authors found the three significant contributions to death in the study were age, duration of mechanical ventilation, and diabetes.
For patients and caregivers, the nurses served as a healthcare expert, provided clinical experience in the care and management of the individual patients, and assisted as an advocate for the patient and caregiver.
Nurses made contact with the patients and their caregivers during hospitalization and helped prepare them for the next steps. They completed a thorough patient care summary that was forwarded to the next location. The summary provided details about the patient’s condition, stay in the ICU, medications, treatments, and goals and preferences.
Wiencek says discharge summaries, though sometimes written or dictated, are not always forwarded to the discharge facility in a timely manner and don’t provide the next facility with enough detailed information. This lack of timely information during high-risk transitions could place a chronically critically patient at risk, says Wiencek.
“By including details about the in-hospital stay in the patient care summary, we tried to give more richness and fullness than just the discharge orders would give,” says Wiencek.
Within 24 hours from hospital discharge, the APNs visited the patients in their new location. Douglas says this comforted the family and provided information about the patient’s health status to the care leaders in the new location. The nurses checked in at least once per week with the patients and caregivers.
“To see someone who you have seen in the hospital who knew your family member to show up in the nursing home was very comforting on that level,” says Douglas.
Having 30 years of experience as a critical care nurse and knowing the healthcare system for chronically critically ill patients allowed Wiencek to help families and caregivers navigate a complicated and often intimidating system.
“Most families of the chronically ill need help, especially if the patient has a prolonged hospitalization and continued dependence on nursing and medical care. Family caregivers relied on us as someone who they could call for support, for nursing advice, and for problem solving. Many people don’t have that, so you have people out there floundering on their own. When they flounder, it has the potential to have a bad outcome for the patient,” says Wiencek.
The majority of physicians and facilities accepted the APNs’ assistance in the patients’ care, but Wiencek says others were not receptive. It was possible, Wiencek says, that the facilities did not want the nurse case managers coming to their facility because they felt the program was too time-consuming, did not want to take part in a research project, or feared the nurses were there to keep tabs on them.
“If the receiving facility or physician could see that we could help them, we were not there to be a burden, and that we were there to help the care of the patient, then they really bought into it,” she says.
Although the authors found the program caused fewer hospital days via readmission, the study showed: nonsignificant differences between the experimental and control groups in the areas of survival rates after discharge, the patients’ health-related quality of life, and number of readmissions (29% of the experimental group and 24% of the control group were readmitted in the study period).
Douglas says chronically critically ill patients are complicated cases, and because of this, the authors were not able to see any cost savings for patients who stayed in the ICU for prolonged periods of time. Plus, the authors question the length of the study period (two months). In retrospect, Douglas believes the time frame should have been longer to better analyze the effect the program had in patient care in the long run.
The report was Douglas and Daly’s third study on critically ill patients. Douglas says that their other intervention studies examined the effect of a special care unit on in-hospital outcomes from 1991 to 1994, and the postdischarge outcomes and resource use of long-term ventilators from 1996 to 1999. The university received funding for the DM study from the National Institute of Nursing Research in 2000, and it performed the most recent study until 2004.
“We are doing further investigation to see if there are subgroups of chronically critically ill that benefited most from intervention and may consider examining an intervention that targets specific subgroups of chronically critically ill patients and their caregivers,” says Douglas.
To take part in the Case Western Reserve University advanced practice nursing program, the following was needed:
➤ More than three days of mechanical ventilation at a university medical center
➤ English comprehension
➤ No ventilator dependency before the index hospitalization
➤ Discharge location within 80 miles of the study site (for those patients who lived less than 30 miles away, nurses made personal visits; those who lived between 30–80 miles away were contacted by telephone)