C O L L A B O R A T I V E C A SE
The Power of Partnerships: Employing a Multidisciplinary Approach to Reduce
Neurosurgery Length of Stay
By L. Ann Teske, MS, RN
Within healthcare institutions there can be a variety of motivators for organizational improvement. Perhaps the most compelling indicator
of an organization’s need for improvement is national benchmarking data and metrics comparing the organization to like institutions. Such
data and information can serve as a strong indicator of an organization’s effectiveness, or may highlight opportunities for changes and
updates to current processes and routine procedures.
In 2007, the Clinical Case Management Department at Ben
Taub General Hospital (BTGH), part of Harris County Hospital
District (HCHD) in Houston, TX, noticed patients on the
neurosurgery service stayed in the hospital an average of 19 days.
According to national benchmarks, the average length of stay
(LOS) for hospitalized patients on a neurosurgery service was
approximately 12 days.1 This seven-day difference represented
significant cost and fiscal risk for the hospital. The realization that
BTGH was recording LOS well above the national average drove
the organization’s clinical case management department to
develop effective solutions to decrease LOS.
The Neurosurgical Intensive Care Unit
BTGH is a 650-licensed bed Level I Trauma Center. BTGH is
considered to be one of the busiest trauma centers in the U.S.,
with more than 108,000 patients seen each year. The Neurosurgery
Intensive Care Unit (Neuro ICU) is a 16-bed unit caring for
patients with traumatic brain injuries, gunshot wounds, strokes,
and other neurologically devastating conditions. In 2008, 547
patients were admitted to the Neuro ICU.
Identified Problem
After finding that the Neuro ICU experienced an LOS
significantly higher than the national benchmark, the clinical
case management, neurosurgery, and nursing leadership met to
develop strategies to reduce the LOS on the service. During the
discussion, the leadership team identified the following
opportunities for improvement:
• Hospital leadership was not visible during neurosurgery
team rounds, creating the perception that hospital
administration was not concerned about reducing the high LOS
• Physical therapy did not receive referrals to assess patient
needs early in the hospital stay
• Consistent, interdisciplinary collaboration was not evident
on the unit
Interventions
To address these concerns, the care team made the decision to
increase hospital administration visibility, increase the number of
patients assessed by physical therapy within 24 hours of admission
M A N A G E M EN T
to the Neuro ICU, and increase interdisciplinary collaboration.
The goal of increasing interdisciplinary collaboration was a
key intervention identified by the care team. At BTGH, the
rounding team was initially composed of nurses, nurse case
managers, the attending physician, the medical director of the
Neuro ICU, the director of clinical case management, and any other
physicians involved in the patient’s plan of care. In order to help
increase interdisciplinary collaboration, BTGH’s nursing leadership
made the decision to invite a multidisciplinary team of specialists
to join the existing rounding team. This multidisciplinary team
included the organization’s physical therapist, nutritionist, and
trauma outcome manager. Soon the organization’s wound-ostomy
case manager, diabetes case manager, and occupational therapist
would also elect to join the rounding team. The fact that BTGH’s
average LOS fell well above the national average helped orient
and motivate these various disciplines within the care team
toward the common cause of reducing LOS.
Within HCHD, a district wide-communication tool was also
employed, known as the Situation, Background, Assessment,
and Recommendation (SBAR) communication framework. By
using the SBAR, each patient’s plan of care is discussed by the
entire rounding team – each member of the team provides input
during this process and weighs in on the patient’s plan of care.
Through the use of the SBAR, any concerns regarding the 25-30
additional neurosurgery patients recovering on other nursing units
are also discussed. The rounding team then follows-up on all
concerns identified.
Physical Therapy/Occupational Therapy Services
Occupational and physical therapy services noticed that Neuro
ICU patients were generally referred to physical therapy services
one to two weeks after admission. By the time of referral, patients
have often developed contractures and a decrease in strength and
mobility. The director of clinical case management and the
manager of rehabilitation services worked collaboratively to assess
processes and barriers preventing earlier assessment, with the goal
of increasing the number of patients assessed by physical therapy
within 24 hours of admission. A physical therapist also began to
attend the weekly morning rounds and work with the rounding
team to encourage referrals of appropriate patients. This strategy
created closer communications and more immediate referrals, and
also assisted the rounding team to develop skills to identify physical
continued on page 11
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 w w w . a c m a w e b . o r g

The Power of Partnerships (continued from page 10)

therapy needs in the overall plan of care for the patient. As a result,
Percentage of Neuro ICU Patients with currently all Neuro ICU patients are assessed by physical therapy
Hospital-Acquired Pressure Ulcers (HAP) within 24 hours of admission and documentation of the treatment
plan. A further benefit has been that, by evaluating patients on the
30%
day of admission, the rounding team is able to develop plans for
25% patients who are likely candidates for post-acute care.

20% Wound-Ostomy Care Services

Recently, the National Pressure Ulcer Advisory Panel (NPUAP)
15% reported a rise in incidence and prevalence of hospital-acquired
pressure ulcers, resulting in a significant impact on the cost of
10%
healthcare.2 Effective October 1, 2008, the Centers for Medicare
5%
and Medicaid Services (CMS) will no longer reimburse facilities for
hospital-acquired stage III and IV pressure ulcers.3 Hence, when the
0% wound-ostomy case manager joined the rounding team and
4 Qt. 07 1 Qt. 08 2 Qt. 08 3 Qt. 08 4 Qt. 08 explained the statistics, the physicians and nurses worked quickly
to develop appropriate interventions to prevent and treat skin
Table 1 complications. Bedside discussions, linen layers on bed surfaces,
turning schedules, moisture barriers, creams, positioning devices,
Average Length of Stay 8 and aggressive nutritional interventions were implemented –
25
incorporating several members of the rounding team. Consults
with the wound-ostomy case manager reduced delays in initiation
20
of treatment and the need to use unnecessary supplies. As
15 evidenced in Table 1, implementation of wound-ostomy care
Days

services on multidisciplinary rounds helped drastically reduce

10
pressure ulcer incident rates in the Neuro ICU.
5

0 Nutritional Services
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Medical evidence demonstrates that initiation of enteral
Month nutrition within 48 hours is vital for those with traumatic brain
2007 2008 20098
injury (TBI). Early TBI intervention benefits include: decreased
Figure A inflammatory response, decreased ICU infections, and improved
neurological outcomes at three months.4
Neuro ICU Average Length of Stay for 2007, 2008 & 20098 Prior to the team focus on Neuro ICU LOS, nutrition
recommendations were written in the progress notes section of the
Month 2007 2008 2009
patient’s medical record. All too often, the notes were overlooked by
January 19.35 9.91 14.1 the interdisciplinary team. When the nutritionists joined the
February 15.64 11.26 10.92 rounding team, communication improved between physicians,
March 17.07 9.25 9.38 nurses, and nutritionists. The increased visibility of the nutritionist
April 15.89 10.04 9.73
on the rounding team also led to increased trust, understanding,
May 17.98 9.7 12.33
June 13.85 13.26 9.2
and acceptance of recommendations by the nutritionist. Once the
July 13.34 12.18 – nutritionist team began writing in the order section of the patient’s
August 15.25 15.06 – medical record and obtained a physician signature, the turnaround
September 15.92 12.39 – time of nutritionist recommendations acknowledged by physicians
October 14.19 12.76 –
went down from over 24 hours to less than 12 hours.
November 13.49 10.18 –
December 10.67 9.24 –
Diabetes Case Management Services
Approximately 50% of HCHD patients are diagnosed with
Table 2 diabetes mellitus. Thus, the issues of diabetes prevalence and

continued on page 12

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 C O L L A B O R A T I V E C A SE M A N A G E M EN T

The Power of Partnerships (continued from page 11)

disease management are important initiatives for HCHD.
Additionally, effective October 1, 2008 CMS no longer reimburses
a facility if hospital-acquired poor blood glucose control results
in either increased cost of care and/or prolonged hospital stay.5
At BTGH, “Neuro ICU patients frequently presented in a
hyperglycemic state.”6 These patients were either heavily sedated or
recovering from serious neurological insult and often were unable
to exhibit early warning signs customarily associated with
hyperglycemia. In addition, patients on extended periods of
nothing by mouth (NPO) and bed rest made glycemic control
even more difficult.
Recognizing the importance of blood glucose control, the
diabetes case manager joined the core team in multidisciplinary
rounds. In doing so, the goals for the diabetes case manager were
to raise physician awareness of glucose levels in this patient
population, maintain glycemic control, improve patient
outcomes, and decrease LOS.7 To further address this issue, an insulin
drip order set was piloted in the Neuro ICU with encouraging results.
of 19 days. As shown in Table 2 and Figure B (Page 11), this has been
a process of continual improvement.
As a result of the initiatives implemented at BTGH, a
partnership was developed amongst a variety of disciplines
within the organization, which allowed the care team to
collaboratively assess barriers that could be removed in order
to effectively decrease LOS and improve overall patient care
and outcomes.
L. Ann Teske, MS, RN, has been the Director of Clinical Case
Management at the Harris County Hospital District in Houston, TX
for four years. Her healthcare experience includes leadership
positions as a clinical practitioner, educator, consultant, researcher,
and administrator. She earned her BS in Community and Human
Services from The State University of New York in Albany, NY, and her
MS in Nursing Administration, with a concentration in Managed
Care for High Risk Populations, from St. John Fisher College in
Rochester, NY.

Care for a Challenging Demographic: Contributors

Addressing Psychosocial Issues Zenaida Alabbasi, MBA/HCM, BSN, RN
The majority of patients at BTGH share one or more of
Ruben Ceron, BSN
the following characteristics: recent immigrants to the U.S.,
undocumented status, comparatively low socio-economic Sulata Daniel, BSN
level, language barriers, lack of understanding or trust in Nancy DuFrane, RN, MSN, MPH, FNP-C
healthcare, and lack of prior access to consistent, formal
Dora Glaser, PT
healthcare. Many of these patients are also unemployed, and
live at or below the poverty level. Consequently, these patients face Shanker Gopinath, MD
a number of internal and external challenges in their attempts to Leela J. Joseph, MHA, RN, BSN, CCRN, CNRN
achieve optimal health and well-being. Additionally, many of the
Tina Meyers, BSN, CWOCN, ACHRN
patients do not routinely seek healthcare or receive standard
disease management, and when they present at the hospital; they Claudia S. Robertson, MD
typically maintain a poor nutritional status, reach advanced stages Dana Wilson, RD, LD
of illness, and often experience complications due to
co-morbidities associated with chronic illnesses. References
Such specific issues and needs are identified and 1
2007 – 2008 National Database for Nursing Quality Indicators (NDNQI).
addressed early in the patient’s hospital stay in order to decrease
2
their effect on the patient’s overall LOS. Following each week’s National Pressure Ulcer Advisory Panel (NPUAP), 2007.
round, BTGH’s nurse case managers confer with two of the 3
Centers for Medicare and Medicaid Services (CMS), 2007.
organization’s social workers regarding the patient’s plan of 4
Weissman, C, 1999. “Nutrition in the intensive care unit.” Critical Care, 1999,
care, and any specific needs or issues that must be addressed. 3: R67-R75.
Family meetings are also held early in the patient’s hospital stay, 5
United States Department of Health and Human Services (HHS), 2008.
and serve to foster trust, communication, and relationships 6
Weiner RS, Weiner DC, Larson RJ. “Benefits and risks of tight glycemic
between patients, families, and hospital staff. control in critically ill adults: a meta-analysts.” JAMA; 2008; 300(8): 933-944.
7
Angus DC, Abraham E. “Intensive Insulin Therapy in critical illness: when is
Overall Findings evidence enough?” American Journal of Respiratory and Critical Care
Today, the average LOS on the neurosurgery service is Medicine; 2005; 172: 1358-1359.
approximately nine days, well under the national benchmark 8
Monthly Statistic Report, Harris County Hospital District Financial Planning
of 12 days, and a vast improvement from the previous average and Budgets Department, 2007-2009.

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