I am joined this month by Anne Beekman, RN, BSN, NEC, who leads the Terumo Business Edge Care Pathway team, and Dr. José Alfredo Merino Rajme, Hospital Director, ISSSTE Centro Medico Nacional 20 de Noviembre of Mexico City, Mexico. In the latter half of 2018, we were approached by Terumo Mexico to see whether we could provide our care pathway services for one of their customers. The Care Pathway team, led by Anne Beekman, traveled to Mexico City in January to begin the project. I am very pleased that the successes we have seen in the U.S. were recognized as valuable to another healthcare system. Seven months later, we can appreciate the evolution of an active same-day discharge program that is bringing tremendous value to this institute. Thanks to visionaries like Dr. Merino, his goals of bringing improved processes for delivery of care to his patients and the people of Mexico City are being realized. — Gary Clifton, Vice President, Terumo Business Edge
What led to Terumo Business Edge partnering with Dr. Merino and the Mexico Heart Team to review the same-day discharge potential at their institute in Mexico City?
Anne Beekman, RN, BSN, NEC, Senior Manager, Care Pathway Solutions: The relationship started as a basic conversation after the release of the revised Society for Cardiovascular Angiography and Interventions (SCAI) criteria on same-day discharge.1,2 SCAI is an international group, so the question was, how would same-day discharge play out for hospitals in other countries? Dr. Merino and his colleagues were a natural choice to institute same-day discharge, as their program is a guideline-driven program that already had a strong radial platform. The purpose of our working together was to understand the clinical, financial, and operational benefits a same-day discharge program could bring to their program. In addition, we were curious as to whether a different healthcare environment with different community needs and cost structure would experience the same challenges and frustrations we have in the U.S. with same-day discharge.
Dr. Merino, can you tell us about your program and your role at as a hospital director at 20 de Noviembre Hospital?
Dr. José Alfredo Merino Rajme, Hospital Director, ISSSTE Centro Medico Nacional 20 de Noviembre: Our medical center is the second largest hospital in the country. It covers 13 million people and ischemic heart disease is present in half of our consulting patients. As the director of the medical center, I am aware of cutting-edge advances in processes around length of stay, and in making our resources available for renewal and not budgeting for resources that may not materialize. My role is unique in that I work closely with the government, and manage capital resources and budgets for the program. In addition, my role as leader of the Mexico Heart Team is to integrate multidisciplinary teams that enhance the use of technologies and process reengineering.
After establishing mutual interest in pursuing a project to establish a same-day discharge program, how did the work progress?
Anne Beekman: We started our work in what I would consider a traditional process design fashion. Members of Terumo Business Edge arrived on site with the intent of spending four days to map the process and identify the necessary implementation elements. We then proceeded to interview key stakeholders and built a business case. The need for same-day discharge in the U.S. arises out of a compelling financial driver; in contrast, the Mexico Heart Team was looking to streamline the process to promote access for their community. Prior to coming on site, the program had submitted excellent operational data, so we knew generating metrics would be relatively easy. The unique process of patient intake and how the patient moves through the system presented some challenges that are not typical for a U.S. facility. For this reason, we spent extra time understanding not only the administrative process, but also the dynamics of how the patient interacts with the various medical consultants prior to being considered for a heart cath.
Dr. Merino, now that you have a pilot process in place, what results are you seeing?
Dr. Merino: We have piloted the same-day discharge process for 12 weeks and the results have been highly satisfactory. Over the 12 weeks, we kept a record of 41 patients who went through the same-day discharge pilot program. Patients had an average length of stay of 11 hours (minimum 8 hrs — maximum 12 hrs). All have been radial access patients. Three patients fell off the same-day discharge screening guidelines and were hospitalized for some type of complication; all three were in hospital for two nights. The success rate of the same-day discharge pilot is currently at 93%. This is measured by the patients that were screened according to the SCAI criteria. No patient has had a fatal event. The process tends to be facilitated by radial access; however, we had 8 patients whose puncture was femoral. We have been able to provide same-day discharge for these patients in the same safe, cost-effective fashion. If we take into account that according to official figures, our day-bed costs are US $375 per night, we are talking about an impact of saving US $28,500 for the 38 patients who successfully graduated from the same-day discharge program. Economics may not be as pressing of a driver for same-day discharge, as it is in the U.S., but it is still an important metric to report.
When you compare the process for implementation of same-day discharge between the U.S. and Mexico, what similarities and differences did you notice?
Anne Beekman: All the physicians I work with, both in Mexico and in the U.S., put safety and quality first. This statement is used all the time. The physicians are all data-driven and are more likely to adjust the process if they are provided with trusted data. I have found this to be a common attribute, regardless of location. Applying the SCAI criteria works well in both countries. Some unique differences between implementing SDD in the U.S. and Mexico that I experienced were:
- Physicians in Mexico have a better understanding, transparency, and greater responsibility for resources.
- Physicians in the U.S. have more quality and registry data to drive decisions.
- 100% of the physicians at Mexico Heart Team participated in the same-day discharge pilot.
Overall, we found process design from a clinical perspective to be quite similar. The real differences were market-specific, such as motivating factors, access to data and incentives.
Dr. Merino, getting 100 percent participation from practitioners in same-day discharge is a difficult task in many U.S. programs. How did you achieve this?
Dr. Merino: The doctors who have benefited from the process adopted it quickly and efficiently, and have adapted. As evidence of this, we know that the two high cardiology specialties work as a team: interventional cardiology and electrophysiology. I invited and had participation from all cardiologists in designing the same-day discharge process. This allowed us to grow a same-day discharge pathway for percutaneous coronary intervention (PCI) and devices. The Heart Team Mexico used the SCAI guidelines to create and support clinical documents and guidelines to help practicing physicians optimize patient care in the same-day discharge program. In addition, patients are provided a quality survey that contemplates three spheres: infrastructure, processes, and results. The average rating of our patients has been 3.3 out of 4 stars. This gives us an opportunity for improvement. That is my permanent agreement with the Heart Team, to obtain diagnoses of improvement opportunities, so we carry out evaluations of the quality of the granted process.
Any closing remarks?
Anne Beekman: A few components added to the scope included creating a radial lounge, which went from concept to open for business in a few months, as well as generating a quality report. Figure 1 is an example of a trend looking at co-morbidities and same-day discharge percentages the team is tracking. The same-day discharge program tracks several demographic and risk metrics to better understand their same-day discharge opportunity. The Mexico Heart Team also provided a skilled process design individual to work closely with the local Terumo team to support the pilot program. The work done in Mexico City highlights that a safe, high quality same-day discharge program requires physician leadership and a team commitment.
Dr. Merino: The search for universal health coverage is a commitment of almost all the countries of the Americas; it is a wave that travels throughout the continent and the entire world. I, as director of a National Medical Center, am convinced and therefore, to some extent, obliged to contribute with processes that help us achieve this objective.
- Seto AH, Shroff A, Abu-Fadel M, et al. Length of stay following percutaneous coronary intervention: An expert consensus document update from the society for cardiovascular angiography and interventions. Catheter Cardiovasc Interv. 2018 Apr 24. doi: 10.1002/ccd.27637.
- Seto AH, Clifton G. SCAI expert consensus document supports decreased length of stay for PCI. Cath Lab Digest. 2018 Jun; 26(6): 14-15. Available online at https://www.cathlabdigest.com/content/scai-expert-consensus-document-supports-decreased-length-stay-pci. Accessed August 19, 2019.