Establishment of Nurse Case Manager Role in a Pediatric Orthopedic Team

Incorporating a nurse case manager (NCM) directly into a pediatric orthopedic department was implemented to address gaps in processes that had previously led to common delays in discharge planning. The orthopedic NCM works within an interdisciplinary team and provides guidance and support for both elective and emergent pediatric admissions. Applying continuous improvement techniques, the NCM role included the review of existing processes and determination of root causes of delays. This article describes some of the unique challenges and new processes included in the NCM role in the pediatric orthopedic setting, several solutions created and implemented to address identified delays, and statistical results of anticipatory discharge planning.

An NCM role was initiated in the orthopedic department at a quaternary-level freestanding pediatric hospital.

After interdisciplinary planning and implementation, the NCM role was established within the orthopedic department to facilitate timely, efficient, safe, and sustained discharges of patients. Success was realized through decreased denials and decreased number of avoidable inpatient days. Once rapport was established and streamlined work was developed, a retrospective review of length of stay was conducted to compare time periods prior to and after embedding this position. Changes in discharge planning processes positively affected the average length of stay for patients managed by the NCM. Cost savings are found in decreased avoidable inpatient days, decreased number of denials of inpatient medical necessity, and improved progression of care, which resulted in timely transitions and discharges. The effects of a consignment process and web-based ordering of durable medical equipment were also evaluated. Although this process in and of itself did not seem to impact length of stay, it did foster an improvement in team satisfaction around discharge readiness.

Pediatric orthopedic service teams benefit from the role of the NCM when there is interdisciplinary involvement and a focus on streamlining processes from preadmission through transition of care. Further study in a concurrent design will shed light on other factors that impact length of stay, such as specific diagnoses and medical complexity. Average length of stay is an effective metric for services with a high percentage of elective admissions but may not be as dependable for teams that do not have prescribed lengths of stay. Study with a specific focus around those factors that impact both team and family satisfaction is also indicated.