3. 3
Advocate Lutheran General Hospital
3
638 – bed hospital
Level 1 Trauma Center
Tertiary care referral hospital
1,303 physician representing 51 specialties
and subspecialties
25 operating rooms / over 19,000 surgeries
per year
Part of Advocate Health Care, Illinois’ largest
health care system and one of the nation’s
top 10 health care systems
4. Client logo
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The main goal is to enhance value while achieving the
Triple Aim: a better patient experience, better health outcomes
and lower costs
What is the Main Goal?
5. Client logo
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Provide a portal of entry to perioperative care
Ensure continuity of coordinated care throughout the surgical experience
Reduce
• Cost of care
• LOS
• Complication rates
• Readmissions
Promote optimal patient safety
Standardization using evidence based practices and research
Improve the patient and caregiver experience and satisfaction
Provide quality and improvement measures demonstrating success and
outcomes
Specific Goals and Objectives
6. 6
Perioperative Surgical Home: Who, Where, When, How
6
Surgical
Home
Multi-
departmental
Initiative
Transform
Surgical Care
Developing a
Standardized
Set of
Evidenced
Based
Protocols
Continuity of
Care
Throughout
Surgical
Experience
8. 8
First Step: The Most Important One
8
Assemble anesthesia champions
Select 1 surgical service line
• High Cost / High Complexity / High Volume Procedure with ERAs protocol
• Enthusiastic surgeons
Obtain senior leadership support
• Allocate money and support personnel
Obtain benchmark data on performance
9. 9
Steering Committee
Project Team
Intra-op
Surgeon in
Chief
Post –Op
Post
Discharge
AHH and PAN
Surgeons
Lead
Anesthesiologist
Anesthesia
Ad HOC
Nutrition
Geriatric MD
Nursing Education
IT
Marketing
Pharmacy
Service
Physical
Therapist
Project
Manager
Pre-
Surgical
Testing
Research and
Quality
PACU
Finance
Administration
Care
Managers
Ostomy
RN
Hospitalists
10. 10
Next Steps
10
Interview Staff
Assemble
Steering Team
Gather
Literature
Collect Quality
Baseline Data
Gather List of
Protocols
Learn About
Current State
Develop New
Pathways
Trial and Carry
Out Plan and
New Pathways
Analyze Data
Finalize
Protocols and
Pathways
Roll Out New
Protocols
11. 11
Information Retrieval is Challenging
11
Information Needed: How Best To Obtain:
EHR Nomenclature to Schedule
Financial – Cost Per Case Hospital Financial System
ICD10
L.O.S. NSQIP Database
Quality
SSI
DVT
Crimson
NSQIP
HCAHP Press-Ganey/NRC
12. 12
Lean Methodology
12
Step 1
Step 5
Step 2
Step 3
Step 4
Step 6
Step 7
Step 8
Interview
Staff
Assemble
steering
team-
choose a
physician
leader for
each phase
and its
members
Gather
literature.
Collect
quality
baseline data
Observe
current state.
Value –
stream
Mapping.
Develop
protocols
and clinical
pathways
Collect list
of
protocols
for each
phase
Trial
protocols
And Clinical
Pathways
Step 9
Analyze the
pathways
and
protocols
and new
Workflows
and
handoffs.
Monitor
Data
Finalize
protocols,
processes
and clinical
pathways.
Develop
Physician
Scorecards
and
Colorectal
dashboard.
Plan +
Study
Step 10
Implement
finalized
processes
and clinical
pathways.
Finalize
physician
scorecards
and
dashboard
Act
• Carry our plan
• Document
observations
• Record data
• Analyze data
• Compare results to
predictions
• Summarize what was
learned
• Reason for action
• Current state
• Ideal state
• Gap analysis
• Causal Analysis
• Possible solution
•What
changes are
to be made?
•Next cycle?
Act
Plan
+
Do
Study
13. 13
How Did We Educate Ourselves?
13
ASA Learning
Collaborative
Networking
ERAS Project
Management
Group
Literature
Reviews
Attend
Conferences
14. 14
Bundled Payment Overview
14
Preoperative
• Patient
engagement
• Assessment
and triage
• Optimization
• Education
• Transitional
care planning
Intraoperative
• Multimodal
pain therapy
• GDFT
• Supply chain
• Operational
efficiencies
• Reduced
variations
Postoperative
• Right level of
care
• Integrated
pain
management
• Prevention of
complications
Long-Term
Recovery
• Coordination of
discharge plans
• Education of
patients and
caregivers
• Transition to
appropriate level
of care
• Rehabilitation and
return to function
Physician Director of Perioperative Services Surgical Home Leadership Management Team
Quality Improvement Health Care
Analytics
Human
Resources
Nursing Pharmacy Laboratory Radiology
Central
Supply
Information
Technology
Social
Services
Home
Health
ECF
Nutrition
PSH
Return to
PCP/Medical
Home
expectations
met
SUPPORTING MICROSYSTEMS
*Figure develop by Daniel J. Cole, M.D.
18. 18
Perioperative Optimization Clinic (POC)
18
Multidisciplinary Clinic:
“One Stop Shopping”
Concept
• Hospitalist
• Anesthesiologist
• Nurses
Additional Clinicians –
AD HOC
• Discharge
Consultant
• Nutritionist
• Skilled Nursing
Home Rep or Home
Health
• Ostomy Nurse
19. 19
Opportunities of the POC
19
Develop Preoperative Risk Assessment for all surgical patients
• Preoptimize patient 2-3 weeks before surgery
Serve as home base for patient and point of contact before and after
surgery
Allow for proactive planning for post-discharge and transitional care
• Active follow-up with high-risk patients
Patients will be well prepared for discharge before admission
Patients will be educated on postop expectations and their healing
process
20. 20
POC Requires Support From…
20
Goal is Standardization
Administration
Anesthesiologists
Primary Care MDs/Hospitalists
Surgeons (some)
Staff
Building
Blocks
21. 21
Anchors of Best Practice in Preoperative Preparation
21
• Benchmark cost/patient preparation <$50/patient
• RN’s is the POC manages patient preparation, education, and
clearance processes
• Charts completed at least 3-5 days prior to day of surgery
• Surgeon’s office supplies timely H&P, Orders, Consents and faxes to
POC
• Anesthesia assists in the POC with patient preparation/clearance
–Developing Preparation Algorithms
–Staffing POC most common only with physician-extender/hospitalist
(relationship)
• Seamless, efficient paperwork or use of IT system
22. 22
What Elements Are Needed to Create A Successful POC Center?
22
• Accurate surgical scheduling
• Immediate triage-as soon as patient scheduled for
surgery
• Pre-registration (telephone screen completed within 24-
48 hrs. of scheduling for surgery)
• Pre-op Order sets for surgeon and or anesthesia- future
orders completed for surgery
• History tool (more complete triage)
• Lab/EKG on-site
• Matrix for labs required for surgery
23. 23
What Elements Are Needed to Create A Successful POC Center?
23
• MD/DO Review of all abnormal tests
(Hospitalist/Anesthesiologist)
• Medications to hold with updated list (250 plus)
prior to surgery
• Communication with Primary and Surgeon’s
Office (after visit within 72 hours)
• Hospitalists/charge capture
• Tracking form for all patients- who were identified
as high risk
• Evening before phone call /scripted instructions-
automated reminders from APP
• Incomplete chart summary performed 2-3 days
before surgery
28. 28
ERAS (What)
28
A multimodal perioperative care pathway
designed to achieve early recovery for patients
undergoing major surgery by minimizing organ
dysfunction and reducing the profound stress
response brought on by surgery
29. 29
Components of ERAS for Colorectal
29
Education and
prehabilitation of
patient
Clear fluids and a
carbohydrate
beverage up to 2-3
hours prior to surgery
Narcotic sparing,
multimodal pain
therapy
Goal directed IV fluid
therapy - GDFT
Active intraoperative
warming
Routine administration
of prophylactic
antiemetic
Minimally invasive
surgical technique
No drains or
nasogastric tubes
Early ambulation and
enteral nutrition
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Intraop Anesthesia Protocols – Day of Surgery
Home
• NPO after midnight for solids and non-clear
liquids
• Clear liquids up to 4 hrs
• High carbohydrate up to 3hrs before surgery
POCU
• PO meds to be given 2 hrs before surgery
• Celecoxib 400mg PO (hold for epidurals or
impaired renal function)
• Pregabalin 75 mg PO
• Alvimopan 12mg PO (hold with opioid usage
of 7 days pre-op)
• Tylenol 1000mg PO
• Scopolamine patch for a PONV risk score of
3 or 4
• Avoid Versed and Scopolamine with positive
screen for delirium/frailty/falls
• Fluids – 1ml/kg/hr for laparoscopic;
3ml/kg/hr for open
• Epidurals – if ordered by surgeon it will be
placed in the OR
• T7-10 epidural for all left sided procedures
such as LAR
***Epidurals not indicated for right hemi-colectomies
***If in doubt, ask surgeon
32. 32
Intraop
32
Dexamethasone Fluids Ventilation Epidural Dosing Titrate Opioid
Administration
Toradol Ondansetron
8mg IV at induction
(4mg w/DM or
borderline DM)
Initial PIV on infusion
pump in POCU at
basal rate:
Aim to ventilate at
8ml/kg IBW
PF 1% Lidocaine –
5ml bolus dose 20
min prior to incision
to test placement
Minimize PONV Usual dose 30mg,
decrease to 15mg
with moderate kidney
disease
4mg at emergence
1ml/kg/hr for
laparoscopic cases;
3ml/kg/hr for open
cases
To assure analgesia
postop, dose
epidural intra-op
intermittently or at
conclusion of case
with 0.25%
Bupivacaine; or
initiate standard
infusion of 0.125%
Bupivacaine with
2mcg Fentanyl
Administer 30
minutes prior to end
of procedure
IV rate based on lean
body weight with
max of 80kg
Bolus dose may
result in a decrease
in SVR – treat with
vasopressors
Hold with epidural,
severe renal
impairment, Crohns,
Ulcerative Colitis
2nd PIV on Fluid
warmer to be used
for GDFT; place in
OR
Fluids 1mg/kg/hr in
PACU
33. 33
Goal Directed Fluid Therapy
33
Clearsite of Flo-
Trac used with all
major cases to
optimize fluid
administration
Wait 10-15
minutes following
epidural bolus,
abdominal
insufflation or
changes in patient
position to assure
SVV value is
stable and nor an
aberration
SVV Guided Fluid
Intervention:
•If SVV < 12% - Fluid
status stable; no
therapy indicated
•If SVV > 12% - Fluid
deficit vs SVR
decrease
•If fluid deficit – infuse
250-500 ml bolus of
crystalloid
•If SVR decrease –
administer
vacopressors
•Reassess status
every 15 minutes
Monitor SVV
trends
Factors that may
affect SVV
accuracy:
•Cardiac arrhythmias
(more than 4 times a
minute)
•Spontaneous
ventilation
•Change in intra-
abdominal/thoracic
pressures
•Frequent cardiac
arrhythmias negate
the use of Flo-Track /
Clearsite
34. 34
Post-Operative Delirium & Miscellaneous
34
Avoid Versed in patient who screen
positive for delirium/frailty/fall risk
Give muscle relaxant at beginning of
case and reverse at the end of case
with as little reversal as needed
OG tube removed at the end of the
case; no NG tubes
35. 35
Additional Intra-Op
35
Identified Colorectal anesthesia
and OR nursing team
Colorectal SSI Bundle – July 2014
• Sage wipes the night before surgery – full
body
• Sage wipes the morning of surgery – site
specific
• Dedicated closing tray and changing
gloves and gowns
• Maintenance of Normothermia
37. 37
Post-Op Protocols
37
No PICC line
delays – Patient
screened POD 1
to determine
PICC line
necessity
All ostomy
patients will be
seen on POD 1;
additional floor
nursing staff
trained to
educate patients
on ostomy care
PT – all
colorectal
patients will be
consulted on
POD 1
Activity and early
mobilization
Early feeding
and diet
Early removal
of Foley
catheter
Post-op
analgesia
Daily goals
developed for
patients
39. 39
Education Video Links and Patient Engagement
39
Build patients’
expectations and
prepare them for
entire surgical
experience
Can be viewed on
tablets
Provide
Education
Video Links
Twistle- used to
remind patients
pre-op and to
monitor and
surveillance
patients up to 30
days post
discharge
Patient
Technology
Engagement
App
40. 40
Twistle – Patient Engagement Platform (Pre and Post-Discharge Reminders)
40
Reminders Cadence
• Notifications 3 days
and 1 day before clinic
visit
• Pre-op reminders send
7 days before surgery
Reminder Content
• Stop taking blood
thinners
• Arrive to pre-op dept.
on 1st floor
• Bowel prep
instructional video
• SAGE wipes
instructional video
• NPO reminder
• Clearfast or G.E.D.
high carbohydrate drink
reminder
Post-Op Monitoring
• Sent daily questions for
the first 3-5 days up to
30 days post-discharge
-HIPPA compliant
-Patients can send
pictures
• Alerts RN or surgeon if
having any fever,
hydrating, visit from
Home Health RN
• Follow-up appointment
reminders for PCP and
surgeon
• Patient outcome
questions
42. 42
Post-Discharge
42
Developed hand-
off process
•Care management to home health
Identified 6
preferred PAN
SNF’s
Develop Protocols
for colorectal
patients
•Patients with colostomy, lleostomy, open incision, closed incision
In-services home
health staff and 6
SNF’s on the PSH
•Educated on ostomy care & protocols
Implementation of
Automated Patient
Engagement
System
44. 44
Preoperative Phase
44
Protocols / Clinical Care
Pathways
Current Standard of Care
(Before the PSH)
Perioperative Surgical Home
Patient Education No formal education provided to patients Videos and written education for patients – what to
expect during the entire surgical experience
Pre-operative Testing Lack of pre-operative testing Perioperative clinic visit – Rick reduction clinical with
lab testing and EKG testing.
Multi-disciplinary team (hospitalists, anesthesiologist,
RN)
Nutrition No nutritional screening Nutrition screening performed in PSH clinic.
Nutritionist is consulted
NPO Guidelines NPO for solids and liquids after midnight NPO for solids after midnight. Carbohydrate drink
taken 3 hours before surgery
Standardized Order Sets Lack or pre-op order sets Order sets of PONV, diabetes, VTE, pain
Risk Assessments Lack of assessments for co-morbidities Risk assessment screenings performed by
hospitalists for cardiac, pulmonary, delirium, frailty,
falls, OSA, nutrition
Pre-habilitation None Pre-screening for exercise, alcohol use and smoking
Automated Patient Reminder None Use for pre-op. Remind patient regarding bowel
prep, NPO, antibiotics, CHG bath, when to arrive to
POCU
Discharge Planning Delayed discharge planning.
Starts at admission to inpatient unit
Case manager consulted based on social screening
tool. Post discharge care identified (home with AHH
vs. SNF) Introduction to home health and agencies if
needed. Stoma teaching performed if needed.
45. 45
Intraoperative Phase
45
Protocols / Clinical Care
Pathways
Current Standard of Care
(Before the PSH)
Perioperative Surgical Home
Anesthesia Anesthetics and fluid management
based on individual anesthesia
providers preference
Standardized anesthesia protocols
– use of thoracic epidurals
Standardized goal directed therapy
protocols
Anesthesia Staff No dedicated team Dedicated OR Colorectal
Anesthesia team developed
Pain Management Opioids given Multi-modal pain protocols utilized
Equipment Equipment used per surgeon
preference
Standardized set-up
OR Nursing Staff No dedicated team Dedicated OR Colorectal team
developed
Surgical Site Infection
(SSI)
No formal protocol SSI Protocol developed. Separate
closing mayo utilized, gowns,
gloves, cautery and suction
changed
46. 46
Post-Op Phase
46
Protocols / Clinical Care
Pathways
Current Standard of Care
(Before the PSH)
Perioperative Surgical Home
Education Generic education provided to patient Specific post-op education developed for
Colorectal patients – video links for education
Pain Management Use of opioids and PCA Multimodal pain management protocols with an
emphasis on oral medication. Avoidance of
opioids
Nutrition / Diet Based on patient passing gas POD #0 – tea and coffee, POD #1 – full liquid for
breakfast and lunch, at dinner soft diet
Activity Up in chair POD #1 Up in chair POD #0, ambulation starting POD #1
Physical Therapy No standard protocol PT Consultation on all colorectal patients within
24 hours post-op
PICC Line Placement No standard protocol All ileostomy patients will have a PICC placed
within 48 hours post-op
Ostomy Education Patient may receive first education 1 week before
surgery and 48 hours post-op if available on the
weekend
Patient will receive first teaching in PSH clinic if
he/she is unable to meet ostomy RN. An RN on
the floor will be available to provide additional
education on the unit if needed before discharge
Discharge Planning Discharge plan developed POD #1 by care
manager. Updated / revised on POD #3 or when
patient is scheduled for discharge
Care manager and / or social worker meets with
patient daily. Disposition may change based on
patient status
47. 47
Post-Discharge Phase
47
Protocols / Clinical Care
Pathways
Current Standard of Care
(Before the PSH)
Perioperative Surgical Home
Automated patient reminder None To be re-activated when patient is
discharged from hospital
Education Lack of post discharge education for
patients
Written and video education materials
for patients – wound care, ostomy care,
nutrition and hydration, activity
Protocols of Care No standard protocols Hand-off form will be completed by care
manager. Form and protocols given to
home health or SNF
Pain Management No standard protocol Standardized pain management
protocol
Patient follow-up Follow-up with surgeon within 1-2
weeks
Follow-up with surgeon. RN phone call,
automated reminder calls with Twistle
48. 48
Perioperative Surgical Home Protocols
48
Each phase of care has a well-defined series of care elements and protocols- each with an
emphasis on patient centered care and shared decision making
Preoperative
Phase(Scheduling from
office & PST)
Postoperative Phase
(Phase 1 PACU, 7 Tele)
Post Discharge
Phase
(Home/Facility)
Intraoperative Phase
(POCU/MOR)
Education & Expectation Management
Skin Prep (SSI Bundle)
Identify Risk Factors
Bowel Prep
Anemia
evaluation/management
Lab orders
Nutrition
Pre-op Analgesia
MD preference lists
Early removal of NG tubes/catheters
Intraop Analgesia- Epidurals
Fluid Balance/Therapy
Transfusion Therapy
Nausea and vomiting control
Pain Management
Diabetes Optimization
Post-op Analgesia
PIC Line
Primary Care Follow-up
Prescriptions
Physical Therapy
Stoma Care
Visit by Care Coordinator
Home visit by Home Health
Early feedings /diet
Early Ambulation
Anesthesia clinical pathways Wound Care
Arrangements made for
SNF/LTC if needed
Standardize nursing care
Transition Phone Call Center
D/C of Antibiotics
Inclusion of Primary Med MD
Stoma Education
Chemical Prophylaxis
50. 50
Patient Satisfaction / Experience
50
Satisfaction has also increased, since implementing the PSH with support from the Patient
Engagement Technology support from Twistle. The following are a few of the questions that
were asked 30 days after discharge:
51. Client logo
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Get everyone’s feedback early on current state to understand where opportunities
and barriers exist
Difficult to collect baseline data; found in multiple places: Midas, Crimson and Cerner
• Procure data analyst to help with data collection and automate it
Handoffs missing from discharge to post-discharge
Inconsistencies in SNF ostomy care even after in-service by ostomy nurse
Difficult to ensure protocols are being followed with patients that transition to a non-
PAN SNF or a non-AHH. Care managers ensure the protocols are attached in EMR
If patient is discharged early, based on the ERAS protocols, he or she has higher
risk of readmission if patient is not managed properly post-discharge
Need to monitor patient 30,60 and 90 days post-discharge to determine if patient is
back to normal activity
Program is essential for bundled payments
****TIME
Lessons Learned and Barriers
54. Surgical Directions
541 N. Fairbanks Court
Suite 2740
Chicago, IL 60611
T 312.870.5600 F 312.870.5601
www.SurgicalDirections.com
Editor's Notes
LGH
Our story
Committee on future models of anesthesia practice
Project manager: perioperative RN, Lean/6sigma experience
Provides cost saving and quality improvement by coordinating care before, during, and after surgery.
Improves the patient experience by helping the patient share in decisions and navigate successfully through the complex perioperative care process.
It’s a physician-led model that encourages cooperation across specialty lines.
Encourages cost-efficient use of providers and support staff at all levels.
It works beyond the OR doors. It emphasizes "prehabilitation"--optimizing the patient's condition before surgery.
Works to reduce complications and readmissions by following up on the patient's progress during post-acute care--whether the patient is at home, in rehabilitation, or in a skilled nursing facility.
Stratify and manage patient populations according to acuity, comorbidities, and risk factors
Institutes prehabilitation interventions to optimize the patient before surgery
Achieves these goals by providing evidence-based clinical care
Manages, coordinates, and follows up on perioperative care across specialty lines
Improve performance and cost-efficiency through measured outcomes
Many definitions but they all describe the same concept
With the PSH, the care of the surgical patient is standardized thru a series of protocols which results in a decr in variability, redundancy, omissions
It’s this standardization of best practices that transforms care, leading to improved outcomes with decreased costs.
Sunny start here
Crimson is the name of the database
Networked to learn about surgical home; connected with other hospitals, articles; attending conferences focusing on colorectal and moving to same day joints, Whipple
Defines the perioperative home starting preoperatively to engage the patient and establish standards and make the transitional planning start at that point. Goal is to reduce variability as variability is what drops people from the benefit of the ERAS. Integrated pain management to avoid opioids. Coordinate discharge plans from the beginning; identify preferred nursing homes to develop and continue protocols, and ensure the transition at home to f/u with PCP for maintaining preoperative comorbidities.
Flo- 15 start here
**** Need a person to keep it together.
Need 3-4 anesthesiologists to share the work load of protocols, order sets and meetings
Younger members often more idealistic and enthusiastic
Most to gain (or lose) as HC evolves
Greatest impact with high complexity/high cost procedures
Fastest results with higher volume procedures
Once service lines are narrowed down, find corresponding ERAS protocols – many available in the anesthesia and surgical literature.
Last but not least, find a surgeon you can work with who will partner with you and handle their piece of the program.
Administrative support is key. There are countless studies and articles supporting the value of a PSH/ERAS program. I expect that most, if not all, are aware of the concept and are eager to find enthusiastic physicians to partner with.
Administrative endorsement may be needed to insure active participation of the various departments.
We were very lucky at LG, we had no resistance in pulling the team together. Staff was thrilled when presented with the PSH concept. At the front lines, they were all well aware of the current shortcomings in HC and eager to participate.
The hospitalist that we have partnered with along with the anesthesiologist has also developed the algorithms in clinic
19 tools and screens use in clinic
END- FLO
Sunny 30-35
FLO Start here
In 2015 we implemented 3 protocols where we saw an immediatel decrease in LOS as soon as they were implemented
PICC Lines, PT consultation and Ostomy education reinforecment. Immediately LOS went down by an average of 2 days from 6 to 4 days
WE developed these tools because we knew we needed to closely monitor and survellance our patients since they were leaving2-3 days sooner than average the year before.
Free App- patients are invited ether by the office or when they are scheduled for their POC visit
Develop protocols for colorectal patients
Patients with colostomy
Patients with Ileostomy
Patients with Open incision
Patients with Closed incision
In-serviced the Advocate home health staff and 6 SNF’s on the PSH
Educated on ostomy care
Educated on protocols
Implementation of Automated Patient Engagement system- pending with SNF’s and Home health agencies
FLO END HERE
Sunny- when we starting building the project in Dec of 2014 we thought we would be implemented by April 2015- 4 months.
It took actually a total of 15 months to build the project becase of the time, training and commitment
