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THE PATIENT ADVANTAGE | NEW ALBANY, OHIO
Optimizing the TJR Patient Experience in the ASC Setting
August 18, 2017
DSUS/INS/1116/2301c
THE PATIENT ADVANTAGE | NEW ALBANY, OHIO
Mark Gittins, DO, FAOAO
OrthoNeuro
Diane Doucette, RN, ONC, MBA
President of Mt Carmel New Albany Surgical Hospital
The New Albany JourneyA 12 YEAR JOURNEY
Corn ASCHospital
The New Albany JourneyA 12 YEAR JOURNEY
2003Hospital Built
2011ASC Built
2012ASC Open
2016
MCNA Hospital• 42-bed specialty hospital built in 2004
• For-profit, physician-owned New Albany Surgical Hospital
• Expanded from 42 inpatient beds to 60, accounting for more than 90,000 patient days
• Ranked among top 10 of ALL HOSPITALS for procedural volume of THA & TKA in U.S.
• December 2006: New Albany Surgical Hospital is sold to Mt. Carmel Health System and converted to non-profit
MCNA Hospital
OUTCOMES• Been recognized as a Top
Hospital for Safety and Quality by the Leapfrog Group
• Successfully passed 5 Joint Commission Surveys
• Achieved and Maintained Disease Specific Certification for Total Knee Replacement, Total Hip Replacement and Spinal Fusion
RECOGNITION
PATIENT EXPERIENCE• Won 11 consecutive Press
Ganey Inpatient Satisfaction Awards – every year of eligibility
• Most recent physician satisfaction survey indicates that 92% of physicians practicing at MCNA are “Dedicated Partners” with high satisfaction and high engagement
MCNA Hospital
• Patient and Family First
• Team work/recognition
• Triad Alignment
• Data guided decisions
CRITICAL SUCCESS FACTORS
Development of the Orthopedic Team
• Orthopedic Physician Triad– Surgeon, Internist or Hospitalist, Anesthesiologist
• Dedicated Staff– Pre-Admission Testing Nurse
– Pre-operative Block Team (Pre-op Nurses and Anesthesia)
– Orthopedic Service Line Leaders
– Orthopedic OR Coordinator (Materials and Staffing)
– Operating Room Team: RN, ST, OA, and Physician Assistant
– Inpatient Nursing Unit: Dedicated Nursing, Physical Therapy and Case Management
Development of the OP Orthopedic Team
• Orthopedic Physician Triad– Surgeon, Medical Clearance, Anesthesiologist
• Dedicated Staff– ASC Clinical Staff
• Multi-skilled in PAT, Pre-Op PACU and Discharge Planning
• OR Team – Multi-skilled RN, Scrub Tech, Central Sterile and Supply Chain
• Anesthesia
• Medical Clearance Physician
• Home Health Staff– Nursing
– Physical Therapy
Break ground on free-standing ASC next to hospital
First cases performed (no total joints)
First total joints at ASC - Uni knees
40 totals performed at ASC
117 totals performed at ASC
ASC Journey
200 totals performed thru July
2010 2011 2012 2013 2014 2015
Health Care is Changing
• Affordable Care Act
• Loss of autonomy
• Decreased reimbursement
• Loss of ancillary revenue
• ICD 10
• Mergers and acquisitions1. http://www.beckersasc.com/asc-turnarounds-ideas-to-improve-performance/physician-employment-vs-private-practice-14-statistics-on-pay-satisfaction-more.html
50% residents & fellows seek
salaried employment
More emphasis on quality metrics & outcomesMoving toward shared risk contracts and capitation models
Impact of the Affordable Care Act (2010)
Payment reform is accelerating the pace of change.Shifting from volume based payments to value based payments
13
Bundled Payment for Care
Improvement
(Voluntary)
BPCI
Comprehensive Care for Joint Replacement
(Mandatory)
CJR
Hospital Readmission
Reduction Program
HRRP
Hospital Acquired Conditions
HAC
Value Based Purchasing
VBP
Medicare Quality Initiatives (Every Hospital)
Bundled Payments (Select Hospitals)
Bundled Pay for AMI and CABG procedures
(Mandatory)
Hip FxAMI + CABG
$$$
$$
$
$
Fee-For-Service Bundled Payment
Payment for each service regardless of quantity or quality Payment for comprehensive, coordinated intervention
Vs.
Bundled Payment - Overview
Pre-Admission
Services
Part A Inpatient
Services (Hospital)
Part B Inpatient
Services (MDs)
Post-Acute Costs
(Part A & Part B)Readmissionshttp://innovation.cms.gov/initiatives/bundled-payments
Identified Opportunities for EfficienciesPATIENT THROUGHPUT DRIVERS
Patient Type1
Department1
Patient Type2
Patient Type3
Department2
Department3
Physician Practices
• Physician Triad• Scope of practice• Evidence-based
medicine (clinical guidelines/order sets/care protocols)
• Physician preference items
• Physician outreach
• Interdisciplinary rounding
• Quality initiatives• Teaching/research
responsibilities• On-call coverage
Workflow/ Processes
• Time Stamped Workflow
• Standardization• Resource
optimization• Outcome
variability• Waste/process
inefficiency• Interdepartmental
service level expectations
• Supply chain• Quality/patient
safety surveillance• Patient “pull”
mechanisms
Staff Effectiveness
• Communication• Skill
mix/Productivity• Staffing to
demand/ flexible staffing
• Training/continuing education
• Service Excellence
• Service Recovery• Clinical pathways• Continuous
performance improvement culture
• Unit of measures development
Patient/Family Engagement
• Care planning/ coordination
• Educational Binder depicting pre and post op care for 6 weeks
• DVD educational video of entire length of stay
• Communication• Patient access• Patient financial
services• Scripting• Contact point
person listed for financial and discharge planning
Service Utilization
• Room/bed occupancy
• Dedicated EVS pre inpatient unit
• Capacity management
• Surge protocols• Room turnover
performed by OR Team
• Physical layout/ configuration
• Scheduling • Demand
management
IT Systems Capability
• Tracking of time stamps
• CPOE/results reporting
• Decision support• Real-time
monitoring/alerts• Reporting/analytic
s• End-user access/
mobility solutions• Workflow
integration/ automation
• Bar coding• Telecom devices• System uptime/
performance
Functional Area
Patient Encounter
Throughput Improvement Opportunities
Elements of the Patient Experience
PRE-
ENCOUNTER
ARRIVAL/
CHECK-INCARE
INITIATION
CARE
DELIVERY
CARE
ASSESSMENT
DEPARTURE/
CHECK-OUT
POST-
ENCOUNTER
CARE
COORDINATION/
SUPPORT
PATIENT
CARE
ENCOUNTER
Pre-Encounter
• Provider to Provider
interface (e.g.,
Hospital to Clinic)
• Referral
management
• Scheduling
• Pre-registration
• Clinical history/
information capture
• Financial counseling
• Patient instructions/
expectations
Arrival/
Check-in
• Drop-off/greeting
• Wayfinding/
orientation
• Visitor identity
management
• Patient needs
accommodation
• Registration/
admission
• Check-in at POS
• Consent for Service
• Co-pay collection
Care Initiation
• Patient placement
• Patient interview &
intake (H&P)
• Patient preparation/
assessment/triage
• Provider notification
• Care protocols
• Discharge planning
• Medication
reconciliation
• Rounding
Care Coordination/
Support
• Clinical and non-
clinical support
coordination
• Multidisciplinary
communication and
information sharing
• Case management
• Supply chain
management
• Patient satisfaction
monitoring
Care Assessment
• Health status and
treatment efficacy
evaluation
• Results review
• Patient and family
education
Departure/
Check-Out
• Transfer of care
arrangements
• Follow-up
appointment
scheduling
• Co-pay collection
• Urgent consultations
• Prescriptions
• Patient escort to
point of departure
• Room turnover
Post-Encounter
• Provider to Provider
interface (e.g.,
Hospital to Clinic)
•Clinical information/
results reporting
•Patient follow-up
communication
•Medical records/
coding
•Billing/collections
•Patient monitoring
•Education and
research visits
Care Delivery
• Physician
consultation/orders
• Diagnostic services
• Treatment/
procedural services
• Medication
management
• Pain management
• Clinical information
capture/
documentation
• Nurse charting
• Charge capturePatient Care Encounter
Key Drivers of Efficiency
To identify opportunities aimed at optimizing patient throughput, we should assess current performance according to six key drivers of patient throughput. Our experience has shown that by targeting focused patient throughput drivers, hospitals can rapidly achieve significant improvement in patient flow and service excellence.
Patient Throughput
Optimization
Physician Practices
Workflow/Processes
Staff Effectiveness
Patient/Family Engagement
Service Utilization
IT Systems Capability
Outcomes of Hospital Efficiency
• Increased patient and family satisfaction due to a clear understanding of expectations.
• Increased physician satisfaction due to Physicians not having to train new employees on a daily basis.
• Increased employee satisfaction due to standardization of care and understanding the expectations of Team!
www.caresense.com
Touch Screen Data Collection
Email Surveys/EMR Integration
Outcomes data
• 100+ standard surveys over all specialties
• Collect custom questions
• Conduct research
• Benchmark results
• Use with payors
• Improve quality of care
Patient Satisfaction
• Realtime results
• Immediately address patient dissatisfaction
• Improve HCAHPS scores
• Collect thousands of forms anonymously at checkout
• Improve satisfaction
Outpatient TJA:
• Why for patient
• Why for surgeon
• Why for healthcare
Why are patients staying in a hospital?
FEAR• Unknown
• Pain
RISKS• Co-morbidities
• Medical Complications
SIDE EFFECTS OF TREATMENT• Narcotics/Anesthesia
• Blood Loss
• Surgical Trauma
Handheld Robotics• Precision freehand sculpting technology
tracks the position of the handpiece and bur relative to the surgical plan and adjusts the bur to control cutting
31
Outpatient Arthroplasty
Outpatient THA
• Outpatient THAHigher satisfaction of scores at 4 weeks
– Experienced more pain POD #1
• No difference in complications, office visits, patients visits, phone calls
• 24% outpatient THA required overnight stay
• 16 inpatient THA were discharged DOS
209 PROSPECTIVE RANDOMIZED IN PATIENT VS. OUTPATIENTBMI <40 AGE<75 FUNCTIONALLY INDEPENDENT
RECEIVED SAME PRE OP COUNSELING, ANESTHESIA/ANALGESIA AND THERAPY
Goyal et al, AAOS Annual Meeting 2016
Outpatient THARetrospective 549 THA
376 male 173 female average age 54.4
• Post operative
• 4 Acute readmission ( 2 days) 0.18%
– Component migration, hypotension, pain control, sedation
• 10 healing wound 1.8%
• 5 Periprosthetic infection 0.9%
• 6 Dislocation 1%
• 3 DVT 0.5%
Klein et al, AAOS Annual meeting 2016
Complications, Mortality, and Costs for Outpatient and Short-Stay Total Knee Arthroplasty Patients in Comparison to Standard-Stay Patients
Scott T. Lovald, PhD, Kevin L. Ong, PhD, Arthur L. Malkani, MD, Edmund C. Lau, MS, Jordana K. Schmier, MA, Steven M. Kurtz, PhD, Michael T. Manley, PhD
Received 14 May 2013; accepted 17 July 2013. published online 23 August 2013.
AbstractThe purpose of the present study is to determine the differences in cost, complications, and
mortality between knee arthroplasty (TKA) patients who stay the standard 3–4 nights in a hospital compared to patients who undergo an outpatient procedure, a shortened stay or an extended stay. TKA patients were identified in the Medicare 5% sample (1997–2009) and separated into the following groups: outpatient, 1–2 days, 3–4 days, or 5+ days inpatient. At two years, costs associated with the outpatient and the 1–2 day stay groups were $8527 and $1967 lower than the 3–4 day stay group, respectively. Out to 2years, the outpatient and 1–2 day stay groups reported less pain and stiffness, respectively, though the 1–2 day group also had a higher risk for revision.
5+ day complications
DVTDislocationInfectionMortalityWound Complication
Mechanical ComplicationImplant FailureImplant LooseningRe-admission
1-2 days complications
RevisionStiffness in joint
Outpatient Complications
Pain in joint
Mortality - 90 days
▪Outpatient 0.2%
▪1-2 days 0.4%
▪3-4 days 0.3%
▪5+ days 0.8%
Cost Savings2 Years Post Op
Outpatient: $8527
1–2 Day: $1967
Cost comparison THA
• Single surgeon case control study
• N=119 Patients
• Direct Anterior approach
• No difference in EBL or complications
• Average Cost
• Inpatient $31,327
• Outpatient $24,529
Aynardi et al, HSS J 2014
Transforming the Patient Experience
THE PATIENT ADVANTAGE | NEW ALBANY, OHIO
Patient Experience Best Practices
PRE OP • PERI • POST OP
THE PATIENT ADVANTAGE | NEW ALBANY, OHIO
Preoperative
Managing Patients Upfront: Indication vs Optimization
1. Diabetes: Hgb A1c if >7.9 delay and refer
2. Smoker: if YES then refer to smoking cessation
3. BMI: if >40 refer for counseling, metabolic consult
4. Anemia: if Hgb <12 in females and <13 in males, delay and refer for wu or blood management
5. Staph colonization: if in HC facility or HC worker or hx of MRSA, screen and decolonize
6. Narcotic dependence, manage upfront
7. Anticoagulation history or need perioperatively
8. Lack of supportive home environment
• Is this patient indicated for surgery?
– Sufficient symptoms interfering with ADL, work or recreation, QOL
– Inability of alternative treatment to resolve symptoms
– Objective evidence of joint disease amenable to surgical correction
• Develop a method to assess: Is this patient optimized for outpatient surgery?
– Should it be scheduled or delayed based on:
– Psychologically and medically fit for surgery
– Adequate support for home environment
Patient Selection• Surgeon• Patient• BMI<40• Medical History• Myocardial infarction, Stroke, PE < 1 year• Uncontrolled medical condition• Solid organ transplant• Dialysis• Psychological
Patient Expectations
Physician Office/Hospital Interface Recommendations
• Physician explains the Team concept to patient and family
• Pro-active medical and anesthesia clearance guidelines established at the surgical procedural level: TKR, THR.
• Dedicated PAT Nurse to Physician Practice as the point of contact for Hospital
• Develop Physician Office/Hospital communication binder to include scheduling sheets, education materials, PAT information etc.
• Establish semi-annual physician office/hospital education forums to include change in processes, Medicare updates, billing and coding updates, etc.
• Development of patient and family educational binder, DVD, & other resource materials depicting the entire continuum of care.
• Hospital provides the Physician Office with all educational materials, hibi-cleanse scrubs, etc.
THE PATIENT ADVANTAGE | NEW ALBANY, OHIO
Perioperative
Perioperative EfficienciesPatient Flow Time Stamps
Patient Flow for scheduled 7:30 in OR room 5:30 AM 5:40 AM 5:50AM 6:00AM 6:00AM 6:45AM 6:45AM
Patient Arrives at Hospital
Registration Starts
Registration Stops
Walks or escorted, arrives in Pre-op Area
Pre-op starts: This is Nursing's time to complete assessment, patient
change clothes, day of surgery diagnostic testing, H&P, notify Surgeon
of any concerns, ensure consent signed etc.
Patient transported to designated 'Holding Area"
Registration Pre-op
Patient Flow for scheduled 7:30 in OR room 6:50AM 6:55 AM 7:15 AM 7:15 AM 7:20 AM 7:25 AM 7:30AM 8:00AM
Arrives in Holding and RN checks in Patient and prepares for Block
Anesthesia Arrives, Assessment and Block insertion started
Anesthesia Block completed
Surgeon arrives in holding
Circulator reviews chart and assists Anesthesia with Transportation
Transportation to OR
Arrives in OR: Team position, preps and drapes
Surgeon makes incision
Holding Area OR
Track and post results weekly at the Physician and staff level.
Perioperative Efficiencies
• Define OR Team Roles and Responsibilities
– Anesthesia provider, Circulator, Scrub Techs, Orthopedic Assistant, Anesthesia Assistant, Physician Assistant or Private Scrub
• All blocks initiated OUTSIDE of Operating Room, patient brought to OR by Anesthesia
• Development of custom packs to include sterile supplies, non-sterile clean up kit and anesthesia set up kit.
• Standardize positioning, prepping, draping based upon surgical approach and procedural level to be performed by team
Perioperative Efficiencies
• Team turns over their own rooms
• Develop “swing”, “flip”, or “double occupancy” criteria
• Timing of when to initiate block for next case
• Skin closure routine by Physician Assistant, NP, Private Scrub
• Pro-Active approach to prepare case carts day before surgery
• Develop a formalized communication process for patient flow issues: Nextel Phones
OR Cycle Time Currently 160 Minutes For Joints
00:00
01:12
02:24
03:36
04:48
06:00
Wheels In to Wheels In Time - Knees
Time
62
4 Knee Replacements – Observed Data: Flipping 2 ORs
PP = Patient Prep Time: begins when patient enters O.R. and ends with skin incision (approx. 50 (avg) min.)S = Surgery Time: begins with skin incision and ends when surgeon breaks scrub (approx.46 min.)C = Wound Closure Time/Patient Exit Time: begins with surgeon breaking scrub and ends when patient exits O.R. (approx. 25 min.)TO = Turnover Time: begins when patient exits O.R. and ends when O.R. is ready to accept next patient (approx. 20 min.)
169 min avg Jul 2010 thru Oct 2011
151 min avg Oct 2011thru Jan 2012
Observed 136 min –consistent
with best days
Combined with hips at 190 minutes (not shown) current average is 160 minutes
Rate Limiting Step
Possible to Reduce Time by 38 to 53 Min, Increasing Total OR Capacity
20
49
37.5
45
46
37.5
20
28
37.5
13
13
37.5
Future OR
Observed OR
Sys Data OR
Wheels In to Wheels In Time - Knees
PP
S
C
TO
10 Total Joint Replacements on a standard surgery dayTeam 1: 7am – 5:10pm Team 2: 7:20am – 4:40pm
1) 3)
2) 4)
OR 2
OR 1 75
6 8
9
10lunch
Surgery Times Detail on cases 6 to 10Note: uses 10 minutes between cases for Dr. B and a 12 minute excess run-over for the team between turnover and prepPP = Patient Prep Time: begins when patient enters O.R. and ends with skin incision (approx. 20 min.)S = Surgery Time: begins with skin incision and ends when surgeon breaks scrub (approx.45 min.)C = Wound Closure Time/PT wakes up: begins with surgeon breaking scrub and ends when wound is closed (approx. 20 min.)TO = Turnover Time: begins when wound is closed and ends when patient exits O.R. (approx. 13 min.)
20 mins
45 mins 10 mins
98
Potential to reduce each
case by 38 - 53minutes.
45 minutes
• $17–50 per minute
• Average $23 per minute
45 minutes saved at $23 per minute
= $1035 per case savings
Role of the Orthopedic Representative
THE PATIENT ADVANTAGE | NEW ALBANY, OHIO
Postoperative
Post-Operative Process Recommendations
• DOS Post-operative order set depicts orders for the entire length of stay: Medical Management, pain control, etc.
• Discharge Goals reviewed with patient and family on day of surgery: Nursing, Case Management and Physical Therapy. Discharge is anticipated for POD 1.
• Permit family member who will be the caregiver to room in with patient.
• Patients ambulate day of surgery if they have arrived on the unit by 4pm. Gait and ROM updated on patient communication board.
Post-Operative Process Recommendations
• Labs drawn at 4am, Case Management arrives at 5am, Physical Therapy at 5:45am in preparation for 6am rounds.
• Surgeons round early am consistently (6am-7am) with Physical Therapy, Nursing, and Case Management.
• Evening before a clip board is assembled with patient list, progress notes, order sheets, continuity of care, prescriptions, etc. for the surgeon
• Surgeon reiterates team concept on rounds.
• Post rounds: Case Management notifies Medical Management Team of Surgical discharges to assist Internist in prioritizing patients.
THE PATIENT ADVANTAGE | NEW ALBANY, OHIO
Pain Management
THE PATIENT ADVANTAGE | NEW ALBANY, OHIO
Barrington, et al 2014
Brain
Spinal Cord
Peripheral Nerve
Nerve Stimulation
Inflammation
Tissue Injury
Narcotics Cox 2 inhibitors
Spinal/epidural narcoticsCox 2 inhibitors
Peripheral block
Local injections
Cox 2 inhibitors
Minimally invasive surgery
Brain
Spinal Cord
Peripheral Nerve
Nerve Stimulation
Inflammation
Tissue Injury
Narcotics Cox 2 inhibitors
Spinal/epidural narcoticsCox 2 inhibitors
Peripheral block
Local injections
Cox 2 inhibitors
Minimally invasive surgery
Nausea Malaise HypotensionBrain
Spinal Cord
Peripheral Nerve
Nerve Stimulation
Inflammation
Tissue Injury
Anesthesia
• Short acting spinal (hips)
• Adductor canal block (knees)—sciatic?
• General anesthesia
• Pericapsular injectable cocktail
• IV acetaminophen 1000mg x 2
• IV steroid dexamethasone 10 mg/4mg
• Celecoxib pre-op and post-op
Pericapsular Cocktail
• 20ml 1.3% bupivacaine liposome suspension
• 25ml 0.5% bupivacaine
• 0.5ml 1:1000 epinephrine
Home Health and PT
Advocacy
Ambassador program
2011
joints
total cases
2012
joints
total cases
2013
joints
total cases
2014
joints
total cases
2015
NASC Growth
2011 2012 2013 2014 2015
Joints
Revenue
cases
Conclusion
• Safe
• Cost efficient
• Improved short term outcome1
OUTPATIENT ARTHROPLASTY
1Conclusions based on data/experience at Mount Carmel New Albany
Questions and Thank You
Transforming the Patient Experience
PHYSICIAN
OFFICE/ PAT/
PATIENT ACCESS
PREOPERATIVE
PROCESS/
ANESTHESIA
PERIOPERATIVE
PROCESS
INVENTORY
MGMT PROCESS
POSTOPERATIVE
PROCESS/
MEDICAL
COVERAGE
CLINICAL
INTEGRATION
How to Develop the Outpatient TJR Process
Patient Indications Defining Cohort Risk Stratification
Best Practice Process Compliance (SCIP)
Patient Optimization Avoiding Complications, re-operations, and re-admissions
Supply Chain Management, Lab, Radiology, Path (eliminate unnecessary)
Getting the Team On Board to Prepare for OP TJR
ASSESSING THE CURRENT HOSPITAL-BASED EPISODE OF CARE
Optimizing Personnel: Practicing to limits of license, Align Message
Patient Education / Expectation Management Family LOS / Discharge Disposition
Data Collection and Reporting: Clinical and Financial Correlation
Pre-Operative
Hospital Course
Discharge Planning
Post Acute Outpatient
Efficiency Drivers within the ASCEVERYONE KNOWS THEIR ROLE AND EVERYONE ELSE’S ROLE
Managing Patients Upfront: Indication vs Optimization
1. Diabetes: Hgb A1c if >7.9 delay and refer
2. Smoker: if YES then refer to smoking cessation
3. BMI: if >40 refer for counseling, metabolic consult
4. Anemia: if Hgb <12 in females and <13 in males, delay and refer for wu or blood management
5. Staph colonization: if in HC facility or HC worker or hx of MRSA, screen and decolonize
6. Narcotic dependence, manage upfront
7. Anticoagulation history or need perioperatively
8. Lack of supportive home environment
• Is this patient indicated for surgery?
– Sufficient symptoms interfering with ADL, work or recreation, QOL
– Inability of alternative treatment to resolve symptoms
– Objective evidence of joint disease amenable to surgical correction
• Develop a method to assess: Is this patient optimized for outpatient surgery?
– Should it be scheduled or delayed based on:
– Psychologically and medically fit for surgery
– Adequate support for home environment
Develop Exclusion Criteria for an ASC Environment
• Lack of adult support at home post surgery 24 hours a day
• Medical Exclusion Criteria
Develop Exclusion Criteria for an ASC Environment
• Medical Exclusion Criteria
– Cardiac• Active cardiac disease
• Symptomatic ischemic heart disease
• Valvular heart disease
• Cardiac arrhythmias
• Congestive heart failure
• Asymptomatic patients with stable cardiac conditions or revascularized CAD will require cardiac clearance and anesthesia review
Develop Exclusion Criteria for an ASC Environment
• Medical Exclusion Criteria– Pulmonary
• Chronic lung disease
• Untreated or suspected OSA – anesthesia review
– Morbid Obesity – anesthesia review
– Genitourinary• Chronic kidney disease – exclude patients with ESRD or baseline
creatinine of 2 or above
• Known history of urinary retention
• Men with diagnosis of BPH or prior surgical procedures for prostate cancer
Develop Exclusion Criteria for an ASC Environment
• Medical Exclusion Criteria
– Gastrointestinal• Any history of postoperative ileus
– Chronic liver disease• Exclude patients with Cirrhosis
– Hematology• Known coagulopathy and are likely to require blood products
perioperatively
• Patients with anemia will require surgical and anesthesia review
• Patients on Coumadin® will require anesthesia review
Develop Exclusion Criteria for an ASC Environment
• Medical Exclusion Criteria
– Neurology• Exclude patients that would be considered high risk for
perioperative delirium. This would include dementia, known prior history of postoperative delirium, or prior CVA.
– Solid Organ Transplants
Develop an OP TJR within the Hospital Setting
• Test your protocol
• Assess outcomes over 4–6 months
• Revise as necessary
• No more daily lab draws• Better blood management, TXA, pre-op
screen • No x-ray in PACU for knees• No IV PCA• No Ice Man or CPM• Decrease blocks
• Increase local infiltration• No bipolar sealer• No bulky dressing, no staples• No routine Foley Catheter• DOS Ambulation 30-50 feet• Home / Home with home care
Care Path Protocols: Eliminating Unnecessary Interventions
Discharge Planning for OP Total Joint
• Initiated during surgeon’s consultation– Questions patient regarding adult support for 24 hours post-
operatively
– Leads discussion regarding medical exclusion criteria
• Home Health Assessment by phone prior to surgery– Assess Discharge Environment
• ADLs – Kitchen, Bathroom, Bedroom
• Will 24 hour adult support be available
• Review Home Health visit day of surgery with Patient & Family
• Review all discharge instructions – pain, nausea, antibiotic, physical therapy, etc.
Physician Office/ASC Interface Recommendations
• Physician explains the Team concept to patient and family
• Pro-active medical and anesthesia clearance guidelines established at the surgical procedural level: TKR, THR.
• Explain a Pre-admission testing (PAT) & Home Health RN will be calling the patient before surgery to review the plan of care
• Develop Physician Office/ASC communication binder to include scheduling sheets, education materials, PAT information etc.
• Establish semi-annual physician office/ASC education forums to include change in processes, Medicare updates, billing and coding updates, etc.
• Development of patient and family educational binder, DVD, & other resource materials depicting the entire continuum of care.
• ASC provides the Physician Office with all educational materials, HIBICLENS® scrubs, etc.
PHYSICIAN
OFFICE/ PAT/
PATIENT ACCESS
CLINICAL
INTEGRATION
Distribute Educational Binder and DVD
during pre-op Physician office visit.
Develop Educational Materials
• Pre-Admission Testing
• Pre-Operative Process
• Anesthesia Options: Regional versus General
• Day of Surgery Processes
• Medications on the Day of Surgery
• Pain Management
• Blood and DVT Prophylaxis Management
• Diet Management
• Length of Stay Expectations: 3-4 hours post-op
• Ambulation the Day of Surgery: Exercises, Mechanical Devices
• Discharge Goals; Surgical, Physical Therapy, Medical
• Discharge planning: Home Health
• Home Health Contact Information: Communication Business Card
• Signs and Symptoms of Infection
• Discharge Instructions: Wound Care, Ted Hose, Medications, etc.
• Physical Therapy Exercises for 6 Weeks Post Op
THE MATERIAL COVERED SHOULD INCLUDE
• Preoperative Nutrition Assessment
• Preoperative Smoking Cessation
• Diabetes
• Beta-Blockers
• BMI > 40
• Screening for obstructive sleep apnea1. Do you snore?2. Do you experience frequent daytime napping?3. Do you wake up at night gasping for your breath?4. If yes to the above, do you use a CPAP/Bi-PAP machine?
• Provide the patient with Hibiclens for showering HS and AM
• Schedule preoperative physical therapy appointment to review protocols
Perioperative Protocols for High Risk Patients
PHYSICIAN
OFFICE/ PAT/
PATIENT ACCESS
CLINICAL
INTEGRATION
Pre-Admission Phone Call RN
• Pre-admission RN is dedicated to Physician Practice to enhance patient/family/physician communication
• Review diagnostic testing with patient for Anesthesia Guidelines
• Notifies Surgeon Internist / Family Practice or Anesthesia of any concerns
• Continue to coach patient and their family member regarding what will happen the day of surgery.
• Ask the patient to place the phone on speaker phone if available so their family member can hear as well.
Pre-Admission RN Call Script• Remind the patient they need to have someone with them at all times after
surgery.
• Review with them what to expect pre and post operatively.
• Remind the patient we will need your family member (coach) to be present on the day of surgery to receive coaching on how to take care of you at home.
• Review how their pain will be controlled the day of surgery and at home.
• Remind the patient they will be receiving a call from their Physical Therapist before surgery.
• Remind the patient the Physical Therapist will visit them and their family the day of surgery to coach them on ADLs.
• Remind the patient the Physical Therapist will visit them and their family at home the day after surgery by 10 am.
• You will be given an antibiotic to take after surgery at home.
• Review all discharge instructions.
• Follows Anesthesia Guidelines for diagnostic testing
• Notifies Surgeon, Internist or Anesthesia of anyconcerns
Labs:
• CBC with diff, PT/INR,PTT,U/A C&S, BMP
• Type and screen if Hgb< 11
Medications:
• Take AM of Surgery: Heart, Blood Pressure, Anti-seizure, Steroid, Breathing and all heartburn or gastric medications except for Maalox®, Mylanta®, etc.
• Do not take AM of Surgery: Oral Diabetic medication, Insulin, If on an evening dose of insulin take half the PM before surgery,
• Stop before Surgery: Metformin, Lovenox®, Coumadin, Trental®, Plavix®, Ticlid, MAO Inhibitors, Herbal medications and Anti-inflammatories
Pre-Admission Testing PHYSICIAN
OFFICE/ PAT/
PATIENT ACCESS
CLINICAL
INTEGRATION
Day of Surgery: Pre-OpMEDICATIONS
PREOPERATIVE
PROCESS/ANESTHE
SIA
CLINICAL
INTEGRATION• ANCEF® 2 gm IVPB
• If allergic to PCN give Clindamycin 600mg if patient <80 kg; 900 mg if patient > 100kg.
• Scopolamine 1.5 mg patient transdermally (hold for history of BPH, glaucoma, or greater than 70 years of age
• Versed 1mg/1ml IVP titrated to maximum of 10 mg pre block
• Beta Blocker if indicated
• Decadron® 10mg IV
• Celebrex® 400mg POx1 unless CR>1.5 and if not allergic to NSAIDS
• Acetaminophen 1gm POx1
Day of Surgery: Pre-OpNURSING
• Initiate LR IV, may utilize Lidocaine intradermally
• Bilateral elastic stocking-thigh high- to unaffected extremity preoperatively
• Active Care Sequential compression device-to unaffected extremity preoperatively
• Clip one hand breath above and below the operative knee for TKR or pelvic bone iliac crest down to mid thigh
• Chlorhexadine wipe to surgical site after clipping
PREOPERATIVE
PROCESS/ANESTHE
SIA
CLINICAL
INTEGRATION
Day of Surgery: Pre-OpANESTHESIA• General mask airway with Adductor Canal block or Spinal
for post-op pain control
REGIONAL ANESTHESIA• Performed in the preoperative area
• Patient receives Versed for sedation
• Spinal is placed utilizing straight Lidocaine
• Adductor canal block utilizing 15-30ml 0.5% Ropivicaine
• Potential sciatic block if necessary
• Appropriate monitoring for conscious sedation
PREOPERATIVE
PROCESS/ANESTHE
SIA
CLINICAL
INTEGRATION
Day of Surgery: Pre-OpOPERATING ROOM• Induction of Anesthesia with Propofol drip up to 150
mcg/kg/min
• Propofol and Versed agents of choice for maintenance of Anesthesia
ANTI-EMETICS• Scopolamine patch in pre-op behind left ear as deemed
necessary by surgeon
• Zofran® 8mg IV given 15 minutes before closure
• 2000-2500ml of Lactated Ringers or Normal Saline throughout the periop period.
PREOPERATIVE
PROCESS/ANESTHE
SIA
CLINICAL
INTEGRATION
Day of Surgery: Intra-OpPERIOPERATIVE
PROCESS
CLINICAL
INTEGRATION
NURSING• Continue with mechanical sequential device
• Skin prep with Duraprep™
PAIN INJECTION• Surgeon infiltrates surrounding surgical site
• EXPAREL®(20ml 1.3%), Bupivicaine (25ml 0.5%) and Epinephrine (0.5ml of 1:1000)
• Toradol® 30mg given by Anesthesia if renal function is normal
SKIN CLOSURE• Quill™ suture and DERMABOND® Topical Skin Adhesive
Day of Surgery: Intra-OpPERIOPERATIVE
PROCESS
CLINICAL
INTEGRATION
DRESSING• Dermabond, Aquacel®dressing, ted hose and Active
Care compression pumps
IRRIGATION• 1000ml .9% Normal Saline
• Warm .9% Normal Saline poured over implants to assist in hardening cement
Post-Operative Team ApproachPOST OP ORDERS FOR ENTIRE LENGTH OF STAY
• Surgical Management: Notify Surgeon of the following:– Decrease or lack of pedal pulses
– Inability to plantar/dorsiflex foot
– Change in appearance of wound
• Medical Management: Notify Surgeon/Anesthesia of the following:– Abdominal distention or decreased bowel sounds
– Hemoglobin < 8 grams
– Potassium < 3.5 or > 5.5
– Systolic BP < 90 or > 180 mmHg
– Tachycardia > 120 beats per minute
– Temperature > 101
• Labs: None
Post operative and
Medical Management
CLINICAL
INTEGRATION
Post-Operative Team ApproachPHYSICAL THERAPY
• Home PT visits patient and their family to educate them on how to safely perform ADLs
• Review Therapeutic exercises: Ankle pumps, quad sets, gluteal tucks 10 times/hr. while awake with patient and family
• Patient is ambulated with Nursing to bathroom and back.
• Physical Therapy contact business card given to patient/family.
Post-Operative Team ApproachNURSING
• Vital Signs and Circulation checks q1h until discharge
• Assess limb sensation, pulses, movement, and strength with each check
• May reinforce dressing prn
• Maintain ted hose and compression devices
• Oxygen via nasal cannula at 2 liters per minute, discontinue when patient is alert and room air saturation is 91%
• Incentive spirometry 10 times per hour while awake.
• Deep breathing and coughing exercises q 1hr. while awake
• TXA dose given 3 hours after first dose
Post-Operative Team ApproachDIET
• Initiate clear to full to soft diet as desired
• If no nausea, vomiting or abdominal distention, progress to soft diet before discharge
Post-Operative Team ApproachDISCHARGE INSTRUCTIONS
• Antibiotics and Pain medications ordered by Surgeon
• Home medications reconciled by Surgeon
• Refer to Patient educational binder and DVD for PT exercises
• Follow up phone call by Home Health within 48 hours of Discharge
• Home Health PT 3x for 1st week, then 2x for 2nd week. Usually 10-14 days of Home health
• Follow up appointments reviewed with patient and family
• ASA, ted hose and ActiveCare® compression pumps
Post-Operative Team ApproachMEDICATIONS FOR HOME USE
• Oxycontin® 10 mg PO q 12h: 4 tabs given
• Percocet® 5mg PO q 6h prn
• Vistaril® 25 mg PO 1 tab q 6h prn
• Keflex® 500 mg PO bid x7 days
Perioperative Efficiencies
• Define OR Team Roles and Responsibilities– Anesthesia provider, Circulator, Scrub Techs, Orthopedic Assistant,
Anesthesia Assistant, Physician Assistant or Private Scrub
• All blocks initiated OUTSIDE of Operating Room, patient brought to OR by Anesthesia
• Development of custom packs to include sterile supplies, non-sterile clean up kit and anesthesia set up kit.
• Standardize positioning, prepping, draping based upon surgical approach and procedural level to be performed by team
Perioperative Efficiencies
• Team turns over their own rooms
• Develop “swing”, “flip”, or “double occupancy” criteria– timing of when to initiate block for next case
– skin closure routine by Physician Assistant, NP, Private Scrub
• Pro-Active approach to prepare case carts day before surgery
• Develop a formalized communication process for patient flow issues: Nextel Phones
Post-Operative Process Recommendations
• Imperative to have Nursing and Physical Therapy ambulate the patient as soon as they are stable and in the presence of the family or caretaker
• Goal is to discharge patient within 4 hours
• Ensure patient can drink and tolerate fluids
• Ensure patient understands the frequency of home medication regimen to keep pain and nausea under control
• Home Health visits patient by 10am next morning