The Evolution of a Perioperative Surgical Home - … Evolution of a Perioperative Surgical Home Pediatric Anesthesiology . ... A Comprehensive Review of US and Non-US Studies Shows

Nihar Patel, MD Assistant Professor Anesthesia Director for Spine Surgery Director of Inpatient Pain Service

The Evolution of a Perioperative Surgical

Home

Pediatric Anesthesiology

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Conflict of Interest None


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Objectives • Review sequence of events leading to formation of

a PSH at Texas Children’s Hospital • Examine the rationale behind PSH models • Discuss potential benefits of the PSH model • Explore the future possibilities and outcomes with

the PSH


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History of TCH NM Scoliosis • Since 1995, roughly 40-50 scoliosis surgeries

done on children with neuromuscular disease • Straight-forward pre-op process and various

anesthetic techniques utilized

• No records of M&M, QA/QI or outcomes


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Timeline of Creation of Multi D


Multiple Post-Op Morbidity and Mortality

Cessation of NM Scoliosis Surgery

Formation of Safety Review Panel

Creation of Multidisciplinary Neuromuscular Scoliosis Team

Initiation of Formal Processes for Scoliosis Surgery

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Composition of Multi-D •  Spine Surgeons (4 Orthopedic and 1 Neurosurgical) •  Anesthesia Spine Director •  Orthopedics OR Nurse Coordinator •  Anesthesia Pre-op Screening Clinic Coordinator •  Spine Surgery Nurse Coordinator •  Pulmonologist •  Nutritionist •  Hematology/Blood Banking •  Critical Care Physician •  Ethicist/Chaplain •  Spine Floor Nurse Manager •  Evidence Based Outcomes Personnel


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Safety Review Panel Findings

• Patients lacked proper indications screening

• Medical optimization of patients lacking

•  Large variability in intraoperative anesthesia care

•  Lack of coordination of pre-op and post-op care

PediatricAnesthesiology

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Safety Review Panel Findings

• Appropriate Preoperative workup and optimization

• Consistent team dedicated for these patients

• Better management of pulmonary function


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PHASE 1 INDICATIONS PHASE Patient seen in Ortho Clinic Presented to Indications Conference (1st Tuesdays)

PHASE 2

EVALUATION PHASE Pulmonary Consult Nutrition Consult Other Specialties (as designated)

PHASE 3 SCREENING PHASE PASS #1 Visit

PHASE 4 Multi Disciplinary Review Group approves patient for surgery date Make inpatient preparations

PHASE 5

Final Clearance for Surgery Pre-Op Visit with consent PASS #2 Visit with consent Child Life Tour of OR &11WT

PHASE 6 Ready for Surgery

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Indications Conference

• Patient presented by Surgeon to Indications Committee

• All active spine surgeons, anesthesiologist, ICU,

Pulmonary, Ethics, Outcomes & Impact service • Automatic Consults include Pulmonary & Nutrition


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PHASE 2 – Stage 1


Pulmonology Consult

Sleep Study Indicated? NoYes

Results of Diagnostic

Sleep Study

Sleep Apnea diagnosed

No Sleep Apnea

diagnosed

Titration Sleep Study

One month Compliance

of BiPAP/CPAP

Patient noncompliance

Pulmonary Surgery

Clearance

Pulmonary Surgery

Clearance

Surgery Post-op Recommendations

Work with family to improve compliance or formulate other

plan if unable due to developmental delay

BiPAP/CPAP Indicated

ENT consult recommended

T&A not recommended

T & A scheduled

Sleep study repeated

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PHASE 2 – Stage 2


Nutrition Consult

Malnutrition detected?

Malnutrition diagnosed with

BMI z-score

No malnutrition risk noted

Nutrition clearance

Oral Attempts at Weight Gain Goal

Gastric Tube Recommendation

Goal Weight not achieved

Goal Weight Achieved

Nutrition Clearance

Surgery Post-op Recommendations

Parents Agree to GTube Gtube Surgery

Parents refuse Gtube

Nutrition consult –

Time to use supplemental

formula

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PASS CLINIC


Pulmonology & Nutrition, Other Consults initial visits

PASS #1 Screening including bloodwork

Consult Follow-up

PASS #2 to close all loops

Surgery

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PASS 1 Visit • Once cleared by Indications à Referred to PASS

(2-3 months before Surgery)

• Seen by both NP and Anesthesiologist

• Comprehensive H&P, initial labs drawn

• Anesthesia spine director responsible for reviewing initial PASS clinic visit.

• Coordinate appropriate consults


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Multi-Disciplinary Review •  After all consults/interventions completed, patient

presented at this review •  Members from all services present •  Meets once/month •  Purpose behind Multi-D

1.  Triple Check to make sure all appropriate consults made

2.  Direct face to face communication between Intra-Op and Post-Op teams regarding upcoming patients (anticipate needs & plan accordingly)

•  Conduct quality review of cases to identify opportunities for improvement/learning


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PASS 2 Visit •  2 weeks prior to surgery • Follow-up labs • Type and screen/crossmatch • Anesthesiologist assigned to case • PCU/PICU notified of upcoming surgical date


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NM Anesthetic Protocol


• Midazolam or Valium Premed • Bear Paws Warming Pre-Op

• PIV x2, Arterial Line, Central Line, BIS • TIVA technique • Antibiotics cefazolin 25mg/kg when prone • Tranexamic Acid at 30mg/kg and 3mg/kg/hr

Induction

• IOM • Cell Saver • MAP to 60mm Hg* Maintenance

• PCU/PICU Admit • Pain Service & Consultant Visits • Reinstitution of BiPAP/CPAP Post-Op

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Acute Pain Service Protocol

• Opioid PCA with Basal + Interval • Ofirmev q6h • Ketorolac q6h • Bowel Regimen

POD 0

• Opioid PCA Interval Dose Only • Tylenol po q6h • Ketorolac q6h • Bowel Regimen

POD 1

• Hydrocodone q4-6h •  Ibuprofen/Naproxen • Bowel Regimen

POD 2-6


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Spine Scorecard


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Pre-Op Patient Information


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Post-Op Patient Information


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Current Projects Under Way EBOC • Enhanced Recovery After Surgery • EBOC Antibiotic Prophylaxis • EBOC Transfusion Protocol • PSH for Idiopathic Scoliosis Surgery


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Multi-Disciplinary Committee

Perioperative Surgical Home


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Patient-centered, team-based model of delivering healthcare during the entire patient surgical/procedural experience until their recovery and return to PCP


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Preoperative Intraoperative Postoperative Long-Term Recovery


Surgery PulmonologyAnesthesia

Informa5cs

Nutri5on Nursing

Cri5calCareHematology Ethics

Quality

Improvement

Healthcare

Analy5cs

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History of PSH

1970’s and 80’s

•  IT Innovations

1990’s

•  Pittsburgh Medical School Preioperative Process •  Stanford Pre-op Clinic Study

2000’s

•  VASQIP •  ASA Task Force on Future Paradigms in Anesthesia Practice

2010

•  Patient Protection and Affordable Care Act (PPACA) •  ACO’s


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Essentials of PSH


Patient-Centered Care

Coordination of Care

Commitment to Quality and Safety Accessibility to Care

Comprehensiveness

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Patient-Centered Care

• Replaces a perioperative physician-centric model

• Patient values and preferences are central

• Patient education fundamental

• Shared decision making with all aspects of care

• Communication remains consistent throughout


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Comprehensiveness

• All issues of patient care handled from admission

to discharge

• Detailed, evidence-based, standardized plans of

care delivered to patients

• Every member of patients care team represented

in decision making and discussion


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Coordination of Care

• Begins in surgeon’s office and continues until discharge to PCP

• Updates/results of testing communicated clearly with all members of team

• Facilitated refinement of patient care

•  Lean Management or Six Sigma used to help with improvement processes


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Accessibility to Care

• All care coordinated via EMR and amongst all care

teams

• Close monitoring of patient as inpatient or

outpatient possible

• Readmissions handled more efficiently


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Commitment to Quality and Safety

• Standardization of care

• Evidence-based clinical pathways or protocols

• Reduction of variability

•  Informatics to maintain outcomes and data

• Facilitated pathway for collaborative research


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Potential Benefits of PSH • Safety • Efficiency • Cost-Savings • Quality Outcomes • Collegiality • Patient Satisfaction


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Future Possibilities Craniofacial Hypospadias Idiopathic Scoliosis Neuroblastoma Solid Organ Transplant Colorectal Surgery …


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Questions? Comments?

Thank You!


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References •  Kain ZN, Vakharia S, Garson L, et al. The perioperative surgical home as a

future perioperative model. Anesth Analg. 2014; 118:1126-1130 •  Mariano ER, Walters TL, Kim TE, Kain ZN. Why the perioperative surgical

home makes sense for veterans affairs health care. Anesth Analg. 2015; 120:1163-1166

•  Cannesson M, Kain Z. The perioperative surgical home model: an innovative clinical care delivery model. J Clin Anesth. 2015;27(3): 185-187

•  Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Affairs. 2008; 27(3):759-769

•  Vetter T, Boudreaux AM, Jones KA, Hunter JM Jr, Pittet JF. The perioperative surgical home; how anesthesiology can collaboratively achieve and leverage the triple aim in health care. Anesth Analg. 2014; 118(5): 1131-1136

•  Kash BA, Zhang Y, Cline KM, Menser R, Miller T. The Perioperative Surgical Home (PSH): A Comprehensive Review of US and Non-US Studies Shows Predominantly Positive Quality and Cost Outcomes. Milbank Quarterly. 2014; 92(4): 796-821


Documents

The Evolution of a Perioperative Surgical Home - … Evolution of a Perioperative Surgical Home Pediatric Anesthesiology . ... A Comprehensive Review of US and Non-US Studies Shows