Integrated Care In ActionSurgery Clinical Program

David S. Jevsevar, MD, MBABoard and Executive Learning Series

Vancouver, BCJune 2, 2012

Disclosures

• None pertinent to this presentation

• No trade names will be used in this presentation

The Principles Of Shared Baselines

• Select a high priority care process

• Generate an evidence-based best practice guideline

• Blend the guideline into the flow of clinical work

• Use the guideline as a shared baseline with clinicians free to vary based on individual patient needs

• Measure, learn from and (over time)

• Eliminate variation arising from the professional

• Retain variation arising from patients

Multi-Disciplinary Colon Surgery (MDCS) Background

• Enhanced recovery after colon surgery has not been widely adopted in the United States and Europe despite evidence that postoperative complications and hospital length of stay are decreased.

Objective

• Evaluate the introduction of a comprehensive care process for an enhanced recovery after colon surgery care process in 8 Intermountain Healthcare community hospitals.

Design

• Quality improvement rather than cost containment was the primary focus.

• Use of LOS and cost data as quality metrics to assess results of the intended improvement process are well substantiated in the literature.

• Elements comprising an MDCS care process are not uniformly accepted.

Design

• Common MDCS elements include:• patient education • correct peri-operative fluid management • optimal pain control with limited opioids • thoracic epidural blockade • early postoperative feeding • aggressive patient ambulation • avoiding use of abdominal drains and

nasogastric tubes.

Implementation

• A central committee composed of general surgeons, colorectal surgeons, operations leaders and data experts reviewed the evidence supporting MDCS.

• The committee developed a comprehensive MDCS care process with help from nursing, physical therapy, and the pain and medical nutrition services.

Implementation

• In each hospital, an objective review of MDCS literature was presented to surgeons and anesthesiologists in combination with system-wide, hospital, and surgeon-specific baseline data.

• System-wide and hospital-based leadership teams led by surgeons were essential in implementing the complex MDCS care process.

Implementation

• An electronic self populating dashboard was created from the EDW.• Significant resources

• A postoperative order set was designed to incorporate the essential elements of MDCS.• Incorporating process into the workflow

• A document summarizing the care process was added to each patient’s chart.• Education for patients, nursing staff, and

physicians.

Multidisciplinary Colon Surgery (MDCS) Physician Orders

Implementation

• From inception of the MDCS hypothesis to beginning of implementation took 18 months.

Continuous Process Improvement

• The electronic dashboard made MDCS performance metrics immediately available to physicians and operations leaders and included: • patient demographic • severity of illness (SOI) • clinical and financial outcomes• ambulation, diets, bowel activity, etc.• LOS, POD, cost

Surgeon Education and Control

• Surgeons had the option of enrolling or not enrolling patients in MDCS.

• It was expected that this may lead to some degree of selection bias that might confound direct comparison between enrolled and non-enrolled patients; therefore the study population included enrolled and not enrolled patients and was compared to a historical control.

Demographic, MDCS enrollment comparison data and service population for the 8 community

hospitals

Hospital StaffedBed Count

Avg Resectionsper Year* MDCS Start Date Population 2009 County

A 126 34 6-May-08 115,269 Cache

B 311 132 25-Jun-08 231,834 Weber

C 78 47 28-Jul-08 545,307 Utah

D 245 108 13-Aug-08 137,473 Washington

E 367 101 8-Oct-08 545,307 Utah

F 446 156 2-Feb-09 1,034,969 Salt Lake

G 213 128 5-Mar-09 1,034,969 Salt Lake

H 69 64 13-Apr-09 1,034,969 Salt Lake

The DashboardThe Dashboard

ERAS Financials

Conclusions

• MDCS was successfully introduced into 8 of the Intermountain Healthcare network of hospitals as indicated by:• increasing enrollment rates over time • decreasing LOS and POD from the

baseline period to the study period

Current Status and Next Steps

• Continuing education on patient enrollment

• Revisiting areas of variation and changing as needed

• Continued turnaround of data to physicians and clinical team

Questions?