Fast-Tracking Ambulatory Surgery Patients following Anesthesia: A Process Improvement Plan

Now You See Them, Now You Dont: The Case for Fast-Tracking Ambulatory Surgery Patients A Process Improvement Initiative

Andi Stamper, DNP, CRNAChuck Vacchiano, PhD, CRNA, FAANNCANA Annual MeetingNovember 5, 2016

.1

Project ObjectivesUnderstand process improvement, the general steps to achieve it, and its value to the institutionBe able to define Fast-Tracking and be aware of its potential to shorten the institutional recovery processDiscuss the planning and implementation of a Fast-Tracking process in a community hospitalReview the outcomes associated with adoption of a Fast-Tracking process in a community hospital

2

Definition of Quality / Process Improvement Quality improvement is the science of process managementQuality improvement concepts and techniques have been used to transform almost every major industry in the world The last holdouts, the are primarily healthcare, higher education, and governmentHealthcare is very complexMade up of thousands of interlinked processes Focus on patient care processes one at a time Can fundamentally change the game and deal with the challenges facing healthcareA bad system will beat a good person every time.W. Edwards Deming

3

Why Should We Be Concerned With Process Improvement?Patient outcomes and satisfaction

Financial incentives are increasingly tied to improvements in quality and efficiencyLeads institutions to seek opportunities to improve quality and efficiency in the practice setting

Shift from Cost-Based to Bundled paymentLeads to adoption of practices that will decrease complications and cost

4

What Does Process Improvement Look Like?Area of FocusSet SMART GoalsSpecific, Measurable, Attainable, Relevant & Time-basedDesign the ProcessConduct a baseline data analysisAnalyze the ProcessDetermine the Opportunity for ImprovementCreate an Action PlanImplementMonitor the Process and Review the Data

5

What is the Point of Fast-Tracking?Goal in our clinical setting: To decrease the time Ambulatory Surgery Patients spend in the institutional postsurgical recovery process

6

What is Fast-Tracking? Assessing patients as they emerge from anesthesia for readiness to bypass the postanesthesia care unit and go directly to an ambulatory care unit to facilitate a faster discharge from the facility.

7

What Does the Literature Say About Fast-Tracking?Fast-tracking studied since1996 Multiple studies have demonstrated an increased PACU-bypass rate upon implementation of a fast-tracking process

8

The Organizational SettingCommunity Hospital Southeast U.S.369-bed acute care facility 18 Operating Rooms (ORs)10 Postanesthesia Care Unit (PACU) Beds15 Ambulatory Care Unit (ACU) Beds More than 4,000 Ambulatory Surgical (AS) procedures performed each year

9

Existing Postoperative Recovery PolicyAll AS patients must be admitted to the PACU following emergence from anesthesia Discharged from the PACU to the ACUHas not always been the practice

10

What is the Potential for Fast-Tracking Hospital Based Patients Having Ambulatory Surgery? U.S: 2006 there were 34.7 million ambulatory surgery visits, 19.8 million (57.2%) were hospital basedProject Site: ACU Visits Tracked for January and February 2013:ACU Patients NOT Eligible for Fast-Tracking

11

Project Design Introduce Fast-Tracking in a medium size community hospital and determine its effect on the postoperative recovery process and cost in Ambulatory Surgery patientsCompare outcomes data Before implementation of Fast-Tracking (Reference Period)..

and after implementation of Fast-Tracking (Implementation Period)

12

Project ObjectivesPrimary Project Objectives:Compare outcomes before and after implementation of Fast-Tracking:PACU bypass ratesIncidence of OR HoldLength of Postoperative Hospital Stay (LOS) OR, Anesthesia and PACU costSecondary Project Objectives:Examine patient Demographics and Comorbidities Determine Inter-rater reliability of a tool to determine patient eligibility to be Fast-Tracked

13

Project Methods Overview Acquire Buy In from affected departmentsAnesthesia, Nursing, Executive AdministrationDevelop a plan to implement the Fast-Tracking processAgree on inclusion criteria and method to be used to determine a patients eligibility to be Fast-TrackedInitiate the Reference Period Follow with the Implementation PeriodSee what happens!

14

History of Tools used to Assess Patients for Transfer1970: The Aldrete Score 1980: JCAHO Mandate1995: The Modified Aldrete Score (MAS)1999: The White Fast Track Score (WFTS)

15

How Have These Tools Been Applied to Fast-Tracking Research Tools utilized in fast-tracking researchModified Aldrete Score (MAS) Whites Fast-Track Score (WFTS)Incorporates the most pertinent variables of the MAS toolAdds pain and emesis assessments

Anesthesia and Analgesia. 1999

16

Original White Fast-Track Score Tool

Level of Consciousness 0 2Physical Activity 0 2Hemodynamic Stability 0 2Respiratory Stability0 2Oxygen Saturation0 2Postoperative Pain 0 2Postoperative Emesis0 2Possible range 0 - 14

17

Our Modification of the WFTS Tool

Postoperative Pain None or mild discomfort (0-3) 2Mod. to severe pain controlled / IV meds (4-7) 1Persistent severe pain (8-10) 0Maximum Score 14

Fast Track Eligible: Total Score 12 No category = 0

18

Project Methods SpecificsInclusion CriteriaAmbulatory surgery patients18 years or olderType of Anesthesia:MAC/IVA Local InfiltrationPeripheral nerve blockCombination of theseExclusion CriteriaOther than Ambulatory SurgeryGeneral, spinal or epidural anesthesia

19

Project Methods SpecificsReference Period (Pre-Fast Tracking)75 patients over a 3 week period assessed with the WFTS tool Administered by Anesthesia providers in ORAdministered by nurses on admission to ACU

Patients followed current standard recovery processACU OR PACU ACU WFTS WFTS

Data CollectionHow many patients could have been Fast-TrackedIncidence and duration of OR Hold

20

Project Methods SpecificsImplementation Period (Post-Fast Tracking)75 patients over a 3 week period assessed with the WFTS tool Administered by Anesthesia providers in ORAdministered by nurses on admission to ACU

Patients who met criteria now Fast-Tracked PACUACU OR ACU WFTS WFTS

Data CollectionHow many patients Fast-TrackedIncidence and duration of PACU HoldEvaluate inter-rater reliability

21

Project Timeline Reference Period (3 Weeks)Implementation Period (3 Weeks)

Education Period (5 Weeks)Data Analysis Period (5 Weeks)March 13 April 21 April 21 May 5 May 6 May 26 May 27 June 302013

22

Results: Demographics Total of 150 patients evaluated for eligibility to be Fast-Tracked during the Reference and Implementation PeriodsNo difference between those patients who met Fast-Track criteria (120) and those who did not (30) in:Age GenderASA ClassificationHistory of PONVAnesthesia type

DemographicFast-TrackNon Fast-TrackAge5658Gender (M/F)43/779/21ASA Classification1=161=22=652=143=383=134=14=1History of PONVYes= 21Yes=4No = 99No=16

23

Results: Variety of Procedures GYNUrologyOphthalmologicOrthopedicNeurologicVascularMRI

24

Results: Patient ComorbiditiesCategories / Most Common ComorbiditiesCardiovascularHypertensionRespiratorySmokerGU / Endocrine / MusculoskeletalDiabetesReflux NeurologicNeuropathy

25

Results: PACU Bypass RateProject PeriodAmbulatory Surgeries#Eligible for Assessment#Met PACU Bypass Criteria#Reference1917561 (81%)Implementation1867559 (79%)

81% Could Have Bypassed the PACU during the Reference Period

79% Actually Bypassed the PACU during the Implementation Period

26

Results: OR Hold Incidence & Duration

A significant decrease in the incidence and duration of OR Hold during the Implementation Period

Project PeriodIncidence of OR HoldDuration in MinutesReference18350Implementation323

27

Results: Length of Stay

ACU LOS significantly longer for the Implementation Group?

Total LOS significantly shorter for the Implementation Group

GroupNMean MinutesTime in ACUReference Period FT Eligible6171Implement. Period Actually FT5989Total Time Postop to DischargeReference Period FT Eligible61106Implement. Period Actually FT5994

28

Results: Comorbidities

No single comorbidity was associated with ineligibility for Fast-Tracking

The Fast-Track Eligible group had on average 1 less Total Comorbiditythan the Non Fast-Track eligible group

Combined Reference and Implementation Periods150 Patients Mean # ComorbiditiesFast Track Eligible (n=120)3.23Non Fast Track Eligible (n=30)4.47

29

Kappa CoefficientKappa0.966ASE0.02495% lower confidence limit0.92095% Upper Confidence Limit1.013

Anesthesia Providers and ACU Nurses agreed that patients met the WFTS Fast-Track criteria 98% of the time

Results: WFTS Inter-Rater Reliability

30

Cost AnalysisBaseline Cost Used in the Cost Analysis

PACU Stay Cost: $606.99Operating Room Time: $62/minAnesthesia Time: $4.05/minReference Period / 3 Weeks61 Patients / 350 minutes of OR HoldPACU Cost: $37,026OR Hold-Room Time Cost: $21,700OR Hold-Anesthesia Hold Time Cost: $1,418TOTAL Cost: $60,143 / 3 Weeks Potential Annual Savings: $1,042,494

Although every hospital has a charge master, officials treat it as if it were an eccentric uncle living in the attic.

31

LimitationsProvider PracticeWork Culture

32

SustainabilityPotential for sustainability is highInter-rater reliability of the WFTS allows the population to safely bypass the PACU

33

Conclusions Implementation of a fast-tracking protocol in a community hospital can: Increase workflow efficiency Decrease costsPatientHospitalThird Party Payers

Journal of PeriAnesthesia Nursing, 2015

34

Questions?

35

References1. White PF, Eng M. Ambulatory (Outpatient) Anesthesia. In: Miller RD, Eriksson LI, Fleisher LA, Wiener-Kronish JP, and Young WL. Miller's Anesthesia. 7th ed. Philadelphia, PA: Churchill Livingstone, 2009. 2437-382. Cullen KA, Hall MJ, Golosinskiy A. Ambulatory Surgery in the United States, 2006. National Health Statistics Reports. 2009;11:1-28.3. White PF, Eng M. Fast-track anesthetic techniques for ambulatory surgery. Current Opinion in Anesthesiology. 2007;20:545-557.4. Ellington MJ. BlueCross starting three-tiered system. Times Daily [Florence, AL]. September 28, 2009. Web site: http://timesdaily.com/stories/BlueCross-starting-three-tiered-system,85093. Accessed January 20, 2013. 5. Apfelbaum JL, Walawander CA, Grasela TH, et al. Eliminating Intensive Postoperative Care in Same-day Surgery Patients Using Short-Acting Anesthetics. Anesthesiology. 2002;97(1):66-74.6. Song D, Chung F, Ronyne M, Ward B, Yogendran S, Sibbick C. Fast-tracking (bypassing the PACU) does not reduce nursing workload after ambulatory surgery. British Journal of Anaesthesia. 2004;93(6):768-774.7. Fredman B, Sheffer O, Zohar E, et al. Fast-Track Eligibility of Geriatric Patients Undergoing Short Urologic Surgery Procedures. Anesthesia and Analgesia. 2002:94;560-564.8. Duncan PG, Shandro J, Bachand R, Ainsworth L. A pilot study of recovery room bypass ("fast-track protocol") in a community hospital. Canadian Journal of Anesthesia. 2001;48(7):630-636.9. White PF, Rawal,S, Nguyen J, Watkins, A. Pacu Fast-Tracking: An Alternative to Bypassing the PACU for Facilitating the Recovery Process After Ambulatory Surgery. Journal of PeriAnesthesia Nursing. 2003;18(4):247-253. 10. White, PF and Song D. New criteria for fast-tracking after outpatient anesthesia: a comparison with the modified Aldrete's scoring system. Anesthesia and Analgesia. 1999;88(5):1069-1072.11. Klobuchar CM. Jorge Antonio Aldrete, MD, MS Pioneering Anesthesiologist Continues To Shape His Field. Anesthesiology News. 2005. http://www.anesthesiologynews.com/ViewArticle.aspx?d_id=2&a_id=2517. Accessed November 28, 2012.

36

References12. Maltby JR. Notable Names in Anaesthesia. 1st ed. London, UK: Royal Society of Medicine Press; 2002: 2-4.13. Association of Operating Room Nurses. AORN Guidance Statement: Postoperative Patient Care in the Ambulatory Surgery Setting. AORN Journal. 2005;81(4):881-888. 14. Watkins AC, and White PF. Fast-tracking after ambulatory surgery. Journal of Perianesthesia Nursing. 2003;16(6):379-387.15. Loughlin KA, Weingarten CM, Nagelhout J, and Stevenson JG. A Pharmacoeconomic Analysis of Neuromuscular Blocking Agents in the Operating Room. Pharmacotherapy. 1996;16(5):942-950. 16. Inflation Calculator: Bureau of Labor Statistics. United States Department of Labor Web site. http://www.bls.gov/data/inflation_calculator.htm. AccessedJuly14, 2013. 17. Macario A. What does one minute of operating room time cost? Journal of Clinical Anesthesia. 2010;22:233-236.18. Shippert RD. A Study of Time-Dependent Operating Room Fees and How to Save $100,000 by Using Time-Saving Products. The American Journal of Cosmetic Surgery. 2005;22(1):25-34. 19. PACU Nurse Education, PACU Nurse Requirements, PACU Nurse Education Requirements | Education Requirements. Grand Canyon University Web site. http://www.educationrequirements.org/pacu-nurse.html. AccessedJuly14, 2013. 20. Husted H, Holm G, and Jacobsen S. Predictors of length of stay and patient satisfaction after hip and knee replacement surgery: Fast-track experience in 712 patients. Acta Orthopaedica. 2008;79(2):168-173. 21. Hospital Quality Initiative - Centers for Medicare & Medicaid Services. Centers for Medicare & Medicaid Services Web site. http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/index.html?redirect=/hospitalqualityinits. Accessed July14, 2013. 22. Norris MC. Anesthesia for outpatient surgery: how fast is fast? Anesthesiology. 2005;102(3):694-695.

37