Pre-Operative Evaluations October 2013 – August 2014

1. Pre-Operative EvaluationsOctober 2013 – August 2014 CLINICAL INTEGRATION “The right care, in the right setting, at the right time” CME June 2014

2. Preoperative Evaluations: WORK GROUP • Executive Sponsor • Dean Danner Sr. VP and ACI Chief Operating Officer • Core Work Team • John Wheat, D.O. Primary Care Physician • Kristen Rahn, M.D. Primary Care Physician • Erik Anderson, M.D. Primary Care Physician • Gary Sweet, M.D. General Surgery • Timothy Logemann, M.D. Cardiovascular Associates • Dean Kellner Central Wisconsin Anesthesiology • William Holm, M.D. Anesthesiologist • Aaron Anderson, M.D. Anesthesiologist • Nathan Grabher, M.D. Anesthesiologist • Jennifer Baumann Clinical Integration Project Coordinator • Supporting Work Team • Carrie Murray Patient Centered Medical Home • Gregory Sewall, M.D. ENT • Tristan Laszewski IT/EPIC • Andrea Blaubach Fiscal Services • Susan Courtney MHC Quality Services • Angela Guden, CRNA MHC Anesthesia

3. Preoperative Evaluations: GUIDING PRINCIPLES • Patient Centered • System-Wide Approach • Physician Compact

4. Preoperative Evaluations: OBJECTIVE Pre-operative visits are conducted in a timely manner to provide standardized, essential, evidence-based, preoperative information to anesthesia and surgical care teams.

5. Preoperative Evaluations:OPPORTUNITIES FOR IMPROVEMENT • Wide Variation in Care • Inconsistent pre-operative information and process flow between clinics and providers • No consistent, documented evidenced–based pathway guiding appropriate care • Unnecessary or duplicated tests • Incomplete information, increased cost, inconvenience for patients • Out-of –System evaluations add variation, complexity to process • Expertise alignment with Severity of Care • No process to evaluate appropriate preoperative work-up based on surgical risk • Non-complex cases H&P could be conducted at the time of the surgical consult • Non-Integrated Process • Difficultly with Timeliness/Access of H&P visit in Primary Care • Inefficient for providers and patients • Communication difficulty/gap between involved specialties

6. Preoperative EvaluationsOPPORTUNITIES FOR IMPROVEMENT Expertise Alignment with Severity of Care Wide Variation in Care and Process Suboptimal Integration and Access ACI Pre-Operative Clinic Integrated with Anesthesia Evidence Based Epic Template Risk Assessment Tool Standardized clinic work flow and provide guideline based evaluations • Out-Of-System patients • High surgical risk procedures Surgical Groups performing low risk Evaluations

7. Preoperative Evaluations: TIMELINE 2013 2014 April October November March May July August December January February June Workgroup representing all stakeholders to improve the HnP process. Pilot: Risk Algorithm Assess and Improve Develop Epic template based on ICSI guidelines Communicate with Primary Care, Anesthesia and Surgical Sites. Implement Risk Algorithm Tool and Evidence Based Guidelines at Clinic and Surgical Sites. Assess and Improve ACI Preoperative HnP Clinic

8. Pre-Operative Evaluations: SURGICAL ASSESSMENT TOOL

9. Pre-Operative Evaluations: SURGICAL ASSESSMENT TOOL

10. Pre-Operative Evaluations: SURGICAL ASSESSMENT TOOL

11. Pre-Operative Evaluations: PATIENT ASSESSMENT TOOL Assessment Survey 1. Patient is either Male, over 50 or Female, over 60? ⃝ Yes ⃝ No 2. Patient has a BMI of greater than 35? (?) ⃝ Yes ⃝ No 3. History of severe Gastro Esophageal Reflux Disease (Heartburn)? ⃝ Yes ⃝ No - continue current drug therapy through day of surgery. 4. History of Pulmonary Disease or related (ie. COPD, Asthma)? ⃝ Yes ⃝ No 5. History of Obstructive Sleep Apnea (Excessive Snoring)? ⃝ Yes ⃝ No 6. History of Hypertension (High Blood Pressure)? ⃝ Yes ⃝ No - continue current beta blockers, hold ACE inhibitors and diuretics for the day of surgery. 7. History of Coronary Artery Disease (Heart Attack or Blockage of Arteries in the Heart)? ⃝ Yes ⃝ No

12. Pre-Operative Evaluations: PATIENT ASSESSMENT TOOL Assessment Survey (Continued) 8. History of other Heart Disease? ⃝ Yes ⃝ No - cardiomyopathy, arterial fibrillation, other arrhythmia, pacemaker or AICD. 9. History of High Cholesterol? ⃝ Yes ⃝ No 10. History of Endocrine Disease, Diabetes, Hyper/Hypothyroid or related? ⃝ Yes ⃝ No 11. History of Renal Disease (Kidney Failure)? ⃝ Yes ⃝ No 12. History of Hepatic Disease or Chronic Hepatitis or other Liver Problems? ⃝ Yes ⃝ No

13. Pre-Operative Evaluations: PATIENT ASSESSMENT TOOL Assessment Survey (Continued) 13. History of Alcohol Abuse or Illicit Drug Use? ⃝ Yes ⃝ No 14. Does the patient get winded when climbing just one flight of stairs? ⃝ Yes ⃝ No NOTES:

14. Preoperative EvaluationsCARDIOVASCULAR Class I • Emergency Surgery OR • Active Cardiac Conditions Evaluate, Manage First • Low-Risk Surgery OR • No Clinical Risk Factors OR

15. Preoperative Evaluations:CARDIAC RISK INDEX • Hx of ischemic heart disease • Hx of compensated or prior HF • Hx of cerebrovascular disease • Diabetes mellitus • Renal insufficiency Lee et al. Circulation 1999

16. Preoperative Evaluations:GUIDELINE: ELECTROCARDIOGRAM • ICSI EKG Guidelines • Perform EKG for all patients age 65 and older within one year prior to procedure • EKGs not indicated, regardless of age for patients having cataract surgery • EKGs not recommended for patients undergoing other minimal risk procedures unless medical history/assessment indicate a high risk patient.

17. Preoperative Evaluations:GUIDELINE: ELECTROCARDIOGRAM

18. Preoperative EvaluationsNON-INVASIVE STRESS TESTING • Class I - NONE • Class IIa • Pts with > 3 RFs • Functional Capacity < 4 METs • Vascular Surgery JACC 2009

19. Preoperative EvaluationsWHICH STRESS TEST ? Exercise Echo if normal LV Or MIBI ABLE TO EXERCISE? YES NO Pharmacologic Stress Imaging JACC 2009

20. Preoperative EvaluationsANTICOAGULATION BRIDGING THERAPY Recent Stenting • Aspirin 81 mg should be continued. • Patients anticipating “necessary elective” surgical procedures that meet the following criteria may hold their medications based on the following recommendations: • > than 2 weeks post angioplasty • > than 4 weeks post bare metal stent • > 6 months post drug eluding stent (DES) • Clopidegrel should be stopped 5 days before procedure • Prasugrel should be stopped 7 days before procedure • Ticagrelor should be stopped 5 days before procedure • Medications should be resumed 48 hours post-surgery, if there are no signs of active bleeding.

21. Preoperative EvaluationsANTICOAGULATION BRIDGING THERAPY Atrial Fibrillation • Use the CHADSVASC risk calculator • Use the online creatinine clearance calculator • Briding therapy is recommended for patient with the following: • CHADS 2 > 4 or CHADSVASC of 6 • Prior CVA or TIA • Mitral valve stenosis • Prior embolic event • Intra-cardiac thrombus

22. Preoperative EvaluationsANTICOAGULATION BRIDGING THERAPY

23. Pre-Operative Evaluations: BASIC HEALTH ASSESSMENT

24. Preoperative Evaluations:GUIDELINE: LABORATORY TESTS

25. Pre-Operative Evaluations:MEDICATION GUIDELINES

26. Pre-Operative Evaluations:MEDICATION GUIDELINES

27. Pre-Operative Evaluations:MEDICATION GUIDELINES

28. Pre-Operative Evaluations:MEDICATION GUIDELINES

29. Pre-Operative Evaluations:MEDICATION GUIDELINES

30. Preoperative Evaluations:AIMS and MEASURES • Increase the percentage of COMPLETE preoperative history and physical examination obtained for patients two years of age and older undergoing elective, non-high-risk surgery and eliminate diagnostic tests performed without clinical indications. • Increase the percentage of patients two years of age and older undergoing elective non-high-risk surgery who receive appropriate management of stable comorbidities prior to procedure. • Eliminate canceled or delayed elective, non-high-risk surgical procedures for patients two years of age and older due to incomplete preoperative history and physical examination and ineffective communication between clinics. • Fiscal Implications

31. Preoperative Evaluations:Summary • All: • Review/Familiarize with ICSI guidelines. • Provide insight on areas of input and communicate with Work Group or others involved in process. • Surgical Groups: • Incorporate Preoperative assessment tool and identify lower risk surgeries that may not need separate evaluation and perform at time of surgical consult/scheduling. • When separate evaluation needed, allow guidelines to direct preoperative testing at time of evaluation. • Primary Care: • Trial use of SmartSet / Template, give constructive feedback and move towards standardizing visits around a set of guidelines. • Anesthesia: • Serve greater role in consulting, communication with surgical teams and primary care in guiding pre-operative management.

32. Preoperative Evaluations:Implementation Plan • Surgical Groups: • Operations/Board meetings: introducing Pre-Operative Assessment tool and asking to incorporate into work flow • Monitor trend/number of Pre-operative Evaluations that can be done at time of consultation. • Primary Care: • Operations meetings. • Managers, Super-Users, and Epic Trainers trained on use of template to provide on-site physician support. • Identification of upcoming pre-ops and use of tools on subsequent visits. • Anesthesia: • Collaborating with Anesthesia Department, PARC, other surgical centers to adapt current guidelines in their protocols. • Monitoring process with subgroup focused on aims/measures listed above.

33. Pre-Operative Evaluations: Dr Joseph F Smith Medical Library • Select Staff Picks • Select Aspirus Guidelines • Preoperative Evaluation Section • Presentation • ICSI Guidelines • Patient Risk Assessment Tools • Epic Tip Sheet • ACVA Protocol for Bridging Therapy

34. Pre-Operative Evaluations: October 2013 – August 2014 CLINICAL INTEGRATION “The right care, in the right setting, at the right time” CME June 2014