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Practice Redesign and Enhanced Recovery Pathway in Colorectal Surgery: The journey to better…

Practice Redesign and Enhanced Recovery Pathway in Colorectal Surgery: The journey to better…. Jenna Lovely, PharmD, RPh, BCPS. Overview. Enhanced Recovery Pathway (ERP) Description ERP within the CRS Project Actions Results Lessons Learned How you can do this too! Questions / Answers.

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Practice Redesign and Enhanced Recovery Pathway in Colorectal Surgery: The journey to better…

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  1. Practice Redesign and Enhanced Recovery Pathway in Colorectal Surgery: The journey to better… Jenna Lovely, PharmD, RPh, BCPS

  2. Overview • Enhanced Recovery Pathway (ERP) Description • ERP within the CRS Project • Actions • Results • Lessons Learned • How you can do this too! • Questions / Answers

  3. Learning Objectives: • Describe 3 or more critical elements of an evidence based perioperative care pathway • Discuss 3 or more ways to identify practice redesign initiatives • Identify 3 or more action steps the audience members can use for implementing evidence based perioperative care pathway in their practice No disclosures

  4. ERP Background • First initiated 15 years ago by Dr. Henrik Kehlet • 6 randomized controlled trial • 452 patients • Outcomes • Decreased morbidity • Shortened length of hospital stay • Improved Resource utilization • Bundling of data driven interventions which improve value Case-matched series of enhanced versus standard recovery pathway in minimally invasive colorectal surgery. J. K. Lovely1, P. M. Maxson2, A. K. Jacob3, R. R. Cima4, T. T. Horlocker3, J. R. Hebl3, W. S. Harmsen5, M. Huebner5 and D. W. Larson4 BJS 2011.

  5. Enhanced Recovery Pathway (ERP) … • Evidenced based practice accelerated recovery program that aims to decrease stress responses, organ dysfunction, and improve postoperative recovery by focusing on: • Patient education • Optimal pain control • Fluid balance • Early nutrition • Early ambulation

  6. Method • November of 2009-Feb 2010 all MIS patient on 2 surgeon services were en-rolled in ER • 66 ERP case matched to 66 FTP patients • Case matched: • Surgeon, operation, age • January through July 2011 all MIS surgery at Mayo • Prospective monthly reviewed data base • 396 ERP compared to 177 FTP

  7. Pathway differences

  8. Demographics • All demographics were equal in both pilot and Larger study • Age • Gender • ASA • Disease • Procedure type • Pre operative use of Opioids

  9. Fluid management under ERP • Fluid Management ERP FTP • Mean OR volume 2404 3780 • Mean PACU volume 396716 • Mean Unit volume 975 3245 All significantly different p<0.001

  10. Pain control under ERP Pilot ERP achieved Goal Pain Score 80 vs 60% of the time 38 OME/day vs 182 OME/day Larger study ERP achieved Goal Pain Score 80 vs 55% of the time 161 OME/Day vs 301 OME Day All statistically significant p>0.01, <10% of patient required a PCA

  11. GI recovery and LOS • Pilot: 66 vs 66 pts • Return of Bowel function 1 vs. 2 daysp<0.001 • LOS Median 3 vs. 3 days p<0.001 • LOS Mean 3.1 vs. 4.4 p>0.001 • DC on day 2 44% vs. 8% p>0.001 • Trial: 396 vs 177 pts • Return of Bowel function 2.1 vs. 2.5 p<0.04 • LOS Median 3 vs. 4 p<0.01 • LOS Mean 3.8 vs. 4.75 p>0.01 • DC on day 2 38% vs. 5% p>0.001

  12. Complications • Pilot: 66 vs 66 pts • All complications 36% vs. 45% P=NS • ARF 1% vs. 1% P=NS • Ileus 9% vs. 12% P=NS • Leak/abscess 2.3% vs. 1.9% P=NS • Re-admission 15% vs.7.6% P=NS • Trial: 396 vs 177 pts • All complications 30% vs. 40% P>0.05 • ARF 1% vs. 1% P=NS • Ileus 13% vs. 13% P=NS • Leak/abscess 3% vs. 1.9% P=NS • Re-admission10.8% vs.12.3% P=NS

  13. NSQIP Participating Hospitals Number of Participating Sites by State and Region Total Number of Sites: 204 July 2009 Semiannual Report

  14. Colorectal Surgery Length of Stay Observed Rate: 17.74% Expected Rate: 17.63% O/E Ratio: 1.01 Status: As Expected

  15. Colorectal Surgery Length of Stay Observed Rate: 14.67% Pred. Obs. Rate: 16.46% Expected Rate: 20.99% Odds Ratio: 0.71 Status: Non-Outlier

  16. Known Benefits With ERP at MCR: • Improved recovery • ERP decreases opioid use without impacting pain scores • Earlier return of GI function • ERP decreases hospital LOS without impacting 30 day complications and 30 day readmission rates • ERP decreases cost of hospital stay

  17. Next steps to better: Multidisciplinary Team • Dr. David Larson (Physician Champion) • Jenna Lovely, PharmD (Lead) • Diane Foss (Nurse Manager Lead) • Gene Dankbar (Systems Engineering Analyst) • Leslie Fedraw (Project Manager) • Data Abstractors • Residents • Pharmacists • Midlevel Providers • Nursing Staff • Clinical Nurse Specialist

  18. How Did We Continue to Improve… • Discovery of an optimal state through a diverse workgroup • Commitment to Safety framework to guide our Mayo funded Practice Redesign Initiative. • Team efforts fostered • Compliance with the enhanced recovery pathway through • Transparency of data • Innovative efforts to transmit goals into reality • Feedback loops for all involved

  19. Huddle Structure • Weekly Meetings – Thursday at noon • 30 minutes • Multi-disciplinary • Quick review of current performance • Review of current PDSAs • Open forum for bringing up ideas / concerns • Leave with assignments / next steps

  20. Improve compliance in ERP within one month • Daily weight will be charted prior to 6am with >95% compliance • Goal discharge date identified on patient’s white board with >95% compliance • Improve compliance with administering NSAIDs and Acetaminophen to our patient’s > 95% • Increase awareness of in and out catheterization practice standardization • Promote consistent patient messaging • Maintain euvolemic state (fluid neutral)

  21. Intervention/PDSA’s • Communicate in nurse to nurse handoff when weight not obtained by night shift. Note weight needed and date via patient room white board. (Example: Date ____ & Wt. ____). • The goal discharge date is written on the patient’s white board during unit briefings and updated daily. • Educate patients on importance/benefit of taking NSAID/Tylenol in the short term hospital setting. Reinforce by using multidisciplinary team when needed. Send note/email to pharmacist identifying the reason NSAID/Tylenol was not given to patient. (Example: pt. nauseated, gone to test). • Formulate an educational multidisciplinary correspondence which encompasses influential factors supporting in and out catheterization practice standardization. • Scenario development and role modeling sessions during Professional Development Days. • Creation of Intake and Output recording log to be placed in patient folder.

  22. Outcomes/Results • Review of patient’s electronic medical record for documentation of weight . • Data was collected by observation and daily audits of the white boards in the patient room. • Data was collected by RN abstractor reviewing electronic medical record for documentation of medication given. • Review of charting to see if patient has been bladder scanned opposed to in and out catheterized. • Consistent messaging to patient and family members related to ERP and specific situations/concerns. • Increase accuracy of intake and output recording through incorporation of patient involvement in recording process.

  23. Enhanced Recovery Pathway Compliance in 2013

  24. Intake & Output Patient Log

  25. Communicating Changes : Bladder Scanning

  26. Met and Exceeded our Goal! “Wait for it….” Year to Date: Enhanced Recovery Pathway – 96.6%

  27. Goal Alignment • Standardization of care • Practice Redesign • Sustainable and Reproducible • Enterprise Diffusion

  28. Where we fit in the Big, Big Picture Institutional Priorities Practice Re-Design MTR Projects CRS Project Local CRS Team Weekly Team Huddles PDSA Cycles Local ideas

  29. Lessons Learned Along the Way • Be sure to celebrate along the way • Transparent • Data without communication and leadership alignment is not as successful

  30. Communicating Expectations and Roles

  31. Example of case based learning: • What can I do for the GOAL of Optimal pain control for patient? • Maximize non-pharm • Coach patient to recovery • Patient ‘refusal’ is discussed with team • Scheduled NSAIDs and Acetaminophen need to be given and proactively encouraged • Discuss issues openly and early with the surgical team and multidisciplinary team • GOAL is great pain management that meets patients’ goals with the lowest opioids.

  32. Taking This Back to your Work Unit • SMART goals • Specific • Measurable • Achievable • Realistic • Time-based • Culture of Safety – Team Collaboration • Align with leadership / enterprise roadmap

  33. What we are still working on… • Innovation to automate • Innovation to improve efficiency and outcomes • Culture around transparency of data • Coaching • Understanding feedback loops

  34. EASEEnhanced Analytics for Surgical Excellence David Larson MD, MBA Matt Burton MD Jenna Lovely Pharm D Tim Miksch Keith Toussaint

  35. See-Think-Act • Developing Tools that work in your Workflow • Making Information (All Automated) • Meaningful • Accessible • Actionable • Goal • Add Value to your practice • Improve your Cognitive Burden • Facilitate Best Practice • Facilitate your QI, Research, Management (Diagnosis, Procedures, Data, Complications, Standard pathways, Decision Support i.e. rules)

  36. Current State of Electronic Environment • Numerous Apps (20+/ user) • Users: “Hunting & Gathering” • Not Optimized to Workflow • No Pathway Monitoring • Still use Paper Intermediates • Lots of Clicking • Frequent switching between Apps

  37. Current Electronic Environment vs. New CRS ToolEliminating waste, Improving Quality Burton, Sunday, Larson et al. submitted to AMIA 2014

  38. Point-of-Care Tools with Expert Rules

  39. Mayo Clinic Example of Practice Management Dashboards

  40. Actions We Took Along the Way • Multiple PDSAs to address gaps in the key ERP elements • Staff engagement • Communicating with ALL staff involved • Continuing to redesign processes to support the best practice initiatives

  41. Overview • Enhanced Recovery Pathway (ERP) Description • ERP within the CRS Project • Actions • Results • Lessons Learned • How you can do this too! • Questions / Answers

  42. Learning Objectives 1, 2, 3… • #1 …. Describe 3 or more critical elements of an evidence based perioperative care pathway • # 2… Discuss 3 or more ways to identify practice redesign initiatives • #3…

  43. Learning Objective # 3: What are the Next Steps for You and Your teams… • Identify 3 or more action steps the audience members can use for implementing evidence based perioperative care pathway in their practice • YOUR ‘best practice initiative here’ • YOUR Project draft (SMART goals) • YOUR Actions • YOUR Results • YOUR Lessons Learned • YOUR Diffusion: How you can do this too! • YOUR Questions / Answers

  44. Thank you for your attention!lovely.jenna@mayo.edu

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