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My Best Care Path for VATS Lobe: You Will Not Miss What You Do Not Need

My Best Care Path for VATS Lobe: You Will Not Miss What You Do Not Need. Robert J McKenna Jr. MD Head, Thoracic Surgery Cedars Sinai Medical Center. Presenter Disclosure Rob McKenna The following relationships exist related to this presentation :. Ethicon: Consultant, Speakers Bureau

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My Best Care Path for VATS Lobe: You Will Not Miss What You Do Not Need

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  1. My Best Care Path for VATS Lobe: You Will Not Miss What You Do Not Need Robert J McKenna Jr. MD Head, Thoracic Surgery Cedars Sinai Medical Center

  2. Presenter DisclosureRob McKenna The following relationships exist related to this presentation: Ethicon: Consultant, Speakers Bureau Covidien: Speakers Bureau

  3. As medical student • Internal med rotation, given a symptom, given a patient’s symptom. Told to: • List 10 possible diagnoses • List 10 tests to rule out each diagnosis • ORDER THEM ALL???

  4. 2 weeks ago • ICU team over the weekend ordered: • 3 daily unchanged CXR’s • 3 daily unchanged, normal CBC’s • 3 daily unchanged, normal ionized Ca, Mag, Phosphate • 2 normal coag studies I WENT BALISTIC

  5. Fast-tracking after Lobectomy • Era of Cost Containment and Pay for Performance • Need to track our results and develop protocols to reduce costs and improve performance

  6. Fast-tracking: Protocol • No routine postoperative xrays • No routine postoperative labs • Remove chest tube when: • No air leak • Output < 300 ml hours • Discharge with Heimlich valve if persistent air leak and low output

  7. Fast-tracking: Results • 282 patients • 158 women (56%) • 124 men (44%) • Mean age 71.2 years • Range 46-95 years

  8. Fast-tracking: Age

  9. Fast-tracking: Age

  10. Fast-tracking: Results • RUL 107 LUL 74 • RML 17 LLL 30 • RLL 27 SEG 15 • BILOBE 1 SLEEVE 3 • RUL +LVRS 1 PNEUM 1 • Nissen/RUL 1

  11. Fast-tracking: Results • Lung Cancer 253 • Granuloma 8 • Carcinoid 6 • Pulmonary met 5 • Bronchiectasis 4 • Hamartoma 3 • Lymphoma 1 • Sequestration 1 • Solitary Fibrous Tumor 1

  12. Fast-tracking: Results • Mean LOS = 3.26 days • Median LOS = 3 days • Mortality = 1 (0.4%)

  13. Fast-tracking: Complications • None 251 (89.3%) • Air Leak 8 (2.8%) • AF 5 (1.8%) • Pneumonia 4 • Atelectasis 3 • Urinary Ret 2 • CVA/TIA 2 • Readmit 2 • RLN 2

  14. Fast-tracking: Complications • Empyema 1 • CDIFF 1 • Chylous drainage 1 • Confusion 1 • DVT 1 • Pyelonephritis 1 • Takeback 1

  15. Fast-tracking: Results • Blood tranfusion = 11 (3.9%) • Readmission = 2 • TIA • SQ emphysema

  16. Fast-tracking: Results • Reinsert chest tube: • none

  17. Fast-tracking: Conclusions • Routine use of ICU is not necessary • Routine use of labs and xrays is not necessary

  18. Fast-tracking: Conclusions Protocols may reduce length of stay and not compromise morbidity and mortality

  19. Fast-tracking: Look at costs Sealant costs $800 per dose

  20. Fast-tracking: Sealant Bertolaccinii JCTS 2010

  21. Chest Tube Management

  22. Fast-tracking: RCT: Suction / No Suction

  23. Fast-tracking: RCT: Suction / No Suction

  24. Fast-tracking: Suction / No Suction • Several RCT’s have shown shorter LOS with no suction • Level of evidence = 1

  25. Chest Tube RemovalOn suction or water seal? Martino

  26. Chest Tube RemovalOn suction or water seal? • Level 1 data • No difference in CT duration or LOS • Suction associated with increased PTX or CXR’s • If tube reinserted, double LOS Martino

  27. Fast-tracking: Chest Tube Management • Recommendations (level 1): • No suction on drainage system • No transition from suction to seal before removal

  28. Fast-tracking: Chest Tube Management • Use suction on drainage system: • Empyema • Increased postop drainage • Pleurodesis • Clinically Significant SQ air

  29. Chest Xrays

  30. Fast-tracking: Daily CXR in ICU • 525 routine daily CXR’s reviewed • 89 showed cardiopulmonary disease (12%) • 3 (0.006%) required intervention Silverstein

  31. Fast-tracking: Daily CXR in ICU • Recommendation: • Daily CXR not warranted • Order CXR only when clinically indicated

  32. Nebulizer Treatments 4

  33. Nebulizer Treatments • 25% of respiratory care procedures delivered were not indicated, whereas 12% of patients were not receiving respiratory care that was indicated 4

  34. Nebulizer Treatments • 2011 at Cedars Sinai, big push to order nebulizer only for proper indications • 60% reduction in nebulizer treatments 4

  35. Nebulizer Treatments • Not indicated for: • routine cases of pneumonia • Atelectasis • fever 4

  36. European Respiratory Society Nebulizer Guidelines • PCP Pneumonia • Nebulizedpentamidine is more effective than placebo but less effective than oral co-trimoxazole (Grade A) • Nosocomial pneumonia • HHN for treatment of hospital acquired pneumonia (Grade C) No RCT to prove benefit

  37. European Respiratory Society Nebulizer Guidelines • Surfactant for ARDS: • Improves gas exchange (Grade B) • RCT showed no improvement in outcome measurements (Grade A) • HHN for Pulmonary HTN • nebulizedprostacyclin (iloprost) (Grade A) • inhaled prostacyclin provide superior physiological outcomes (Grade B)

  38. European Respiratory Society Nebulizer Guidelines • Bronchoscopy: • HHN local anesthesia better than by bronchoscopy (Grade B) • HHN to reduce bronchospasm (Grade C)

  39. European Respiratory Society Nebulizer Guidelines • Lung Transplant: • steroids and nebulizedcyclosporin reduce obliterativebronchiolitis because of frequent episodes of rejection in the first 3 months post-transplantation. (Grade C)

  40. Chest Physiotherapy 4

  41. Fast-tracking: Resp Treatments • Indications for chest PT: • Difficulty expectorating secretions • Indications for nebulizer treatments: • Wheezing • Difficulty expectorating secretions

  42. Chest PT Guidelines: Meta-analysis • Hypercapneic Respiratory • Failure (pH 7.25-7.35, CO2 > 50) (Grade A) • Secretions (Grade A) • IPPB not recommended • PEP uncertain • Rosièrea, Swiss med 2009

  43. Chest PT / HHN Guidelines: Meta-analysis • Indications for chest PT / HHN: • Difficulty expectorating secretions • Wheezing • Rosièrea, Swiss med 2009

  44. Financial Impact of what we do 4

  45. Financial Pressures on Hospitals • Decreasing Reimbursement • Cost Containment by Hospitals • Attempts to Reduce support for Cardio Thoracic Surgery

  46. Revenue for Hospital Programs • Hospitalization • Downstream revenue • Lab tests • Xrays • Referrals to other programs

  47. Profit of Surg Specialties Resnick: Ann Surg, 2005

  48. Surgeon’s Productivity(Relative Value Units- RVU) • Thoracic and Transplant programs were the biggest surgical contributors to hospital profit margin Resnick: Ann Surg, 2005

  49. Medicare LobectomyProfit / hospital bed

  50. Medicare LobectomyProfit / hospital bed

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