Integrated Care In Action Surgery Clinical Program

1. Integrated Care In ActionSurgery Clinical Program

2. Disclosures None pertinent to this presentation No trade names will be used in this presentation

3. 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

4. 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.

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

6. 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.

7. 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.

8. 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.

9. 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.

10. 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.

11. Multidisciplinary Colon Surgery (MDCS) Physician Orders

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

13. 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

14. 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.

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

16. The Dashboard

17. ERAS Financials

18. 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

19. 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

20. Questions?