©2014 MFMER | slide-1 Practice Redesign and Enhanced Recovery Pathway in Colorectal Surgery: The...

©2014 MFMER | slide-1

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


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


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.


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


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


Pathway differences


Demographics

• All demographics were equal in both pilot and Larger study

• Age• Gender• ASA• Disease• Procedure type• Pre operative use of Opioids


Fluid management under ERP

• Fluid Management ERP FTP

• Mean OR volume 2404 3780

• Mean PACU volume 396 716

• Mean Unit volume 975 3245

All significantly different p<0.001


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


GI recovery and LOS• Pilot: 66 vs 66 pts• Return of Bowel function 1 vs. 2 days p<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


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-admission 10.8% vs.12.3% P=NS


NSQIP Participating Hospitals

Number of Participating Sites by State and RegionTotal Number of Sites: 204

July 2009 Semiannual Report

Number of Participating Sites by State and Region (237)

June 2010 Semiannual ReportCANADA 4

WEST 49

SOUTH 51

LEBANON 1

MIDWEST 72

NORTHEAST59

2

8

28

1

2

1

2

3

2

1

1

8

3

2

4

2

4

11

2

10

1

33

5 6

6

1

7

6

10

20

4

3

2

417

2

3

1

1

ABU DHABI 12


Colorectal Surgery Length of Stay

Observed Rate: 17.74%

Expected Rate: 17.63%

O/E Ratio: 1.01Status: As Expected


Colorectal Surgery Length of Stay

Observed Rate: 14.67%Pred. Obs. Rate:16.46%Expected Rate:20.99%Odds Ratio: 0.71Status: Non-Outlier


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


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


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


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


Improve compliance in ERP within one month1. Daily weight will be charted prior to 6am with >95%

compliance

2. Goal discharge date identified on patient’s white board with >95% compliance

3. Improve compliance with administering NSAIDs and Acetaminophen to our patient’s > 95%

4. Increase awareness of in and out catheterization practice standardization

5. Promote consistent patient messaging

6. Maintain euvolemic state (fluid neutral)


Intervention/PDSA’s1. 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. ____).

2. The goal discharge date is written on the patient’s white board during unit briefings and updated daily.

3. 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).

4. Formulate an educational multidisciplinary correspondence which encompasses influential factors supporting in and out catheterization practice standardization.

5. Scenario development and role modeling sessions during Professional Development Days.

6. Creation of Intake and Output recording log to be placed in patient folder.


Outcomes/Results1. Review of patient’s electronic medical record for documentation

of weight .

2. Data was collected by observation and daily audits of the white boards in the patient room.

3. Data was collected by RN abstractor reviewing electronic medical record for documentation of medication given.

4. Review of charting to see if patient has been bladder scanned opposed to in and out catheterized.

5. Consistent messaging to patient and family members related to ERP and specific situations/concerns.

6. Increase accuracy of intake and output recording through incorporation of patient involvement in recording process.


Jan.

28t

h-Feb

1st

Feb. 4

th-8

th

Feb. 1

1th-

15th

Feb. 2

1st-2

7th

Mar

. 28t

h-Apr

il 1st

April 1

st- 5

th

April 8

th-1

2th

April 1

5th-

19th

April 2

3rd-

25th

April 2

9th-

May

3rd

May

6th

- 10t

h

May

12t

h-17

th

May

20t

h-24

th

May

27t

h-31

st

June

3rd

-7th

June

10t

h-14

th50%

60%

70%

80%

90%

100%

Patient Weights Documented by 0600 a.m.


April 1

st- 5

th

April 8

th-1

2th

April 1

5th-

19th

April 2

3rd-

25th

April 2

9th-

May

3rd

May

6th

- 10t

h

May

12t

h-17

th

May

20t

h-24

th

May

27t

h-31

st

June

3rd

-7th

June

10t

h-14

th50%

60%

70%

80%

90%

100%

Administer NSAIDs / Acetaminophen


Enhanced Recovery Pathway Compliance in 2013


Feb 4th - 8th Feb 13th - 15th Feb 21st - Feb 27th March 21st May 21st May 29th 40%

50%

60%

70%

80%

90%

100%

Goal Discharge Date


April 4th April 7th - 11th April 14th - 18th April 22nd - 24th May 21st June 5h - 6th90%

92%

94%

96%

98%

100%

In and Out Catheterization


Intake & Output Patient Log


Communicating Changes : Bladder Scanning


Met and Exceeded our Goal!

Year to Date:Enhanced RecoveryPathway – 96.6%

“Wait for it….”


Goal Alignment

• Standardization of care

• Practice Redesign

• Sustainable and Reproducible

• Enterprise Diffusion


Where we fit in the Big, Big PictureInstitutional Priorities

Practice Re-Design

MTR Projects

CRS Project

Local CRS Team

Weekly TeamHuddles

PDSA Cycles

Local ideas


Lessons Learned Along the Way• Be sure to celebrate along the way

• Transparent

• Data without communication and leadership alignment is not as successful


Communicating Expectations and Roles


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.


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


What we are still working on…

• Innovation to automate

• Innovation to improve efficiency and outcomes

• Culture around transparency of data• Coaching• Understanding feedback loops


EASEEnhanced Analytics for Surgical Excellence

David Larson MD, MBAMatt Burton MDJenna Lovely Pharm DTim Miksch Keith Toussaint


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)


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


Current Electronic Environment vs. New CRS ToolEliminating waste, Improving Quality

Provider Workflow/EffortCurrent EMR

Needs to RoundNew PoC Tool (mobile)

Needs to Round

Information Systems 11+ 1

Use of Paper Intermediates 5+ 0

Manual Pathway/ Complication Calculations >36 0

Screen Transitions(Inter-application) 237 (43) 25 (0)

Mouse Clicks 619 25

Estimated CognitiveLoad Index 1,623 75 (<5% of current)

Time (minutes) 30:14 (95% on navigation) < 4:30 (95% on Clinical)

Burton, Sunday, Larson et al. submitted to AMIA 2014


Point-of-Care Tools with Expert Rules


Mayo Clinic Example of Practice Management Dashboards


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


Overview

• Enhanced Recovery Pathway (ERP) Description

• ERP within the CRS Project

• Actions

• Results

• Lessons Learned

• How you can do this too!

• Questions / Answers


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…


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


Thank you for your [email protected]

©2014 MFMER | slide-1 Practice Redesign and Enhanced Recovery Pathway in Colorectal Surgery: The...

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