Integrated Care In Action Surgery Clinical Program
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Transcript of Integrated Care In Action Surgery Clinical Program
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Integrated Care In ActionSurgery Clinical Program
David S. Jevsevar, MD, MBABoard and Executive Learning Series
Vancouver, BCJune 2, 2012
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Disclosures
• None pertinent to this presentation
• No trade names will be used in this presentation
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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
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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.
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Objective
• Evaluate the introduction of a comprehensive care process for an enhanced recovery after colon surgery care process in 8 Intermountain Healthcare community hospitals.
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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.
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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.
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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.
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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.
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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.
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Multidisciplinary Colon Surgery (MDCS) Physician Orders
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Implementation
• From inception of the MDCS hypothesis to beginning of implementation took 18 months.
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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
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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.
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Demographic, MDCS enrollment comparison data and service population for the 8 community
hospitals
Hospital StaffedBed Count
Avg Resectionsper Year* MDCS Start Date Population 2009 County
A 126 34 6-May-08 115,269 Cache
B 311 132 25-Jun-08 231,834 Weber
C 78 47 28-Jul-08 545,307 Utah
D 245 108 13-Aug-08 137,473 Washington
E 367 101 8-Oct-08 545,307 Utah
F 446 156 2-Feb-09 1,034,969 Salt Lake
G 213 128 5-Mar-09 1,034,969 Salt Lake
H 69 64 13-Apr-09 1,034,969 Salt Lake
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The DashboardThe Dashboard
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ERAS Financials
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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
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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
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Questions?