Optimizing the TJR Patient Experience in the ASC Setting · PDF fileOptimizing the TJR Patient...

THE PATIENT ADVANTAGE | NEW ALBANY, OHIO

Optimizing the TJR Patient Experience in the ASC Setting

August 18, 2017

DSUS/INS/1116/2301c


Mark Gittins, DO, FAOAO

OrthoNeuro

Diane Doucette, RN, ONC, MBA

President of Mt Carmel New Albany Surgical Hospital

The New Albany JourneyA 12 YEAR JOURNEY

Corn ASCHospital

The New Albany JourneyA 12 YEAR JOURNEY

2003Hospital Built

2011ASC Built

2012ASC Open

2016

MCNA Hospital• 42-bed specialty hospital built in 2004

• For-profit, physician-owned New Albany Surgical Hospital

• Expanded from 42 inpatient beds to 60, accounting for more than 90,000 patient days

• Ranked among top 10 of ALL HOSPITALS for procedural volume of THA & TKA in U.S.

• December 2006: New Albany Surgical Hospital is sold to Mt. Carmel Health System and converted to non-profit

MCNA Hospital

OUTCOMES• Been recognized as a Top

Hospital for Safety and Quality by the Leapfrog Group

• Successfully passed 5 Joint Commission Surveys

• Achieved and Maintained Disease Specific Certification for Total Knee Replacement, Total Hip Replacement and Spinal Fusion

RECOGNITION

PATIENT EXPERIENCE• Won 11 consecutive Press

Ganey Inpatient Satisfaction Awards – every year of eligibility

• Most recent physician satisfaction survey indicates that 92% of physicians practicing at MCNA are “Dedicated Partners” with high satisfaction and high engagement

MCNA Hospital

• Patient and Family First

• Team work/recognition

• Triad Alignment

• Data guided decisions

CRITICAL SUCCESS FACTORS

Development of the Orthopedic Team

• Orthopedic Physician Triad– Surgeon, Internist or Hospitalist, Anesthesiologist

• Dedicated Staff– Pre-Admission Testing Nurse

– Pre-operative Block Team (Pre-op Nurses and Anesthesia)

– Orthopedic Service Line Leaders

– Orthopedic OR Coordinator (Materials and Staffing)

– Operating Room Team: RN, ST, OA, and Physician Assistant

– Inpatient Nursing Unit: Dedicated Nursing, Physical Therapy and Case Management

Development of the OP Orthopedic Team

• Orthopedic Physician Triad– Surgeon, Medical Clearance, Anesthesiologist

• Dedicated Staff– ASC Clinical Staff

• Multi-skilled in PAT, Pre-Op PACU and Discharge Planning

• OR Team – Multi-skilled RN, Scrub Tech, Central Sterile and Supply Chain

• Anesthesia

• Medical Clearance Physician

• Home Health Staff– Nursing

– Physical Therapy

Break ground on free-standing ASC next to hospital

First cases performed (no total joints)

First total joints at ASC - Uni knees

40 totals performed at ASC

117 totals performed at ASC

ASC Journey

200 totals performed thru July

2010 2011 2012 2013 2014 2015

Health Care is Changing

• Affordable Care Act

• Loss of autonomy

• Decreased reimbursement

• Loss of ancillary revenue

• ICD 10

• Mergers and acquisitions1. http://www.beckersasc.com/asc-turnarounds-ideas-to-improve-performance/physician-employment-vs-private-practice-14-statistics-on-pay-satisfaction-more.html

50% residents & fellows seek

salaried employment

More emphasis on quality metrics & outcomesMoving toward shared risk contracts and capitation models

Impact of the Affordable Care Act (2010)

Payment reform is accelerating the pace of change.Shifting from volume based payments to value based payments

13

Bundled Payment for Care

Improvement

(Voluntary)

BPCI

Comprehensive Care for Joint Replacement

(Mandatory)

CJR

Hospital Readmission

Reduction Program

HRRP

Hospital Acquired Conditions

HAC

Value Based Purchasing

VBP

Medicare Quality Initiatives (Every Hospital)

Bundled Payments (Select Hospitals)

Bundled Pay for AMI and CABG procedures

(Mandatory)

Hip FxAMI + CABG

$$$

$$

$

$

Fee-For-Service Bundled Payment

Payment for each service regardless of quantity or quality Payment for comprehensive, coordinated intervention

Vs.

Bundled Payment - Overview

Pre-Admission

Services

Part A Inpatient

Services (Hospital)

Part B Inpatient

Services (MDs)

Post-Acute Costs

(Part A & Part B)Readmissionshttp://innovation.cms.gov/initiatives/bundled-payments

http://innovation.cms.gov/initiatives/bundled-payments

Identified Opportunities for EfficienciesPATIENT THROUGHPUT DRIVERS

Patient Type1

Department1

Patient Type2

Patient Type3

Department2

Department3

Physician Practices

• Physician Triad• Scope of practice• Evidence-based

medicine (clinical guidelines/order sets/care protocols)

• Physician preference items

• Physician outreach

• Interdisciplinary rounding

• Quality initiatives• Teaching/research

responsibilities• On-call coverage

Workflow/ Processes

• Time Stamped Workflow

• Standardization• Resource

optimization• Outcome

variability• Waste/process

inefficiency• Interdepartmental

service level expectations

• Supply chain• Quality/patient

safety surveillance• Patient “pull”

mechanisms

Staff Effectiveness

• Communication• Skill

mix/Productivity• Staffing to

demand/ flexible staffing

• Training/continuing education

• Service Excellence

• Service Recovery• Clinical pathways• Continuous

performance improvement culture

• Unit of measures development

Patient/Family Engagement

• Care planning/ coordination

• Educational Binder depicting pre and post op care for 6 weeks

• DVD educational video of entire length of stay

• Communication• Patient access• Patient financial

services• Scripting• Contact point

person listed for financial and discharge planning

Service Utilization

• Room/bed occupancy

• Dedicated EVS pre inpatient unit

• Capacity management

• Surge protocols• Room turnover

performed by OR Team

• Physical layout/ configuration

• Scheduling • Demand

management

IT Systems Capability

• Tracking of time stamps

• CPOE/results reporting

• Decision support• Real-time

monitoring/alerts• Reporting/analytic

s• End-user access/

mobility solutions• Workflow

integration/ automation

• Bar coding• Telecom devices• System uptime/

performance

Functional Area

Patient Encounter

Throughput Improvement Opportunities

Elements of the Patient Experience

PRE-

ENCOUNTER

ARRIVAL/

CHECK-INCARE

INITIATION

CARE

DELIVERY

CARE

ASSESSMENT

DEPARTURE/

CHECK-OUT

POST-

ENCOUNTER

CARE

COORDINATION/

SUPPORT

PATIENT

CARE

ENCOUNTER

Pre-Encounter

• Provider to Provider

interface (e.g.,

Hospital to Clinic)

• Referral

management

• Scheduling

• Pre-registration

• Clinical history/

information capture

• Financial counseling

• Patient instructions/

expectations

Arrival/

Check-in

• Drop-off/greeting

• Wayfinding/

orientation

• Visitor identity

management

• Patient needs

accommodation

• Registration/

admission

• Check-in at POS

• Consent for Service

• Co-pay collection

Care Initiation

• Patient placement

• Patient interview &

intake (H&P)

• Patient preparation/

assessment/triage

• Provider notification

• Care protocols

• Discharge planning

• Medication

reconciliation

• Rounding

Care Coordination/

Support

• Clinical and non-

clinical support

coordination

• Multidisciplinary

communication and

information sharing

• Case management

• Supply chain

management

• Patient satisfaction

monitoring

Care Assessment

• Health status and

treatment efficacy

evaluation

• Results review

• Patient and family

education

Departure/

Check-Out

• Transfer of care

arrangements

• Follow-up

appointment

scheduling

• Co-pay collection

• Urgent consultations

• Prescriptions

• Patient escort to

point of departure

• Room turnover

Post-Encounter

• Provider to Provider

interface (e.g.,

Hospital to Clinic)

•Clinical information/

results reporting

•Patient follow-up

communication

•Medical records/

coding

•Billing/collections

•Patient monitoring

•Education and

research visits

Care Delivery

• Physician

consultation/orders

• Diagnostic services

• Treatment/

procedural services

• Medication

management

• Pain management

• Clinical information

capture/

documentation

• Nurse charting

• Charge capturePatient Care Encounter

Key Drivers of Efficiency

To identify opportunities aimed at optimizing patient throughput, we should assess current performance according to six key drivers of patient throughput. Our experience has shown that by targeting focused patient throughput drivers, hospitals can rapidly achieve significant improvement in patient flow and service excellence.

Patient Throughput

Optimization

Physician Practices

Workflow/Processes

Staff Effectiveness

Patient/Family Engagement

Service Utilization

IT Systems Capability

Outcomes of Hospital Efficiency

• Increased patient and family satisfaction due to a clear understanding of expectations.

• Increased physician satisfaction due to Physicians not having to train new employees on a daily basis.

• Increased employee satisfaction due to standardization of care and understanding the expectations of Team!

www.caresense.com

Touch Screen Data Collection

Email Surveys/EMR Integration

Outcomes data

• 100+ standard surveys over all specialties

• Collect custom questions

• Conduct research

• Benchmark results

• Use with payors

• Improve quality of care

Patient Satisfaction

• Realtime results

• Immediately address patient dissatisfaction

• Improve HCAHPS scores

• Collect thousands of forms anonymously at checkout

• Improve satisfaction

Outpatient TJA:

• Why for patient

• Why for surgeon

• Why for healthcare

Why are patients staying in a hospital?

FEAR• Unknown

• Pain

RISKS• Co-morbidities

• Medical Complications

SIDE EFFECTS OF TREATMENT• Narcotics/Anesthesia

• Blood Loss

• Surgical Trauma

Handheld Robotics• Precision freehand sculpting technology

tracks the position of the handpiece and bur relative to the surgical plan and adjusts the bur to control cutting

31

Outpatient Arthroplasty

Outpatient THA

• Outpatient THAHigher satisfaction of scores at 4 weeks

– Experienced more pain POD #1

• No difference in complications, office visits, patients visits, phone calls

• 24% outpatient THA required overnight stay

• 16 inpatient THA were discharged DOS

209 PROSPECTIVE RANDOMIZED IN PATIENT VS. OUTPATIENTBMI <40 AGE<75 FUNCTIONALLY INDEPENDENT

RECEIVED SAME PRE OP COUNSELING, ANESTHESIA/ANALGESIA AND THERAPY

Goyal et al, AAOS Annual Meeting 2016

Outpatient THARetrospective 549 THA

376 male 173 female average age 54.4

• Post operative

• 4 Acute readmission ( 2 days) 0.18%

– Component migration, hypotension, pain control, sedation

• 10 healing wound 1.8%

• 5 Periprosthetic infection 0.9%

• 6 Dislocation 1%

• 3 DVT 0.5%

Klein et al, AAOS Annual meeting 2016

Complications, Mortality, and Costs for Outpatient and Short-Stay Total Knee Arthroplasty Patients in Comparison to Standard-Stay Patients

Scott T. Lovald, PhD, Kevin L. Ong, PhD, Arthur L. Malkani, MD, Edmund C. Lau, MS, Jordana K. Schmier, MA, Steven M. Kurtz, PhD, Michael T. Manley, PhD

Received 14 May 2013; accepted 17 July 2013. published online 23 August 2013.

AbstractThe purpose of the present study is to determine the differences in cost, complications, and

mortality between knee arthroplasty (TKA) patients who stay the standard 3–4 nights in a hospital compared to patients who undergo an outpatient procedure, a shortened stay or an extended stay. TKA patients were identified in the Medicare 5% sample (1997–2009) and separated into the following groups: outpatient, 1–2 days, 3–4 days, or 5+ days inpatient. At two years, costs associated with the outpatient and the 1–2 day stay groups were $8527 and $1967 lower than the 3–4 day stay group, respectively. Out to 2years, the outpatient and 1–2 day stay groups reported less pain and stiffness, respectively, though the 1–2 day group also had a higher risk for revision.

5+ day complications

DVTDislocationInfectionMortalityWound Complication

Mechanical ComplicationImplant FailureImplant LooseningRe-admission

1-2 days complications

RevisionStiffness in joint

Outpatient Complications

Pain in joint

Mortality - 90 days

▪Outpatient 0.2%

▪1-2 days 0.4%

▪3-4 days 0.3%

▪5+ days 0.8%

Cost Savings2 Years Post Op

Outpatient: $8527

1–2 Day: $1967

Cost comparison THA

• Single surgeon case control study

• N=119 Patients

• Direct Anterior approach

• No difference in EBL or complications

• Average Cost

• Inpatient $31,327

• Outpatient $24,529

Aynardi et al, HSS J 2014

Transforming the Patient Experience


Patient Experience Best Practices

PRE OP • PERI • POST OP


Preoperative

Managing Patients Upfront: Indication vs Optimization

1. Diabetes: Hgb A1c if >7.9 delay and refer

2. Smoker: if YES then refer to smoking cessation

3. BMI: if >40 refer for counseling, metabolic consult

4. Anemia: if Hgb <12 in females and <13 in males, delay and refer for wu or blood management

5. Staph colonization: if in HC facility or HC worker or hx of MRSA, screen and decolonize

6. Narcotic dependence, manage upfront

7. Anticoagulation history or need perioperatively

8. Lack of supportive home environment

• Is this patient indicated for surgery?

– Sufficient symptoms interfering with ADL, work or recreation, QOL

– Inability of alternative treatment to resolve symptoms

– Objective evidence of joint disease amenable to surgical correction

• Develop a method to assess: Is this patient optimized for outpatient surgery?

– Should it be scheduled or delayed based on:

– Psychologically and medically fit for surgery

– Adequate support for home environment

Patient Selection• Surgeon• Patient• BMI<40• Medical History• Myocardial infarction, Stroke, PE < 1 year• Uncontrolled medical condition• Solid organ transplant• Dialysis• Psychological

Patient Expectations

Physician Office/Hospital Interface Recommendations

• Physician explains the Team concept to patient and family

• Pro-active medical and anesthesia clearance guidelines established at the surgical procedural level: TKR, THR.

• Dedicated PAT Nurse to Physician Practice as the point of contact for Hospital

• Develop Physician Office/Hospital communication binder to include scheduling sheets, education materials, PAT information etc.

• Establish semi-annual physician office/hospital education forums to include change in processes, Medicare updates, billing and coding updates, etc.

• Development of patient and family educational binder, DVD, & other resource materials depicting the entire continuum of care.

• Hospital provides the Physician Office with all educational materials, hibi-cleanse scrubs, etc.


Perioperative

Perioperative EfficienciesPatient Flow Time Stamps

Patient Flow for scheduled 7:30 in OR room 5:30 AM 5:40 AM 5:50AM 6:00AM 6:00AM 6:45AM 6:45AM

Patient Arrives at Hospital

Registration Starts

Registration Stops

Walks or escorted, arrives in Pre-op Area

Pre-op starts: This is Nursing's time to complete assessment, patient

change clothes, day of surgery diagnostic testing, H&P, notify Surgeon

of any concerns, ensure consent signed etc.

Patient transported to designated 'Holding Area"

Registration Pre-op

Patient Flow for scheduled 7:30 in OR room 6:50AM 6:55 AM 7:15 AM 7:15 AM 7:20 AM 7:25 AM 7:30AM 8:00AM

Arrives in Holding and RN checks in Patient and prepares for Block

Anesthesia Arrives, Assessment and Block insertion started

Anesthesia Block completed

Surgeon arrives in holding

Circulator reviews chart and assists Anesthesia with Transportation

Transportation to OR

Arrives in OR: Team position, preps and drapes

Surgeon makes incision

Holding Area OR

Track and post results weekly at the Physician and staff level.

Perioperative Efficiencies

• Define OR Team Roles and Responsibilities

– Anesthesia provider, Circulator, Scrub Techs, Orthopedic Assistant, Anesthesia Assistant, Physician Assistant or Private Scrub

• All blocks initiated OUTSIDE of Operating Room, patient brought to OR by Anesthesia

• Development of custom packs to include sterile supplies, non-sterile clean up kit and anesthesia set up kit.

• Standardize positioning, prepping, draping based upon surgical approach and procedural level to be performed by team


• Team turns over their own rooms

• Develop “swing”, “flip”, or “double occupancy” criteria

• Timing of when to initiate block for next case

• Skin closure routine by Physician Assistant, NP, Private Scrub

• Pro-Active approach to prepare case carts day before surgery

• Develop a formalized communication process for patient flow issues: Nextel Phones

OR Cycle Time Currently 160 Minutes For Joints

00:00

01:12

02:24

03:36

04:48

06:00

Wheels In to Wheels In Time - Knees

Time

62

4 Knee Replacements – Observed Data: Flipping 2 ORs

PP = Patient Prep Time: begins when patient enters O.R. and ends with skin incision (approx. 50 (avg) min.)S = Surgery Time: begins with skin incision and ends when surgeon breaks scrub (approx.46 min.)C = Wound Closure Time/Patient Exit Time: begins with surgeon breaking scrub and ends when patient exits O.R. (approx. 25 min.)TO = Turnover Time: begins when patient exits O.R. and ends when O.R. is ready to accept next patient (approx. 20 min.)

169 min avg Jul 2010 thru Oct 2011

151 min avg Oct 2011thru Jan 2012

Observed 136 min –consistent

with best days

Combined with hips at 190 minutes (not shown) current average is 160 minutes

Rate Limiting Step

Possible to Reduce Time by 38 to 53 Min, Increasing Total OR Capacity

20

49

37.5

45

46

37.5

20

28

37.5

13

13

37.5

Future OR

Observed OR

Sys Data OR

Wheels In to Wheels In Time - Knees

PP

S

C

TO

10 Total Joint Replacements on a standard surgery dayTeam 1: 7am – 5:10pm Team 2: 7:20am – 4:40pm

1) 3)

2) 4)

OR 2

OR 1 75

6 8

9

10lunch

Surgery Times Detail on cases 6 to 10Note: uses 10 minutes between cases for Dr. B and a 12 minute excess run-over for the team between turnover and prepPP = Patient Prep Time: begins when patient enters O.R. and ends with skin incision (approx. 20 min.)S = Surgery Time: begins with skin incision and ends when surgeon breaks scrub (approx.45 min.)C = Wound Closure Time/PT wakes up: begins with surgeon breaking scrub and ends when wound is closed (approx. 20 min.)TO = Turnover Time: begins when wound is closed and ends when patient exits O.R. (approx. 13 min.)

20 mins

45 mins 10 mins

98

Potential to reduce each

case by 38 - 53minutes.

45 minutes

• $17–50 per minute

• Average $23 per minute

45 minutes saved at $23 per minute

= $1035 per case savings

Role of the Orthopedic Representative


Postoperative

Post-Operative Process Recommendations

• DOS Post-operative order set depicts orders for the entire length of stay: Medical Management, pain control, etc.

• Discharge Goals reviewed with patient and family on day of surgery: Nursing, Case Management and Physical Therapy. Discharge is anticipated for POD 1.

• Permit family member who will be the caregiver to room in with patient.

• Patients ambulate day of surgery if they have arrived on the unit by 4pm. Gait and ROM updated on patient communication board.


• Labs drawn at 4am, Case Management arrives at 5am, Physical Therapy at 5:45am in preparation for 6am rounds.

• Surgeons round early am consistently (6am-7am) with Physical Therapy, Nursing, and Case Management.

• Evening before a clip board is assembled with patient list, progress notes, order sheets, continuity of care, prescriptions, etc. for the surgeon

• Surgeon reiterates team concept on rounds.

• Post rounds: Case Management notifies Medical Management Team of Surgical discharges to assist Internist in prioritizing patients.


Pain Management


Barrington, et al 2014

Brain

Spinal Cord

Peripheral Nerve

Nerve Stimulation

Inflammation

Tissue Injury

Narcotics Cox 2 inhibitors

Spinal/epidural narcoticsCox 2 inhibitors

Peripheral block

Local injections

Cox 2 inhibitors

Minimally invasive surgery

Brain

Spinal Cord

Peripheral Nerve

Nerve Stimulation

Inflammation

Tissue Injury

Narcotics Cox 2 inhibitors

Spinal/epidural narcoticsCox 2 inhibitors

Peripheral block

Local injections

Cox 2 inhibitors

Minimally invasive surgery

Nausea Malaise HypotensionBrain

Spinal Cord

Peripheral Nerve

Nerve Stimulation

Inflammation

Tissue Injury

Anesthesia

• Short acting spinal (hips)

• Adductor canal block (knees)—sciatic?

• General anesthesia

• Pericapsular injectable cocktail

• IV acetaminophen 1000mg x 2

• IV steroid dexamethasone 10 mg/4mg

• Celecoxib pre-op and post-op

Pericapsular Cocktail

• 20ml 1.3% bupivacaine liposome suspension

• 25ml 0.5% bupivacaine

• 0.5ml 1:1000 epinephrine

Home Health and PT

Advocacy

Ambassador program

2011

joints

total cases

2012

joints

total cases

2013

joints

total cases

2014

joints

total cases

NASC Growth

2011 2012 2013 2014 2015

Joints

Revenue

cases

Conclusion

• Safe

• Cost efficient

• Improved short term outcome1

OUTPATIENT ARTHROPLASTY

1Conclusions based on data/experience at Mount Carmel New Albany

Questions and Thank You

Transforming the Patient Experience

PHYSICIAN

OFFICE/ PAT/

PATIENT ACCESS

PREOPERATIVE

PROCESS/

ANESTHESIA

PERIOPERATIVE

PROCESS

INVENTORY

MGMT PROCESS

POSTOPERATIVE

PROCESS/

MEDICAL

COVERAGE

CLINICAL

INTEGRATION

How to Develop the Outpatient TJR Process

Patient Indications Defining Cohort Risk Stratification

Best Practice Process Compliance (SCIP)

Patient Optimization Avoiding Complications, re-operations, and re-admissions

Supply Chain Management, Lab, Radiology, Path (eliminate unnecessary)

Getting the Team On Board to Prepare for OP TJR

ASSESSING THE CURRENT HOSPITAL-BASED EPISODE OF CARE

Optimizing Personnel: Practicing to limits of license, Align Message

Patient Education / Expectation Management Family LOS / Discharge Disposition

Data Collection and Reporting: Clinical and Financial Correlation

Pre-Operative

Hospital Course

Discharge Planning

Post Acute Outpatient

Efficiency Drivers within the ASCEVERYONE KNOWS THEIR ROLE AND EVERYONE ELSE’S ROLE

Managing Patients Upfront: Indication vs Optimization

1. Diabetes: Hgb A1c if >7.9 delay and refer

2. Smoker: if YES then refer to smoking cessation

3. BMI: if >40 refer for counseling, metabolic consult

4. Anemia: if Hgb <12 in females and <13 in males, delay and refer for wu or blood management

5. Staph colonization: if in HC facility or HC worker or hx of MRSA, screen and decolonize

6. Narcotic dependence, manage upfront

7. Anticoagulation history or need perioperatively

8. Lack of supportive home environment

• Is this patient indicated for surgery?

– Sufficient symptoms interfering with ADL, work or recreation, QOL

– Inability of alternative treatment to resolve symptoms

– Objective evidence of joint disease amenable to surgical correction

• Develop a method to assess: Is this patient optimized for outpatient surgery?

– Should it be scheduled or delayed based on:

– Psychologically and medically fit for surgery

– Adequate support for home environment

Develop Exclusion Criteria for an ASC Environment

• Lack of adult support at home post surgery 24 hours a day

• Medical Exclusion Criteria



– Cardiac• Active cardiac disease

• Symptomatic ischemic heart disease

• Valvular heart disease

• Cardiac arrhythmias

• Congestive heart failure

• Asymptomatic patients with stable cardiac conditions or revascularized CAD will require cardiac clearance and anesthesia review


• Medical Exclusion Criteria– Pulmonary

• Chronic lung disease

• Untreated or suspected OSA – anesthesia review

– Morbid Obesity – anesthesia review

– Genitourinary• Chronic kidney disease – exclude patients with ESRD or baseline

creatinine of 2 or above

• Known history of urinary retention

• Men with diagnosis of BPH or prior surgical procedures for prostate cancer



– Gastrointestinal• Any history of postoperative ileus

– Chronic liver disease• Exclude patients with Cirrhosis

– Hematology• Known coagulopathy and are likely to require blood products

perioperatively

• Patients with anemia will require surgical and anesthesia review

• Patients on Coumadin® will require anesthesia review



– Neurology• Exclude patients that would be considered high risk for

perioperative delirium. This would include dementia, known prior history of postoperative delirium, or prior CVA.

– Solid Organ Transplants

Develop an OP TJR within the Hospital Setting

• Test your protocol

• Assess outcomes over 4–6 months

• Revise as necessary

• No more daily lab draws• Better blood management, TXA, pre-op

screen • No x-ray in PACU for knees• No IV PCA• No Ice Man or CPM• Decrease blocks

• Increase local infiltration• No bipolar sealer• No bulky dressing, no staples• No routine Foley Catheter• DOS Ambulation 30-50 feet• Home / Home with home care

Care Path Protocols: Eliminating Unnecessary Interventions

Discharge Planning for OP Total Joint

• Initiated during surgeon’s consultation– Questions patient regarding adult support for 24 hours post-

operatively

– Leads discussion regarding medical exclusion criteria

• Home Health Assessment by phone prior to surgery– Assess Discharge Environment

• ADLs – Kitchen, Bathroom, Bedroom

• Will 24 hour adult support be available

• Review Home Health visit day of surgery with Patient & Family

• Review all discharge instructions – pain, nausea, antibiotic, physical therapy, etc.

Physician Office/ASC Interface Recommendations

• Physician explains the Team concept to patient and family

• Pro-active medical and anesthesia clearance guidelines established at the surgical procedural level: TKR, THR.

• Explain a Pre-admission testing (PAT) & Home Health RN will be calling the patient before surgery to review the plan of care

• Develop Physician Office/ASC communication binder to include scheduling sheets, education materials, PAT information etc.

• Establish semi-annual physician office/ASC education forums to include change in processes, Medicare updates, billing and coding updates, etc.

• Development of patient and family educational binder, DVD, & other resource materials depicting the entire continuum of care.

• ASC provides the Physician Office with all educational materials, HIBICLENS® scrubs, etc.

PHYSICIAN

OFFICE/ PAT/

PATIENT ACCESS

CLINICAL

INTEGRATION

Distribute Educational Binder and DVD

during pre-op Physician office visit.

Develop Educational Materials

• Pre-Admission Testing

• Pre-Operative Process

• Anesthesia Options: Regional versus General

• Day of Surgery Processes

• Medications on the Day of Surgery

• Pain Management

• Blood and DVT Prophylaxis Management

• Diet Management

• Length of Stay Expectations: 3-4 hours post-op

• Ambulation the Day of Surgery: Exercises, Mechanical Devices

• Discharge Goals; Surgical, Physical Therapy, Medical

• Discharge planning: Home Health

• Home Health Contact Information: Communication Business Card

• Signs and Symptoms of Infection

• Discharge Instructions: Wound Care, Ted Hose, Medications, etc.

• Physical Therapy Exercises for 6 Weeks Post Op

THE MATERIAL COVERED SHOULD INCLUDE

• Preoperative Nutrition Assessment

• Preoperative Smoking Cessation

• Diabetes

• Beta-Blockers

• BMI > 40

• Screening for obstructive sleep apnea1. Do you snore?2. Do you experience frequent daytime napping?3. Do you wake up at night gasping for your breath?4. If yes to the above, do you use a CPAP/Bi-PAP machine?

• Provide the patient with Hibiclens for showering HS and AM

• Schedule preoperative physical therapy appointment to review protocols

Perioperative Protocols for High Risk Patients

PHYSICIAN

OFFICE/ PAT/

PATIENT ACCESS

CLINICAL

INTEGRATION

Pre-Admission Phone Call RN

• Pre-admission RN is dedicated to Physician Practice to enhance patient/family/physician communication

• Review diagnostic testing with patient for Anesthesia Guidelines

• Notifies Surgeon Internist / Family Practice or Anesthesia of any concerns

• Continue to coach patient and their family member regarding what will happen the day of surgery.

• Ask the patient to place the phone on speaker phone if available so their family member can hear as well.

Pre-Admission RN Call Script• Remind the patient they need to have someone with them at all times after

surgery.

• Review with them what to expect pre and post operatively.

• Remind the patient we will need your family member (coach) to be present on the day of surgery to receive coaching on how to take care of you at home.

• Review how their pain will be controlled the day of surgery and at home.

• Remind the patient they will be receiving a call from their Physical Therapist before surgery.

• Remind the patient the Physical Therapist will visit them and their family the day of surgery to coach them on ADLs.

• Remind the patient the Physical Therapist will visit them and their family at home the day after surgery by 10 am.

• You will be given an antibiotic to take after surgery at home.

• Review all discharge instructions.

• Follows Anesthesia Guidelines for diagnostic testing

• Notifies Surgeon, Internist or Anesthesia of anyconcerns

Labs:

• CBC with diff, PT/INR,PTT,U/A C&S, BMP

• Type and screen if Hgb< 11

Medications:

• Take AM of Surgery: Heart, Blood Pressure, Anti-seizure, Steroid, Breathing and all heartburn or gastric medications except for Maalox®, Mylanta®, etc.

• Do not take AM of Surgery: Oral Diabetic medication, Insulin, If on an evening dose of insulin take half the PM before surgery,

• Stop before Surgery: Metformin, Lovenox®, Coumadin, Trental®, Plavix®, Ticlid, MAO Inhibitors, Herbal medications and Anti-inflammatories

Pre-Admission Testing PHYSICIAN

OFFICE/ PAT/

PATIENT ACCESS

CLINICAL

INTEGRATION

Day of Surgery: Pre-OpMEDICATIONS

PREOPERATIVE

PROCESS/ANESTHE

SIA

CLINICAL

INTEGRATION• ANCEF® 2 gm IVPB

• If allergic to PCN give Clindamycin 600mg if patient <80 kg; 900 mg if patient > 100kg.

• Scopolamine 1.5 mg patient transdermally (hold for history of BPH, glaucoma, or greater than 70 years of age

• Versed 1mg/1ml IVP titrated to maximum of 10 mg pre block

• Beta Blocker if indicated

• Decadron® 10mg IV

• Celebrex® 400mg POx1 unless CR>1.5 and if not allergic to NSAIDS

• Acetaminophen 1gm POx1

Day of Surgery: Pre-OpNURSING

• Initiate LR IV, may utilize Lidocaine intradermally

• Bilateral elastic stocking-thigh high- to unaffected extremity preoperatively

• Active Care Sequential compression device-to unaffected extremity preoperatively

• Clip one hand breath above and below the operative knee for TKR or pelvic bone iliac crest down to mid thigh

• Chlorhexadine wipe to surgical site after clipping

PREOPERATIVE

PROCESS/ANESTHE

SIA

CLINICAL

INTEGRATION

Day of Surgery: Pre-OpANESTHESIA• General mask airway with Adductor Canal block or Spinal

for post-op pain control

REGIONAL ANESTHESIA• Performed in the preoperative area

• Patient receives Versed for sedation

• Spinal is placed utilizing straight Lidocaine

• Adductor canal block utilizing 15-30ml 0.5% Ropivicaine

• Potential sciatic block if necessary

• Appropriate monitoring for conscious sedation

PREOPERATIVE

PROCESS/ANESTHE

SIA

CLINICAL

INTEGRATION

Day of Surgery: Pre-OpOPERATING ROOM• Induction of Anesthesia with Propofol drip up to 150

mcg/kg/min

• Propofol and Versed agents of choice for maintenance of Anesthesia

ANTI-EMETICS• Scopolamine patch in pre-op behind left ear as deemed

necessary by surgeon

• Zofran® 8mg IV given 15 minutes before closure

• 2000-2500ml of Lactated Ringers or Normal Saline throughout the periop period.

PREOPERATIVE

PROCESS/ANESTHE

SIA

CLINICAL

INTEGRATION

Day of Surgery: Intra-OpPERIOPERATIVE

PROCESS

CLINICAL

INTEGRATION

NURSING• Continue with mechanical sequential device

• Skin prep with Duraprep™

PAIN INJECTION• Surgeon infiltrates surrounding surgical site

• EXPAREL®(20ml 1.3%), Bupivicaine (25ml 0.5%) and Epinephrine (0.5ml of 1:1000)

• Toradol® 30mg given by Anesthesia if renal function is normal

SKIN CLOSURE• Quill™ suture and DERMABOND® Topical Skin Adhesive

Day of Surgery: Intra-OpPERIOPERATIVE

PROCESS

CLINICAL

INTEGRATION

DRESSING• Dermabond, Aquacel®dressing, ted hose and Active

Care compression pumps

IRRIGATION• 1000ml .9% Normal Saline

• Warm .9% Normal Saline poured over implants to assist in hardening cement

Post-Operative Team ApproachPOST OP ORDERS FOR ENTIRE LENGTH OF STAY

• Surgical Management: Notify Surgeon of the following:– Decrease or lack of pedal pulses

– Inability to plantar/dorsiflex foot

– Change in appearance of wound

• Medical Management: Notify Surgeon/Anesthesia of the following:– Abdominal distention or decreased bowel sounds

– Hemoglobin < 8 grams

– Potassium < 3.5 or > 5.5

– Systolic BP < 90 or > 180 mmHg

– Tachycardia > 120 beats per minute

– Temperature > 101

• Labs: None

Post operative and

Medical Management

CLINICAL

INTEGRATION

Post-Operative Team ApproachPHYSICAL THERAPY

• Home PT visits patient and their family to educate them on how to safely perform ADLs

• Review Therapeutic exercises: Ankle pumps, quad sets, gluteal tucks 10 times/hr. while awake with patient and family

• Patient is ambulated with Nursing to bathroom and back.

• Physical Therapy contact business card given to patient/family.

Post-Operative Team ApproachNURSING

• Vital Signs and Circulation checks q1h until discharge

• Assess limb sensation, pulses, movement, and strength with each check

• May reinforce dressing prn

• Maintain ted hose and compression devices

• Oxygen via nasal cannula at 2 liters per minute, discontinue when patient is alert and room air saturation is 91%

• Incentive spirometry 10 times per hour while awake.

• Deep breathing and coughing exercises q 1hr. while awake

• TXA dose given 3 hours after first dose

Post-Operative Team ApproachDIET

• Initiate clear to full to soft diet as desired

• If no nausea, vomiting or abdominal distention, progress to soft diet before discharge

Post-Operative Team ApproachDISCHARGE INSTRUCTIONS

• Antibiotics and Pain medications ordered by Surgeon

• Home medications reconciled by Surgeon

• Refer to Patient educational binder and DVD for PT exercises

• Follow up phone call by Home Health within 48 hours of Discharge

• Home Health PT 3x for 1st week, then 2x for 2nd week. Usually 10-14 days of Home health

• Follow up appointments reviewed with patient and family

• ASA, ted hose and ActiveCare® compression pumps

Post-Operative Team ApproachMEDICATIONS FOR HOME USE

• Oxycontin® 10 mg PO q 12h: 4 tabs given

• Percocet® 5mg PO q 6h prn

• Vistaril® 25 mg PO 1 tab q 6h prn

• Keflex® 500 mg PO bid x7 days


• Define OR Team Roles and Responsibilities– Anesthesia provider, Circulator, Scrub Techs, Orthopedic Assistant,

Anesthesia Assistant, Physician Assistant or Private Scrub

• All blocks initiated OUTSIDE of Operating Room, patient brought to OR by Anesthesia

• Development of custom packs to include sterile supplies, non-sterile clean up kit and anesthesia set up kit.

• Standardize positioning, prepping, draping based upon surgical approach and procedural level to be performed by team


• Team turns over their own rooms

• Develop “swing”, “flip”, or “double occupancy” criteria– timing of when to initiate block for next case

– skin closure routine by Physician Assistant, NP, Private Scrub

• Pro-Active approach to prepare case carts day before surgery

• Develop a formalized communication process for patient flow issues: Nextel Phones


• Imperative to have Nursing and Physical Therapy ambulate the patient as soon as they are stable and in the presence of the family or caretaker

• Goal is to discharge patient within 4 hours

• Ensure patient can drink and tolerate fluids

• Ensure patient understands the frequency of home medication regimen to keep pain and nausea under control

• Home Health visits patient by 10am next morning

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