the evolution of a perioperative surgical home - … evolution of a perioperative surgical home...
TRANSCRIPT
Nihar Patel, MD Assistant Professor Anesthesia Director for Spine Surgery Director of Inpatient Pain Service
The Evolution of a Perioperative Surgical
Home
Pediatric Anesthesiology
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Conflict of Interest None
Pediatric Anesthesiology
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Objectives • Review sequence of events leading to formation of
a PSH at Texas Children’s Hospital • Examine the rationale behind PSH models • Discuss potential benefits of the PSH model • Explore the future possibilities and outcomes with
the PSH
Pediatric Anesthesiology
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History of TCH NM Scoliosis • Since 1995, roughly 40-50 scoliosis surgeries
done on children with neuromuscular disease • Straight-forward pre-op process and various
anesthetic techniques utilized
• No records of M&M, QA/QI or outcomes
Pediatric Anesthesiology
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Timeline of Creation of Multi D
Pediatric Anesthesiology
Multiple Post-Op Morbidity and Mortality
Cessation of NM Scoliosis Surgery
Formation of Safety Review Panel
Creation of Multidisciplinary Neuromuscular Scoliosis Team
Initiation of Formal Processes for Scoliosis Surgery
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Composition of Multi-D • Spine Surgeons (4 Orthopedic and 1 Neurosurgical) • Anesthesia Spine Director • Orthopedics OR Nurse Coordinator • Anesthesia Pre-op Screening Clinic Coordinator • Spine Surgery Nurse Coordinator • Pulmonologist • Nutritionist • Hematology/Blood Banking • Critical Care Physician • Ethicist/Chaplain • Spine Floor Nurse Manager • Evidence Based Outcomes Personnel
Pediatric Anesthesiology
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Safety Review Panel Findings
• Patients lacked proper indications screening
• Medical optimization of patients lacking
• Large variability in intraoperative anesthesia care
• Lack of coordination of pre-op and post-op care
PediatricAnesthesiology
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Safety Review Panel Findings
• Appropriate Preoperative workup and optimization
• Consistent team dedicated for these patients
• Better management of pulmonary function
Pediatric Anesthesiology
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PHASE 1 INDICATIONS PHASE Patient seen in Ortho Clinic Presented to Indications Conference (1st Tuesdays)
PHASE 2
EVALUATION PHASE Pulmonary Consult Nutrition Consult Other Specialties (as designated)
PHASE 3 SCREENING PHASE PASS #1 Visit
PHASE 4 Multi Disciplinary Review Group approves patient for surgery date Make inpatient preparations
PHASE 5
Final Clearance for Surgery Pre-Op Visit with consent PASS #2 Visit with consent Child Life Tour of OR &11WT
PHASE 6 Ready for Surgery
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Indications Conference
• Patient presented by Surgeon to Indications Committee
• All active spine surgeons, anesthesiologist, ICU,
Pulmonary, Ethics, Outcomes & Impact service • Automatic Consults include Pulmonary & Nutrition
Pediatric Anesthesiology
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PHASE 2 – Stage 1
Pediatric Anesthesiology
Pulmonology Consult
Sleep Study Indicated? NoYes
Results of Diagnostic
Sleep Study
Sleep Apnea diagnosed
No Sleep Apnea
diagnosed
Titration Sleep Study
One month Compliance
of BiPAP/CPAP
Patient noncompliance
Pulmonary Surgery
Clearance
Pulmonary Surgery
Clearance
Surgery Post-op Recommendations
Work with family to improve compliance or formulate other
plan if unable due to developmental delay
BiPAP/CPAP Indicated
ENT consult recommended
T&A not recommended
T & A scheduled
Sleep study repeated
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PHASE 2 – Stage 2
Pediatric Anesthesiology
Nutrition Consult
Malnutrition detected?
Malnutrition diagnosed with
BMI z-score
No malnutrition risk noted
Nutrition clearance
Oral Attempts at Weight Gain Goal
Gastric Tube Recommendation
Goal Weight not achieved
Goal Weight Achieved
Nutrition Clearance
Surgery Post-op Recommendations
Parents Agree to GTube Gtube Surgery
Parents refuse Gtube
Nutrition consult –
Time to use supplemental
formula
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PASS CLINIC
Pediatric Anesthesiology
Pulmonology & Nutrition, Other Consults initial visits
PASS #1 Screening including bloodwork
Consult Follow-up
PASS #2 to close all loops
Surgery
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PASS 1 Visit • Once cleared by Indications à Referred to PASS
(2-3 months before Surgery)
• Seen by both NP and Anesthesiologist
• Comprehensive H&P, initial labs drawn
• Anesthesia spine director responsible for reviewing initial PASS clinic visit.
• Coordinate appropriate consults
Pediatric Anesthesiology
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Multi-Disciplinary Review • After all consults/interventions completed, patient
presented at this review • Members from all services present • Meets once/month • Purpose behind Multi-D
1. Triple Check to make sure all appropriate consults made
2. Direct face to face communication between Intra-Op and Post-Op teams regarding upcoming patients (anticipate needs & plan accordingly)
• Conduct quality review of cases to identify opportunities for improvement/learning
Pediatric Anesthesiology
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PASS 2 Visit • 2 weeks prior to surgery • Follow-up labs • Type and screen/crossmatch • Anesthesiologist assigned to case • PCU/PICU notified of upcoming surgical date
Pediatric Anesthesiology
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NM Anesthetic Protocol
Pediatric Anesthesiology
• Midazolam or Valium Premed • Bear Paws Warming Pre-Op
• PIV x2, Arterial Line, Central Line, BIS • TIVA technique • Antibiotics cefazolin 25mg/kg when prone • Tranexamic Acid at 30mg/kg and 3mg/kg/hr
Induction
• IOM • Cell Saver • MAP to 60mm Hg* Maintenance
• PCU/PICU Admit • Pain Service & Consultant Visits • Reinstitution of BiPAP/CPAP Post-Op
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Acute Pain Service Protocol
• Opioid PCA with Basal + Interval • Ofirmev q6h • Ketorolac q6h • Bowel Regimen
POD 0
• Opioid PCA Interval Dose Only • Tylenol po q6h • Ketorolac q6h • Bowel Regimen
POD 1
• Hydrocodone q4-6h • Ibuprofen/Naproxen • Bowel Regimen
POD 2-6
Pediatric Anesthesiology
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Spine Scorecard
Pediatric Anesthesiology
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Pre-Op Patient Information
Pediatric Anesthesiology
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Post-Op Patient Information
Pediatric Anesthesiology
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Current Projects Under Way EBOC • Enhanced Recovery After Surgery • EBOC Antibiotic Prophylaxis • EBOC Transfusion Protocol • PSH for Idiopathic Scoliosis Surgery
Pediatric Anesthesiology
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Multi-Disciplinary Committee
Perioperative Surgical Home
Pediatric Anesthesiology
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Perioperative Surgical Home
Patient-centered, team-based model of delivering healthcare during the entire patient surgical/procedural experience until their recovery and return to PCP
Pediatric Anesthesiology
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Perioperative Surgical Home
Preoperative Intraoperative Postoperative Long-Term Recovery
Pediatric Anesthesiology
Surgery PulmonologyAnesthesia
Informa5cs
Nutri5on Nursing
Cri5calCareHematology Ethics
Quality
Improvement
Healthcare
Analy5cs
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History of PSH
1970’s and 80’s
• IT Innovations
1990’s
• Pittsburgh Medical School Preioperative Process • Stanford Pre-op Clinic Study
2000’s
• VASQIP • ASA Task Force on Future Paradigms in Anesthesia Practice
2010
• Patient Protection and Affordable Care Act (PPACA) • ACO’s
Pediatric Anesthesiology
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Essentials of PSH
Pediatric Anesthesiology
Patient-Centered Care
Coordination of Care
Commitment to Quality and Safety Accessibility to Care
Comprehensiveness
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Patient-Centered Care
• Replaces a perioperative physician-centric model
• Patient values and preferences are central
• Patient education fundamental
• Shared decision making with all aspects of care
• Communication remains consistent throughout
Pediatric Anesthesiology
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Comprehensiveness
• All issues of patient care handled from admission
to discharge
• Detailed, evidence-based, standardized plans of
care delivered to patients
• Every member of patients care team represented
in decision making and discussion
Pediatric Anesthesiology
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Coordination of Care
• Begins in surgeon’s office and continues until discharge to PCP
• Updates/results of testing communicated clearly with all members of team
• Facilitated refinement of patient care
• Lean Management or Six Sigma used to help with improvement processes
Pediatric Anesthesiology
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Accessibility to Care
• All care coordinated via EMR and amongst all care
teams
• Close monitoring of patient as inpatient or
outpatient possible
• Readmissions handled more efficiently
Pediatric Anesthesiology
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Commitment to Quality and Safety
• Standardization of care
• Evidence-based clinical pathways or protocols
• Reduction of variability
• Informatics to maintain outcomes and data
• Facilitated pathway for collaborative research
Pediatric Anesthesiology
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Potential Benefits of PSH • Safety • Efficiency • Cost-Savings • Quality Outcomes • Collegiality • Patient Satisfaction
Pediatric Anesthesiology
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Future Possibilities Craniofacial Hypospadias Idiopathic Scoliosis Neuroblastoma Solid Organ Transplant Colorectal Surgery …
Pediatric Anesthesiology
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Questions? Comments?
Thank You!
Pediatric Anesthesiology
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References • Kain ZN, Vakharia S, Garson L, et al. The perioperative surgical home as a
future perioperative model. Anesth Analg. 2014; 118:1126-1130 • Mariano ER, Walters TL, Kim TE, Kain ZN. Why the perioperative surgical
home makes sense for veterans affairs health care. Anesth Analg. 2015; 120:1163-1166
• Cannesson M, Kain Z. The perioperative surgical home model: an innovative clinical care delivery model. J Clin Anesth. 2015;27(3): 185-187
• Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Affairs. 2008; 27(3):759-769
• Vetter T, Boudreaux AM, Jones KA, Hunter JM Jr, Pittet JF. The perioperative surgical home; how anesthesiology can collaboratively achieve and leverage the triple aim in health care. Anesth Analg. 2014; 118(5): 1131-1136
• Kash BA, Zhang Y, Cline KM, Menser R, Miller T. The Perioperative Surgical Home (PSH): A Comprehensive Review of US and Non-US Studies Shows Predominantly Positive Quality and Cost Outcomes. Milbank Quarterly. 2014; 92(4): 796-821
Pediatric Anesthesiology