Optimizing the TJR Patient Experience in the ASC Setting

Transcription

1 Optimizing the TJR Patient Experience in the ASC Setting August 18, 2017 THE PATIENT ADVANTAGE NEW ALBANY, OHIO DSUS/INS/1116/2301c

2 Mark Gittins, DO, FAOAO OrthoNeuro Diane Doucette, RN, ONC, MBA President of Mt Carmel New Albany Surgical Hospital THE PATIENT ADVANTAGE NEW ALBANY, OHIO

3 The New Albany Journey A 12 YEAR JOURNEY Corn Hospital ASC

4 The New Albany Journey A 12 YEAR JOURNEY 2003 Hospital Built 2011 ASC Built ASC Open

5 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

6 MCNA Hospital RECOGNITION 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 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

7 MCNA Hospital CRITICAL SUCCESS FACTORS Patient and Family First Team work/recognition Triad Alignment Data guided decisions

8 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

9 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

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11 ASC Journey Break ground on free-standing ASC next to hospital First total joints at ASC - Uni knees 117 totals performed at ASC First cases performed (no total joints) 40 totals performed at ASC 200 totals performed thru July

12 Health Care is Changing Affordable Care Act Loss of autonomy Decreased reimbursement Loss of ancillary revenue ICD 10 Mergers and acquisitions 50% residents & fellows seek salaried employment 1.

13 Impact of the Affordable Care Act (2010) Payment reform is accelerating the pace of change. Shifting from volume based payments to value based payments Bundled Payments (Select Hospitals) Medicare Quality Initiatives (Every Hospital) BPCI CJR Hip Fx AMI + CABG HRRP HAC VBP Bundled Payment for Care Improvement (Voluntary) Comprehensive Care for Joint Replacement (Mandatory) Bundled Pay for AMI and CABG procedures (Mandatory) Hospital Readmission Reduction Program Hospital Acquired Conditions Value Based Purchasing More emphasis on quality metrics & outcomes Moving toward shared risk contracts and capitation models 13

14 Bundled Payment - Overview Fee-For-Service Payment for each service regardless of quantity or quality Vs. Bundled Payment Payment for comprehensive, coordinated intervention $ $ $ $ Pre-Admission Services $ $ $ Part A Inpatient Services (Hospital) Part B Inpatient Services (MDs) Readmissions Post-Acute Costs (Part A & Part B)

15 Identified Opportunities for Efficiencies PATIENT THROUGHPUT DRIVERS Functional Area Department 1 Department 2 Department 3 Patient Encounter Patient Type 1 Patient Type 2 Patient Type 3 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 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 Staff Effectiveness Communication Skill mix/productivity Staffing to demand/ flexible staffing Training/continui ng 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 Throughput Improvement Opportunities

16 Elements of the Patient Experience CARE COORDINATION/ SUPPORT CARE DELIVERY CARE ASSESSMENT PATIENT CARE ENCOUNTER PRE- ENCOUNTER ARRIVAL/ CHECK-IN CARE INITIATION DEPARTURE/ CHECK-OUT POST- 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 Delivery Physician consultation/orders Diagnostic services Treatment/ procedural services Medication management Pain management Clinical information capture/ documentation Nurse charting Care Coordination/ Support Clinical and nonclinical support coordination Multidisciplinary communication and information sharing Case management Supply chain management Patient satisfaction monitoring Charge capture Patient Care Encounter 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

17 Key Drivers of Efficiency Workflow/Processes Physician Practices Staff Effectiveness Patient/Family Engagement Service Utilization Patient Throughput Optimization IT Systems Capability 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.

18 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!

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20 Touch Screen Data Collection

21 Surveys/EMR Integration

22 Outcomes data 100+ standard surveys over all specialties Collect custom questions Conduct research Benchmark results Use with payors Improve quality of care

23 Patient Satisfaction Realtime results Immediately address patient dissatisfaction Improve HCAHPS scores Collect thousands of forms anonymously at checkout Improve satisfaction

24 Outpatient TJA: Why for patient Why for surgeon Why for healthcare

25 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

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31 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

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33 Outpatient Arthroplasty

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36 Outpatient THA 209 PROSPECTIVE RANDOMIZED IN PATIENT VS. OUTPATIENT BMI <40 AGE<75 FUNCTIONALLY INDEPENDENT RECEIVED SAME PRE OP COUNSELING, ANESTHESIA/ANALGESIA AND THERAPY Outpatient THA Higher 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 Goyal et al, AAOS Annual Meeting 2016

37 Outpatient THA Retrospective 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

38 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 published online 23 August Abstract The 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 ( ) 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.

39 5+ day complications DVT Dislocation Infection Mortality Wound Complication Mechanical Complication Implant Failure Implant Loosening Re-admission

40 1-2 days complications Revision Stiffness in joint

41 Outpatient Complications Pain in joint

42 Mortality - 90 days Outpatient 0.2% 1-2 days 0.4% 3-4 days 0.3% 5+ days 0.8%

43 Cost Savings 2 Years Post Op Outpatient: $ Day: $1967

44 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

45 Transforming the Patient Experience

46 Patient Experience Best Practices PRE OP PERI POST OP THE PATIENT ADVANTAGE NEW ALBANY, OHIO

47 THE PATIENT ADVANTAGE NEW ALBANY, OHIO Preoperative

48 Managing Patients Upfront: Indication vs Optimization 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 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

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

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52 Patient Expectations

53 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.

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55 THE PATIENT ADVANTAGE NEW ALBANY, OHIO Perioperative

56 Perioperative Efficiencies Patient 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 Track and post results weekly at the Physician and staff level. OR

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60 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, nonsterile clean up kit and anesthesia set up kit. Standardize positioning, prepping, draping based upon surgical approach and procedural level to be performed by team

61 Perioperative Efficiencies 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

62 OR Cycle Time Currently 160 Minutes For Joints 06:00 04:48 03:36 02:24 01:12 00:00 Wheels In to Wheels In Time - Knees Time 169 min avg Jul 2010 thru Oct min avg Oct 2011thru Jan 2012 Combined with hips at 190 minutes (not shown) current average is 160 minutes 4 Knee Replacements Observed Data: Flipping 2 ORs Observed 136 min consistent with best days 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.) 62

63 Rate Limiting Step

64 Possible to Reduce Time by 38 to 53 Min, Increasing Total OR Capacity Wheels In to Wheels In Time - Knees Sys Data OR Observed OR Future OR PP S C TO Potential to reduce each case by minutes. 10 Total Joint Replacements on a standard surgery day Team 1: 7am 5:10pm Team 2: 7:20am 4:40pm 1) 3) 2) 4) Surgery Times Detail on cases 6 to mins 10 mins OR mins OR 2 lunch Note: uses 10 minutes between cases for Dr. B and a 12 minute excess run-over for the team between turnover and prep PP = 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.)

65 45 minutes $17 50 per minute Average $23 per minute 45 minutes saved at $23 per minute = $1035 per case savings

66 Role of the Orthopedic Representative

67 THE PATIENT ADVANTAGE NEW ALBANY, OHIO Postoperative

68 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.

69 Post-Operative Process Recommendations 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.

70 Pain Management THE PATIENT ADVANTAGE NEW ALBANY, OHIO

71 Barrington, et al 2014 THE PATIENT ADVANTAGE NEW ALBANY, OHIO

72 Brain Spinal Cord Peripheral Nerve Nerve Stimulation Inflammation Tissue Injury

73 Brain Narcotics Cox 2 inhibitors Spinal Cord Spinal/epidural narcotics Cox 2 inhibitors Peripheral Nerve Peripheral block Nerve Stimulation Local injections Inflammation Cox 2 inhibitors Tissue Injury Minimally invasive surgery

74 Brain Narcotics Cox 2 inhibitors Nausea Malaise Hypotension Spinal Cord Spinal/epidural narcotics Cox 2 inhibitors Peripheral Nerve Peripheral block Nerve Stimulation Local injections Inflammation Cox 2 inhibitors Tissue Injury Minimally invasive surgery

75 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

76 Pericapsular Cocktail 20ml 1.3% bupivacaine liposome suspension 25ml 0.5% bupivacaine 0.5ml 1:1000 epinephrine

77 Home Health and PT

78 Advocacy

79 Ambassador program

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81 2011 joints total cases

82 2012 joints total cases

83 2013 joints total cases

84 2014 joints total cases

85 2015

86 NASC Growth Joints Revenue cases

87 OUTPATIENT ARTHROPLASTY Safe Cost efficient Improved short term outcome 1 Conclusion 1 Conclusions based on data/experience at Mount Carmel New Albany

88 Questions and Thank You

89 Transforming the Patient Experience

90 How to Develop the Outpatient TJR Process PHYSICIAN OFFICE/ PAT/ PATIENT ACCESS PREOPERATIVE PROCESS/ ANESTHESIA POSTOPERATIVE PROCESS/ MEDICAL COVERAGE CLINICAL INTEGRATION PERIOPERATIVE PROCESS INVENTORY MGMT PROCESS

91 Getting the Team On Board to Prepare for OP TJR ASSESSING THE CURRENT HOSPITAL-BASED EPISODE OF CARE Pre- Operative Hospital Course Discharge Planning Post Acute Outpatient 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) 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

92 Efficiency Drivers within the ASC EVERYONE KNOWS THEIR ROLE AND EVERYONE ELSE S ROLE

93 Managing Patients Upfront: Indication vs Optimization 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 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

94 Develop Exclusion Criteria for an ASC Environment Lack of adult support at home post surgery 24 hours a day Medical Exclusion Criteria

95 Develop Exclusion Criteria for an ASC Environment 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

96 Develop Exclusion Criteria for an ASC Environment 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

97 Develop Exclusion Criteria for an ASC Environment Medical Exclusion Criteria 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

98 Develop Exclusion Criteria for an ASC Environment Medical Exclusion Criteria 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

99 Develop an OP TJR within the Hospital Setting Test your protocol Assess outcomes over 4 6 months Revise as necessary Care Path Protocols: Eliminating Unnecessary Interventions 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 feet Home / Home with home care

100 Discharge Planning for OP Total Joint Initiated during surgeon s consultation Questions patient regarding adult support for 24 hours postoperatively 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.

101 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.

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103 Develop Educational Materials Distribute Educational Binder and DVD during pre-op Physician office visit. PHYSICIAN OFFICE/ PAT/ PATIENT ACCESS CLINICAL INTEGRATION THE MATERIAL COVERED SHOULD INCLUDE 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

104 Perioperative Protocols for Preoperative Nutrition Assessment Preoperative Smoking Cessation Diabetes Beta-Blockers BMI > 40 High Risk Patients Screening for obstructive sleep apnea 1. 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? PHYSICIAN OFFICE/ PAT/ PATIENT ACCESS CLINICAL INTEGRATION Provide the patient with Hibiclens for showering HS and AM Schedule preoperative physical therapy appointment to review protocols

105 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.

106 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.

107 Pre-Admission Testing PHYSICIAN OFFICE/ PAT/ PATIENT ACCESS Follows Anesthesia Guidelines for diagnostic testing Notifies Surgeon, Internist or Anesthesia of any concerns CLINICAL INTEGRATION 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

108 MEDICATIONS ANCEF 2 gm IVPB Day of Surgery: Pre-Op 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 PREOPERATIVE PROCESS/ANESTHE SIA CLINICAL INTEGRATION

109 NURSING Day of Surgery: Pre-Op 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

110 ANESTHESIA Day of Surgery: Pre-Op 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

111 OPERATING ROOM Day of Surgery: Pre-Op 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 ml of Lactated Ringers or Normal Saline throughout the periop period. PREOPERATIVE PROCESS/ANESTHE SIA CLINICAL INTEGRATION

112 NURSING Day of Surgery: Intra-OpPERIOPERATIVE Continue with mechanical sequential device Skin prep with Duraprep PAIN INJECTION Surgeon infiltrates surrounding surgical site PROCESS CLINICAL INTEGRATION 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

113 DRESSING Day of Surgery: Intra-OpPERIOPERATIVE 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 PROCESS CLINICAL INTEGRATION

114 Post-Operative Team Approach POST 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

115 Post-Operative Team Approach PHYSICAL 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.

116 Post-Operative Team Approach NURSING 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

117 DIET Post-Operative Team Approach Initiate clear to full to soft diet as desired If no nausea, vomiting or abdominal distention, progress to soft diet before discharge

118 Post-Operative Team Approach DISCHARGE 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 1 st week, then 2x for 2 nd week. Usually days of Home health Follow up appointments reviewed with patient and family ASA, ted hose and ActiveCare compression pumps

119 Post-Operative Team Approach MEDICATIONS 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

120 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, nonsterile clean up kit and anesthesia set up kit. Standardize positioning, prepping, draping based upon surgical approach and procedural level to be performed by team

121 Perioperative Efficiencies 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

122 Post-Operative Process Recommendations 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