Colorectal Pathway: A Template for the Georgia Surgical Quality Collaborative

Colorectal Pathway: A Template for the Georgia Surgical Quality Collaborative

Disclosure Bryant Wilson, MD Relevant Financial Relationships: I have no actual or potential conflict of interest in relation to this presentation

Georgia Surgical Quality Collaborative GaSQC 2012 Collaborative was initiated 2013 was given Collaborative status by the ACS We began with 8 Hospitals Today we have 18 Hospitals on or becoming enrolled in NSQIP

Georgia Surgical Quality Collaborative Athens Regional Medical Center Children s Healthcare of Atlanta Eisenhower Army Medical Center Emory University Hospital Emory Midtown Hospital Medical Center of Central Georgia Memorial Health University Medical Center MCG/Children s Hospital of Georgia MCG/Georgia Regents Medical Center Northeast Georgia Medical Center Phoebe Putney Memorial Hospital Piedmont Hospital Wellstar Kennestone Hospital Wellstar Cobb Hospital Wellstar Douglas Hospital Wellstar Paulding Hospital

Decile over Time -Colorectal Surgery

Piedmont Hospital Colorectal Quality Improvement Collaborative Bryant W. Wilson, MD Joy McCaffrey, MD Kevin McGill, MD Joseph Mareno, ME

SSI/ERAS Quality Improvement Challenges: Reducing the risk of surgical site infection (SSI) and other complications, while enhancing the overall efficiency of care and patient experience (ERAS). Creating a sustainable quality improvement program.

Quality Improvement Program Requirements for high quality of care: 1. Safe medical environment 2. Clinical quality: Best s 3. Administrative quality: LEAN methodology 4. Clinician engagement 5. Outcome based reporting

Colorectal Surgery QI Program CUSP organizational structure: Safety and engagement Best and ERAS: Clinical Quality improvement Value stream mapping/lean: Administrative Quality improvement NSQIP: Collaboration and Outcome based program

Challenges 1. Obtain consensus from a heterogeneous group of surgeons for Best s 2. Obtain agreement from anesthesia for ERAS needs 3. Obtain Institutional Support 4. Implement EHR optimization

Best Design Establish the best guidelines based on the SSI and ERAS literature Separate the process into 4 phases of care: at home/preadmission testing preop operating room recovery/floor after surgery care

4 Phases of Care and 4 Surgeons

Best Design Design Development Team Joy McCaffrey, MD (Colorectal) Nancy Flanagan, RN (QI Coord. Periop) Kevin McGill, MD (General Sx.) Sharman Caye, RN (SCR) Joseph Mareno, MD (Colorectal) John Meisinger, MD (Anesthesia) Evan Feldman, MD (Colorectal) Chad Anderson, MHA (Sr. Dir. Periop Svcs.) Bryant Wilson, MD (General Sx.)

List of Best s (38) At Home Bowel Prep CHG Wipes Encourage prior day hydration with high carbohydrate drinks. Utilization of a high carbohydrate drink 3 hours prior to surgery Patient Education/Instructions PreOp Skin Prep Clipping hair in Preop Normothermia Normoglycemia Normal Oxygenation Multimodal Use of Antiemetics DVT Prophylaxis Prophylactic Antibiotics IntraOp Anastomotic Technique Chloroprep Normothermia Normoglycemia Anesthetic FiO2 of 60% Paper Towels for Draping Wound Protector Redosing IntraOp Cont d Closing Instruments Skin Closure Skin Closure Judicious use of IVF Minimize Use of Drains Local Anesthesia Wound Classification Recovery Normothermia Normoglycemia Normal Oxygenation Discontinuing Antibiotics Bandage Removal Daily Wipes Judicious use of postoperative IV fluids Discontinuation of IVF POD 2-Unless Contraindicated Post Op Diet Ambulation Night of Surgery Foley Removal

June 18 th : Kickoff Presentation and At Home Discussion At Home Task Force Work July 16 th : PreOp Follow-Up and IntraOp Discussion IntraOp Task Force Work Project Timeline August 13 th : Intra Op Followup and Recovery Discussion Recovery Task Force Work Expect Monthly Follow- Up Sessions to Monitor Success September 10 th : Resolve Barriers and Stage Rollout July 2 nd : At Home Follow-Up and PreOp Discussion PreOp Task Force Work July 30 th : IntraOp Follow-Up and Discussion IntraOp Task Force Work August 27 th : Recovery Follow-Up and Barrier Discussion Resolve Outstanding Barriers

CUSP Workgroup Bold = involved in development group. Name Role Name Role Bryant Wilson Surgeon Debbie Reeves Quality/Regulatory Kevin McGill Surgeon Elizabeth Edwards PreOp RN Evan Feldman Surgeon Gail Cardoso OR Manager Joy McCaffrey Surgeon Jayne Baskin OR RN Joe Mareno Surgeon Traci Oswald OR Supervisor Pam Falk Infection Prev. Shannon Patillo PACU RN Nancy Flanagan Performance Imprv. Deb Mastin EPIC Coord. John Meisinger Anesthesiologist Kurt Kless Nurse Manager Jim McLeod Anesthetist Bernadette Brundidge Charge Nurse Debbie Slough Periop Manager Sharman Caye Clinical Data Analyst Cynthia Johnson PAT RN Pat Marshall Clinical Nurse Spclst. Joanne Harber Performance Imprv. Chad Anderson Periop Director Lorraine Stuart Clinical Coordinator

Historical Updated Best s At Home *Bowel Prep CHG Wipes Prior Day Hydration *High Carb Drink 3 Hours Prior to Surgery *Patient Education Variable practice Most surgeons order bowel prep and oral antibiotics preoparatvely. Not offered to colorectal patients in ATA. NPO past midnight. NPO past midnight. Different instructions from different practices. Reduce/elminate a bowel prep if possible. Distribute in ATA and inform patient of proper use. Drink complex carbohydrate drink on day prior to surgery. Drink complex carbohydrate drink up to 3 hours before surgery. Uniform patient education material delivered by office and ATA.

Historical Updated Best s PreOp *Clipping Hair in PreOp Normothermia Normoglycemia Normal Oxygenation Multimodal Use of Antiemetics Clipped in OR. Older patients who complain of being cold get Bair Hugger. All patients get warm blankets. PreOp needs a place to document interventions. ATA: BMP on diabetics notify at >140 PreOp: POC glucose on diabetics Anesthesia consulted for BS <70 or >200. O2 taken in ATA. If <92% patient to X-Ray. Patients given supplemental O2 if <92% or if on home O2. Minimize use of narcotics All patients get Zofran. Some get scopalamine patch. Some receive additional meds with history of nausea. Clipped in PreOp. All colorectal surgery patients will receive bair huggers in PreOp. Document in EPIC. Preop POC Glucose on all colon surgeries Notify anesthesia for BS> 180 O2 taken in ATA. If <92% patient to X-Ray. Patients given supplemental O2 if <92% or if on home O2 Minimize use of narcotics All patients to get Decadron, Zofran, and Scopalamine patch

Historical Updated Best s PreOp DVT Prophylaxis *Prohylactic Antibiotics Heparin sometimes given in PreOp. All patients receive SCDs. Anesthesia unable to see surgeon orders for antibiotics. Procedure specific antbx hanging on anesth cart. DVT screening and appropriate chemical prophylaxis ordered in PreOp. All patients receive SCDs. Protocol built into EPIC order set. Anesthesia to hang all Antbx except Vanco OR RN alert to Preop for Vanco orders

Historical Updated Best s IntraOp Anastomotic Technique Chloraprep Normothermia Normoglycemia Anesthetic FiO2 Most surgeons staple. Occasionally hand sew. Variable practice Variable practice Follow anesthesia protocol 60% FiO2 as minimum goal. Use of stapling devices as first line. Use of chloraprep on all cases according to insert instructions. Hotline blood and fluid if temp drops OR Room temp increased to protect patient Maintain temp =36C. Follow anesthesia protocol Maintain glycemic control between 100 and 160. 60% FiO2 as minimum goal.

Historical Updated Best s IntraOp Paper Towels for Draping *Wound Protector Redosing Closing Instruments Skin Closure Variable Variable practice between some use of a bag and some the Alexis Wound Protector. Ancef every 4 hours. Variable Subcuticular stitch and skin glue. Separate gloves and gowns if coming from below, otherwise just reglove. All surgeons to use paper towels. Adjust preference cards. Adjust preference Cards. Use in every case. Choice of protector left to surgeon. Ancef every 4 hours. Separate instruments at the start of case and set aside for closing, cover with clean towel. Subcuticular stitch and skin glue. Separate gloves and gowns if coming from below, otherwise just reglove.

Historical Updated Best s IntraOp *IV Fluids Drains Local Anesthesia Wound Class Length of Surgery IV Fluids are given as fluid resuscitation after bowel prep. Variable Variable Confusion between nurses and surgeons about correct wound class. Inconsistent discussion at Sign Out. Not monitored for quality. Judicious use of IV fluids per anesthesia protocol Drains not necessary. Surgeons Discretion All procedures will receive local injections at incision site, 0.5% marcaine. Increased Education. Hardwire at Sign Out. Observe trends in procedure length.

Historical Updated Best s Recovery/Floor Normothermia Normoglycemia Normal Oxygenation Discontinuing Antibiotics Bandage Removal Temp >96.4 to leave PACU Warm Blankets Bair Hugger requested if needed. No trigger to notify MD when temp drops. Baseline established Preoperatively Post procedure protocol started if BS >200 Floor: Hypoglycemia protocol if glucose check ordered and abnormal. PACU: RN intervention <92%, alert anesth if no change Floor: On O2 <92%, with comorbidities on O2 <88% Current : If bandages are used standard calls for removal on POD 2. Protocol to notify MD if temp <96 and place Bair Hugger. POC Glucose on all colon surgery patients Notify anesthesia for BS>180 in prep and recovery. Anesthesia to announce BS at timeout. PACU: RN intervention <92%, alert anesth if no change Floor: On O2 <92%, alert anesth if no change Future : No bandages. Use skin glue.

Historical Updated Best s Recovery/Floor *Judicious Use of Post Op Fluids IV Fluid Discontinuation Post Op Diet *Ambulation Foley Removal Variable Variable Variable Variable Variable Nursing in development of protocol. Replace fluid losses 50 ml/hr default on orderset Heplock IV if taking PO fluids by POD 2. Clears POD 0 Fulls POD 1 Regular Diet on POD2 Patients should ambulate within 2 hours of transfer to the floor. Remove POD 1 unless contraindicated.

Epic Order Set Change Example

SSI/ERAS: Sustaining Quality Improvement Monthly meetings: PDCA Monitor compliance in all clinical areas Changes in EPIC to improve program Review of NSQIP outcomes and recommendations

Lessons Learned Quality Improvement requires a dyad of Clinical QI and Administrative QI Grass Root input/development creates a higher quality product EHR, though essential, can be the rate limiting step Patient education is essential to success Sustaining the quality requires PDCA methodology coupled with compliance measures