Practice Redesign and
Enhanced Recovery Pathway
in Colorectal Surgery:
The journey to better…
Jenna Lovely, PharmD, RPh, BCPS
©2014 MFMER | slide-1
Overview
• Enhanced Recovery Pathway (ERP)
Description
• ERP within the CRS Project
• Actions
• Results
• Lessons Learned
• How you can do this too!
• Questions / Answers
©2014 MFMER | slide-2
Learning Objectives:
• Describe 3 or more critical elements of an
evidence based perioperative care pathway
• Discuss 3 or more ways to identify practice
redesign initiatives
• Identify 3 or more action steps the audience
members can use for implementing evidence
based perioperative care pathway in their
practice
No disclosures
©2014 MFMER | slide-3
ERP Background
• First initiated 15 years ago by Dr. Henrik Kehlet
• 6 randomized controlled trial
• 452 patients
• Outcomes
• Decreased morbidity
• Shortened length of hospital stay
• Improved Resource utilization
• Bundling of data driven interventions which
improve value
Case-matched series of enhanced versus standard recovery pathway in minimally invasive colorectal
surgery. J. K. Lovely1, P. M. Maxson2, A. K. Jacob3, R. R. Cima4, T. T. Horlocker3, J. R. Hebl3, W. S.
Harmsen5, M. Huebner5 and D. W. Larson4 BJS 2011.
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Enhanced Recovery Pathway (ERP) …
• Evidenced based practice accelerated recovery
program that aims to decrease stress
responses, organ dysfunction, and improve
postoperative recovery by focusing on:
• Patient education
• Optimal pain control
• Fluid balance
• Early nutrition
• Early ambulation
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Method
• November of 2009-Feb 2010 all MIS patient
on 2 surgeon services were en-rolled in ER
• 66 ERP case matched to 66 FTP patients
• Case matched:
• Surgeon, operation, age
• January through July 2011 all MIS surgery at Mayo
• Prospective monthly reviewed data base
• 396 ERP compared to 177 FTP
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Pathway differences
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Demographics
• All demographics were equal in both pilot and
Larger study
• Age
• Gender
• ASA
• Disease
• Procedure type
• Pre operative use of Opioids
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Fluid management under ERP
• Fluid Management
ERP
FTP
• Mean OR volume
2404
3780
• Mean PACU volume
396
716
• Mean Unit volume
975
3245
All significantly different p<0.001
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Pain control under ERP
• Pilot
• ERP achieved Goal Pain Score
• 80 vs 60% of the time
• 38 OME/day vs 182 OME/day
• Larger study
• ERP achieved Goal Pain Score
• 80 vs 55% of the time
• 161 OME/Day vs 301 OME Day
All statistically significant p>0.01,
<10% of patient required a PCA
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GI recovery and LOS
• Pilot: 66 vs 66 pts
• Return of Bowel function
• LOS Median
• LOS Mean
• DC on day 2
1 vs. 2 days
3 vs. 3 days
3.1 vs. 4.4
44% vs. 8%
• Trial: 396 vs 177 pts
• Return of Bowel function
• LOS Median
• LOS Mean
• DC on day 2
2.1
3
3.8
38%
p<0.001
p<0.001
p>0.001
p>0.001
vs. 2.5
p<0.04
vs. 4
p<0.01
vs. 4.75 p>0.01
vs. 5% p>0.001
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Complications
• Pilot: 66 vs 66 pts
• All complications
• ARF
• Ileus
• Leak/abscess
• Re-admission
36% vs. 45%
1% vs. 1%
9% vs. 12%
2.3% vs. 1.9%
15% vs.7.6%
P=NS
P=NS
P=NS
P=NS
P=NS
• Trial: 396 vs 177 pts
• All complications
• ARF
• Ileus
• Leak/abscess
• Re-admission
30% vs. 40%
1% vs. 1%
13% vs. 13%
3% vs. 1.9%
10.8% vs.12.3%
P>0.05
P=NS
P=NS
P=NS
P=NS
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NSQIP Participating Hospitals
Number of Participating Sites by State and Region (237)
CANADA 4
2
Number of Participating
Sites by State and Region
Total Number of Sites: 204
June 2010 Semiannual Report
MIDWEST 72
3
2
8
3
1
4
1
20
33
2
2
10
11
2
28
3
1
6
5
17
4 2
3
4 2
July 2009 Semiannual Report
6
4
NORTHEAST
59
1
7
10
1
1
2
WEST 49
8
ABU DHABI 1
2
2
LEBANON 1
6
SOUTH 51
1
1
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Colorectal Surgery
Length of Stay
Observed Rate: 17.74%
Expected Rate: 17.63%
O/E Ratio: 1.01
Status: As Expected
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Colorectal Surgery
Length of Stay
Observed Rate: 14.67%
Pred. Obs. Rate:
16.46%
Expected Rate:
20.99%
Odds Ratio: 0.71
Status: Non-Outlier
©2014 MFMER | slide-15
Known Benefits With ERP at MCR:
• Improved recovery
• ERP decreases opioid use without impacting
pain scores
• Earlier return of GI function
• ERP decreases hospital LOS without impacting
30 day complications and 30 day readmission
rates
• ERP decreases cost of hospital stay
©2014 MFMER | slide-16
Next steps to better: Multidisciplinary Team
• Dr. David Larson (Physician Champion)
• Jenna Lovely, PharmD (Lead)
• Diane Foss (Nurse Manager Lead)
• Gene Dankbar (Systems Engineering Analyst)
• Leslie Fedraw (Project Manager)
• Data Abstractors
• Residents
• Pharmacists
• Midlevel Providers
• Nursing Staff
• Clinical Nurse Specialist
©2014 MFMER | slide-17
How Did We Continue to Improve…
• Discovery of an optimal state through a diverse
workgroup
• Commitment to Safety framework to guide our
Mayo funded Practice Redesign Initiative.
• Team efforts fostered
• Compliance with the enhanced recovery
pathway through
• Transparency of data
• Innovative efforts to transmit goals into
reality
• Feedback loops for all involved
©2014 MFMER | slide-18
Huddle Structure
• Weekly Meetings – Thursday at noon
• 30 minutes
• Multi-disciplinary
• Quick review of current performance
• Review of current PDSAs
• Open forum for bringing up ideas / concerns
• Leave with assignments / next steps
©2014 MFMER | slide-19
Improve compliance in ERP
within one month
1.
Daily weight will be charted prior to 6am with >95%
compliance
2.
Goal discharge date identified on patient’s white
board with >95% compliance
3.
Improve compliance with administering NSAIDs and
Acetaminophen to our patient’s > 95%
4.
Increase awareness of in and out catheterization
practice standardization
5.
Promote consistent patient messaging
6.
Maintain euvolemic state (fluid neutral)
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Intervention/PDSA’s
1. Communicate in nurse to nurse handoff when weight not obtained by night
shift. Note weight needed and date via patient room white board.
(Example: Date ____ & Wt. ____).
2. The goal discharge date is written on the patient’s white board during unit
briefings and updated daily.
3. Educate patients on importance/benefit of taking NSAID/Tylenol in the
short term hospital setting. Reinforce by using multidisciplinary team when
needed. Send note/email to pharmacist identifying the reason
NSAID/Tylenol was not given to patient. (Example: pt. nauseated, gone to
test).
4. Formulate an educational multidisciplinary correspondence which
encompasses influential factors supporting in and out catheterization
practice standardization.
5. Scenario development and role modeling sessions during Professional
Development Days.
6. Creation of Intake and Output recording log to be placed in patient folder.
©2014 MFMER | slide-21
Outcomes/Results
1.
Review of patient’s electronic medical record for documentation
of weight .
2.
Data was collected by observation and daily audits of the white
boards in the patient room.
3.
Data was collected by RN abstractor reviewing electronic
medical record for documentation of medication given.
4.
Review of charting to see if patient has been bladder scanned
opposed to in and out catheterized.
5.
Consistent messaging to patient and family members related to
ERP and specific situations/concerns.
6.
Increase accuracy of intake and output recording through
incorporation of patient involvement in recording process.
©2014 MFMER | slide-22
Patient Weights Documented
by 0600 a.m.
100%
90%
80%
70%
60%
50%
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Administer NSAIDs / Acetaminophen
100%
90%
80%
70%
60%
50%
April 1st5th
April 8th12th
April 15th- April 23rd- April 29th19th
25th
May 3rd
May 6th10th
May 12th17th
May 20th24th
May 27th31st
June 3rd7th
June 10th14th
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Enhanced Recovery Pathway
Compliance in 2013
©2014 MFMER | slide-25
Goal Discharge Date
100%
90%
80%
70%
60%
50%
40%
Feb 4th - 8th
Feb 13th - 15th
Feb 21st - Feb 27th
March 21st
May 21st
May 29th
©2014 MFMER | slide-26
In and Out Catheterization
100%
98%
96%
94%
92%
90%
April 4th
April 7th - 11th
April 14th - 18th
April 22nd - 24th
May 21st
June 5h - 6th
©2014 MFMER | slide-27
Intake & Output Patient Log
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Communicating
Changes :
Bladder
Scanning
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Met and Exceeded our Goal!
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Goal Alignment
• Standardization of care
• Practice Redesign
• Sustainable and Reproducible
• Enterprise Diffusion
©2014 MFMER | slide-32
Where we fit in the Big, Big Picture
Institutional Priorities
Practice Re-Design
MTR Projects
CRS Project
Local CRS Team
Weekly Team
Huddles
PDSA Cycles
Local ideas
©2014 MFMER | slide-33
Lessons Learned Along the Way
• Be sure to celebrate along the way
• Transparent
• Data without communication and leadership
alignment is not as successful
©2014 MFMER | slide-34
Communicating Expectations and Roles
©2014 MFMER | slide-35
Example of case based learning:
• What can I do for the GOAL of Optimal
pain control for patient?
•
•
•
•
Maximize non-pharm
Coach patient to recovery
Patient ‘refusal’ is discussed with team
Scheduled NSAIDs and Acetaminophen
need to be given and proactively
encouraged
• Discuss issues openly and early with the
surgical team and multidisciplinary team
• GOAL is great pain management that
meets patients’ goals with the lowest
opioids.
©2014 MFMER | slide-36
©2014 MFMER | slide-37
Taking This Back to your Work Unit
• SMART goals
• Specific
• Measurable
• Achievable
• Realistic
• Time-based
• Culture of Safety – Team Collaboration
• Align with leadership / enterprise roadmap
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What we are still working on…
• Innovation to automate
• Innovation to improve efficiency and outcomes
• Culture around transparency of data
• Coaching
• Understanding feedback loops
©2014 MFMER | slide-39
EASE
Enhanced Analytics for Surgical Excellence
David Larson MD, MBA
Matt Burton MD
Jenna Lovely Pharm D
Tim Miksch
Keith Toussaint
©2014 MFMER | slide-40
See-Think-Act
• Developing Tools that work in your Workflow
• Making Information (All Automated)
• Meaningful
• Accessible
• Actionable
• Goal
• Add Value to your practice
• Improve your Cognitive Burden
• Facilitate Best Practice
• Facilitate your QI, Research, Management
(Diagnosis, Procedures, Data, Complications, Standard pathways, Decision Support i.e. rules)
©2014 MFMER | slide-41
Current State of Electronic Environment
•Numerous Apps (20+/ user)
•
Users: “Hunting & Gathering”
•
Not Optimized to Workflow
•
No Pathway Monitoring
•
Still use Paper Intermediates
• Lots of Clicking
• Frequent switching between Apps
©2014 MFMER | slide-42
Current Electronic Environment vs. New CRS Tool
Eliminating waste, Improving Quality
Current EMR
Needs to Round
New PoC Tool (mobile)
Needs to Round
Information Systems
11+
1
Use of Paper Intermediates
5+
0
Manual Pathway/
Complication Calculations
>36
0
Screen Transitions
(Inter-application)
237 (43)
25 (0)
Mouse Clicks
619
25
Estimated Cognitive
Load Index
1,623
75 (<5% of current)
Time (minutes)
30:14 (95% on
navigation)
< 4:30 (95% on Clinical)
Provider Workflow/Effort
Burton, Sunday, Larson et al. submitted to AMIA 2014
©2014 MFMER | slide-43
Point-of-Care
Tools with Expert Rules
©2014 MFMER | slide-44
Mayo Clinic Example of Practice Management Dashboards
©2014 MFMER | slide-45
Actions We Took Along the Way
• Multiple PDSAs to address gaps in the key ERP
elements
• Staff engagement
• Communicating with ALL staff involved
• Continuing to redesign processes to support the
best practice initiatives
©2014 MFMER | slide-46
Overview
• Enhanced Recovery Pathway (ERP)
Description
• ERP within the CRS Project
• Actions
• Results
• Lessons Learned
• How you can do this too!
• Questions / Answers
©2014 MFMER | slide-47
Learning Objectives 1, 2, 3…
• #1 …. Describe 3 or more critical elements of
an evidence based perioperative care pathway
• # 2… Discuss 3 or more ways to identify
practice redesign initiatives
• #3…
©2014 MFMER | slide-48
Learning Objective # 3: What are the Next
Steps for You and Your teams…
• Identify 3 or more action steps the audience members
can use for implementing evidence based perioperative
care pathway in their practice
•
•
•
•
•
•
•
YOUR ‘best practice initiative here’
YOUR Project draft (SMART goals)
YOUR Actions
YOUR Results
YOUR Lessons Learned
YOUR Diffusion: How you can do this too!
YOUR Questions / Answers
©2014 MFMER | slide-49
Thank you for your attention!
lovely.jenna@mayo.edu
©2014 MFMER | slide-50
©2014 MFMER | slide-51