Review list of applicable procedures The Applicable Procedures List includes surgical procedures which have demonstrated benefit from PGDT implementation. Review this list to help define the scope of PGDT implementation. Review list of applicable procedures. Consider extending PGDT implementation to include other medium or high risk surgical procedures. Review the Sample Procedure Lists to see where other institutions have applied PGDT. Note: These lists are intended as guides for PGDT consideration. The decision to apply PGDT should be based on clinical evaluation by the healthcare provider. Owner: Clinical Champion Tools • Applicable Procedures List • Sample Procedure Lists Consider patient risk profile Owner: Clinical Champion Surgical risk is related to both procedural and patient risk. Intraoperative hemodynamic optimization is most impactful for medium to high-risk surgeries. Patient risk assessment can be based on ASA score, PPOSUM score, or other surgical score tools. High Risk Predefined population who are currently “expected” to develop significant post-operative clinical issues leading to prolonged stay. “At Risk” Patients who “could” develop post operative complications. Consider applying PGDT for surgical patients with ASA risk score 2b plus one comorbidity or higher. Note: The decision to apply PGDT should be based on clinical evaluation by the healthcare provider. ASA Patient Risk Score: 1a: Normal healthy patient 1b: Patient with mild systemic disease 1b: Normal healthy patient with anesthetic or operative risk 2a: Patient with moderate systemic disease. 2a: Patient with mild systemic disease with anesthetic or operative risk 2b: Patient with moderate to severe systemic disease that does not limit activity 2b: Patient with moderate systemic disease with anesthetic or operative risk 3: Patient with severe systemic disease that is not incapacitating 4: Patient with incapacitating disease that is a constant threat to life 5: A moribund patient who is not expected to live 24 hours with or without surgery Owner: Cinical Champion Select target population Identify which procedures or patients are in-scope for PGDT implementation. 1 Gather morbidity and length of stay (LOS) data for target population Identify a reliable data source for hospital metrics, and understand the available data reporting capabilities. Typically, the hospital’s Quality Officer can obtain required data. Gather data and document current state metrics for selected target population, including the following: Key metrics 1. Morbidity 2. Length of stay 3. Variable cost per case Other metrics to consider tracking Mortality 30-day readmission rate Patient satisfaction score Return on investment Specifying the types of complications to measure before and after PGDT implementation can help to ensure a direct comparison. Consider whether the hospital tracks and can report on the following measures: • • • • • • • • • • • • Post-Op Mechanical Ventilation > 24h Hypotension requiring pharmacological treatment Cardiac arrhythmia requiring pharmacological treatment Wound infection Abdominal infection (GI surgery) Urinary tract infection Bacterial pneumonia Deep Vein Thrombosis (DVT) Pulmonary embolism Pulmonary edema Myocardial infarction Cardiac arrest (exclusive of fatal outcome) 2 Owner: Clinical Champion, Quality Tools • Hospital Data Form Gather morbidity and length of stay (LOS) data for target population (continued) • • • • • • • • • • • • • • • Postoperative delirium Stroke Renal failure requiring dialysis Upper gastro-intestinal bleed Anastomotic leak (GI surgery) Paralytic ileus Length of stay ICU Admission Duration of ICU stay (if ICU admission) Post-operative mechanical ventilation Lactate at end of surgery or at ICU admission Maximum ICU lactate Re-intervention Maximum ICU Sequential Organ Failure Assessment (SOFA) score (or any other organ failure score) Cumulative ICU Therapeutic Intervention Scoring System (TISS) score (or any other resource utilization score) Owner: Clinical Champion, Quality Tools • Hospital Data Form Note: Please follow hospital guidelines on patient protected health information. Prior to sharing hospital confidential information with Edwards Lifesciences, please complete a non-disclosure agreement. Compare to benchmarks Owner: Clinical Champion, Quality Leverage reported data from outside sources on national averages to understand how the hospital compares with regard to morbidity rates and length of stay. Identify specific opportunities for improvement When comparing hospital data to benchmarks, identify specific procedure types where the hospital ranks worse than preferred state (ex. worse than national average). Consider focusing on these opportunities for setting and measuring outcomes against program goals. 3 Owner: Clinical Champion, Quality Define program goals for PGDT outcomes Owner: Clinical Champion; Quality Input hospital data into the PGDT Benefit Estimator to calculate potential improvement in clinical and economic outcomes based on results from published literature. Define project goals and timing based on estimated clinical and economic benefits and expected compliance levels. Tools • PGDT Benefit Estimator • Business Case Template Tips for defining program goals: Set measurable program goals at the start of the project Establish achievable targets using documented baseline data and published study results Align program goals with organizational priorities Build stakeholder alignment with program goals Measure progress to goals periodically Document quantifiable goals and economic benefits in a business case. Estimate clinical and economic benefit Owner: Clinical Champion Input hospital data into the PGDT Benefit Estimator to estimate potential improvement in clinical and economic outcomes from PGDT implementation based on results from published metaanalyses. Document quantifiable goals and economic benefits in a business case. 4 Tools • PGDT Benefits Estimator • Business Case Template • PGDT Literature Define investment need Owner: Clinical Champion Determine required investment, including monitoring equipment (capital and disposables), team member time, and other resources. Monitoring equipment needs can be estimated using the following assumptions: • 1 disposable per procedure • 1 monitor per Operating Room (for target population) or 1 monitor per 5 disposables per month Tools • PGDT Benefits Estimator • Business Case Template Document quantifiable investment requirement in a business case. Develop and communicate business case Owner: Clinical Champion; Executive Sponsor Complete business case to estimate return on investment from benefits of implementing PGDT. Communicate the business case including clinical and economic implications to an authorized approver or executive sponsor. Confirm executive sponsor commitment to implement PGDT. 5 Tools • Business Case Template • Sample Business Case Identify and align core team members Owner: Clinical Champion; Core Team Build a cross-functional, action-oriented core team. Identify team members who can support the project needs. Engage a project coordinator to drive progress. What makes a strong project coordinator? Able to dedicate time to the project Motivated by project participation and leadership role Organized and well-connected within the hospital Tools • Project Charter Template • Team Alignment Presentation Educate and align the core team to the benefits of PGDT and the program goals using the Team Alignment Presentation. Complete business case model to estimate return on investment from benefits of implementing PGDT. Communicate the business case including clinical and economic implications to an authorized approver or executive sponsor. Confirm executive sponsor commitment to implement PGDT. Complete project charter Owner: Project Coordinator or Core Team Completing a Project Charter helps to define program goals and can be used to build stakeholder alignment with goals and action plans. The Project Charter Template provides a suggestion of content to include. 6 Tools • Project Charter Template Develop project plan and schedule meetings Owner: Project Coordinator Define a high-level action plan and timeline for program development and implementation. Schedule regular team meetings (minimum monthly) for at least six months. Invite core team members to attend meetings as required, based on project plan milestones. Tools • Project Charter Template Closely manage meeting agendas and deliverables to drive program progress. Communicate plan to key stakeholders Owner: Clinical Champion or Executive Sponsor Communicate early and often to notify impacted persons of upcoming changes, potential benefits, and expectations. Use the Communication Plan Template to define appropriate messaging, target audience, and timing for program communications. 7 Tools • Communication Plan Template Review and select PGDT protocols Owner: Clinical Champion; Clinical Leads The Protocol Summaries describe multiple PGDT clinical pathways which have demonstrated benefit. Review protocol options and discuss pros and cons of each related to the target population. Identify a PGDT protocol to apply across the target population. Document protocol selection in the Project Charter, and add to standard operating procedures (SOPs). Initiate protocolspecific training with key users. Map current workflow Tools • PGDT Protocol Summary • ESA PGDT Protocol Summary • Project Charter Template Owner: Core Team Workflow mapping helps to create a common vision, uncover variations, and identify areas for process improvement. Use standard flow chart mapping techniques to illustrate workflow, interactions, decisions, and handoffs. Trial the process flow by walking through it in real time. Revise the process map as needed to accurately reflect current state. Process Mapping: • Clearly define process boundaries • Identify first and last steps • Define each step – be accurate and honest • Make sure every loop has an escape. Gather process information through core team experience, observation, conversation, interviews, and research. Note: In most processes: – Few people have seen the total process and fully understand the process 8 Tools • Sample Workflow Map Map current workflow continued – – – – – – – Owner: Core Team Departments are managed, processes are often unmanaged Those that designed the process are typically no longer there Work is being done that adds no value to customers Work the customer needs isn’t being done Rework is built into the process Inefficiencies are built into the process Workarounds have been developed that make the process appear to be working better than it really is Define and build PGDT trigger(s) or checklist(s) Checklists and other triggers help to identify appropriate candidates for hemodynamic optimization using Perioperative Goal-Directed Therapy, and should be built into standard operating procedures, existing workflows, and information systems. Establish multiple triggers – both electronic and paper – to maximize candidate identification and to alert key stakeholders to prepare accordingly (surgeon, anesthesiologist, CRNA, anesthesia tech, OR staff, scheduling, etc). Document PGDT triggers in Project Charter Template. Triggers can be based on surgical procedure type and patient risk assessment (ASA score, PPOSUM, surgical score tools). Consider including triggers in the following workflow steps: – Scheduling • Alert in scheduling software based on surgical procedure • Print notification on daily schedule board with attached protocol – Pre-screen • Surgical pre-screen prior to surgery • At Risk screening tool – Registration / Admission • In-patient registration • Out-patient registration • Emergency Room transfer – Pre-Op • Anesthesia pre-op assessment on day of surgery • Pre-op nurse screening in OR 9 Tools • Sample Workflow Map Owner: Core Team Tools • Sample Workflow Map Define and build PGDT trigger(s) or checklist(s) (continued) – Owner: Core Team Tools • At Risk screening tool Intra-op • Surgical Time Out • Physician Preference Card • Sample Workflow Map Screening Trigger Example Is the patient undergoing one or more of the identified procedures? Yes, PGDT fluid optimization should be considered to improve post-operative outcomes [next question] No, [next question] Does the patient have a risk factor equivalent ASA2b with 1+ comorbidity or higher? Yes, PGDT fluid optimization should be considered to improve post-operative outcomes [next question] No, [next question] Will the patient receive perioperative goal directed therapy for hemodynamic optimization using [the selected protocol]? Yes, Chart on patient record No, Chart reason for declining PGDT on patient record Map and test new PGDT workflow with trigger(s), and handoffs Develop process map for the proposed PGDT workflow incorporating trigger(s), new tasks and handoffs needed to apply PGDT to procedures. Physically walk through the new PGDT workflow. Identify any gaps or obstacles, and make necessary modifications. 10 Owner: Core Team Designate monitoring platform(s) for target population Base monitoring platform designation on patient risk profile. A-line based monitoring can be utilized when arterial line placement is necessary, while non-invasive monitoring can be used when no arterial line is needed. Document platform designations for training purposes. 11 Owner: Clinical Champion; Clinical Leads Tools • Hemodynamic Product Information Website • Right Patient Right Device Sheet Communicate PGDT plan to organization Owner: Clinical Champion Communicate the plan and any changes in workflow to affected stakeholders. Include in your communications plan any clinician, administrator, or staff member who is part of or impacted by the PGDT process. Leverage several types of communications including posters, emails, meeting announcements and training courses, to deliver these messages. Tools • Communications Plan Template A Communication Plan Template can help identify appropriate messages, audience, and timing. Develop comprehensive training plan Owner: Clinical Champion Training for this new PGDT workflow should be inclusive of the following: Benefits of PGDT: reason for implementing Project scope: Selected procedures for PGDT application and expectations of perioperative team PGDT protocol: how to optimize fluid using the selected clinical pathway Hemodynamic monitoring platform: how to use technology and dynamic parameters to apply a PGDT protocol PGDT workflow: changes to current workflow, triggers, and handoffs Compliance: the importance of compliance and ways to monitor adherence to a PGDT protocol. 12 Tools • Team Alignment Presentation • ECCE Resources • Hemodynamic Optimization Modules and Presentations Train super users, end users, and other stakeholders Deliver a comprehensive training program. Identify super users or educators to expand training beyond the core team and to future impacted stakeholders. Visit www.edwards.com/ecce and http://www.youtube.com/ecce4you for educational resources. Owner: Clinical Champion Tools • Edwards.com/ecce • YouTube Channel • PGDT Learning Modules Edwards Lifesciences representatives can provide education on PGDT and the Edwards portfolio of advanced hemodynamic monitoring technologies. Evaluate competencies Owner: Educator; Super Users Ensure adequate comprehension and competency by establishing knowledge checks and skill tests for impacted stakeholders. 13 Launch PGDT trigger(s), checklist(s), and add to SOP Owner: Core Team This is the time to “go live” with the new PGDT workflow, triggers, and handoffs. During this activation period, triggers should clearly identify the target population, and users should apply the selected PGDT protocol to optimize perioperative fluid status. Evaluate workflow, trigger(s), and handoffs Owner: Core Team Closely monitor and evaluate the new PGDT workflow, triggers, and handoffs to ensure a smooth transition and to identify any remaining gaps. Adjust workflow as needed Owner: Core Team If gaps are identified, make slight modifications to the PGDT workflow, triggers, and handoffs as needed. Retrain and clearly communicate any changes to impacted stakeholders. 14 Develop method to track compliance for PGDT application Owner: Core Team and protocol Compliance is key to the successful implementation of any protocol. The purpose of implementing protocols in healthcare is to improve safety, enhance quality of care, and reduce variation that can occur in clinical practice. Lack of compliance with the protocol can impede progress to these goals. Three types of compliance to monitor: 1. Compliance to procedure type Leverage triggers and patient EMR to document and track PGDT application to appropriate patients. 2. Compliance to protocol Use Case Reports generated from monitor data or the Compliance Tracking Worksheet to assess practice consistency with protocol. 3. Compliance to tracking Evaluate completeness of compliance data to understand potential impact on outcome. Track and document compliance levels Tools • Monitor Data Download Instructions • Case Report Generator • Compliance Tracking Worksheet Owner: Core Team Identify a clinical resource to regularly monitor compliance to targeted procedure type and compliance to the selected protocol. 15 Gather morbidity, length of stay (LOS), and PGDT Owner: Core Team compliance data for target population Gather data and document post-PGDT metrics for selected target population, using the same metrics documented in the current state analysis. Specifically, include key metrics such as morbidity, length of stay, and variable cost per case. Ensure a direct comparison by measuring the same types of complications before and after PGDT implementation. Consider taking post-assessment measurements at 60-day, 90day, and 120-day intervals, including a minimum of 60 patients in both the pre- and post-assessment groups. 16 Tools • Aggregate Case Reports • Outcome Improvement Calculator Compare PGDT outcomes to program goals Owner: Core Team Review the goals defined earlier in the program and compare results of PGDT implementation. Tools • Project Charter Template Communicate results to key stakeholders Owner: Clinical Champion Present results to key stakeholders including the program executive sponsor and impacted users to help sustain support for the new PGDT clinical pathway. Identify specific opportunities for improvement or expansion Consider expanding PGDT to other procedure types and/or incorporating PGDT and the ESR Program into hospital quality plan. 17 Tools • PGDT Poster Template Owner: Clinical Champion All information provided by Edwards Lifesciences is gathered from third party sources and is presented for informational purposes only. This information is not intended to describe, recommend, or suggest any use, feature, or benefit of any Edwards product and does not constitute reimbursement, medical or legal advice. Edwards makes no representation or warranty regarding this information or its completeness, accuracy or timeliness. It is not intended to make a recommendation regarding clinical practice. Laws, regulations, and payer policies concerning reimbursement are complex and change frequently; service providers are responsible for all decisions relating to clinical services, coding and reimbursement submissions. Accordingly, Edwards strongly recommends consultation with payers, reimbursement specialists and/or legal counsel regarding coding, coverage, and reimbursement matters. Edwards, Edwards Lifesciences, and the stylized E logo are trademarks of Edwards Lifesciences Corporation. © 2014 Edwards Lifesciences Corporation. All rights reserved. AR10628 18