My best care path for vats lobe you will not miss what you do not need
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My Best Care Path for VATS Lobe: You Will Not Miss What You Do Not Need. Robert J McKenna Jr. MD Head, Thoracic Surgery Cedars Sinai Medical Center. Presenter Disclosure Rob McKenna The following relationships exist related to this presentation :. Ethicon: Consultant, Speakers Bureau

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My best care path for vats lobe you will not miss what you do not need

My Best Care Path for VATS Lobe: You Will Not Miss What You Do Not Need

Robert J McKenna Jr. MD

Head, Thoracic Surgery

Cedars Sinai Medical Center


Presenter Disclosure Do Not NeedRob McKenna

The following relationships exist related to this presentation:

Ethicon: Consultant, Speakers Bureau

Covidien: Speakers Bureau


As medical student
As medical student Do Not Need

  • Internal med rotation, given a symptom, given a patient’s symptom. Told to:

    • List 10 possible diagnoses

    • List 10 tests to rule out each diagnosis

    • ORDER THEM ALL???


2 weeks ago
2 weeks ago Do Not Need

  • ICU team over the weekend ordered:

    • 3 daily unchanged CXR’s

    • 3 daily unchanged, normal CBC’s

    • 3 daily unchanged, normal ionized Ca, Mag, Phosphate

    • 2 normal coag studies

      I WENT BALISTIC


Fast tracking after lobectomy
Fast-tracking after Lobectomy Do Not Need

  • Era of Cost Containment and Pay for Performance

  • Need to track our results and develop protocols to reduce costs and improve performance


Fast tracking protocol
Fast-tracking: Do Not NeedProtocol

  • No routine postoperative xrays

  • No routine postoperative labs

  • Remove chest tube when:

    • No air leak

    • Output < 300 ml hours

  • Discharge with Heimlich valve if persistent air leak and low output


Fast tracking results
Fast-tracking: Do Not NeedResults

  • 282 patients

    • 158 women (56%)

    • 124 men (44%)

  • Mean age 71.2 years

    • Range 46-95 years


Fast tracking age
Fast-tracking: Do Not NeedAge


Fast tracking age1
Fast-tracking: Do Not NeedAge


Fast tracking results1
Fast-tracking: Do Not NeedResults

  • RUL 107 LUL 74

  • RML 17 LLL 30

  • RLL 27 SEG 15

  • BILOBE 1 SLEEVE 3

  • RUL +LVRS 1 PNEUM 1

  • Nissen/RUL 1


Fast tracking results2
Fast-tracking: Do Not NeedResults

  • Lung Cancer 253

  • Granuloma 8

  • Carcinoid 6

  • Pulmonary met 5

  • Bronchiectasis 4

  • Hamartoma 3

  • Lymphoma 1

  • Sequestration 1

  • Solitary Fibrous Tumor 1


Fast tracking results3
Fast-tracking: Do Not NeedResults

  • Mean LOS = 3.26 days

  • Median LOS = 3 days

  • Mortality = 1 (0.4%)


Fast tracking complications
Fast-tracking: Do Not NeedComplications

  • None 251 (89.3%)

  • Air Leak 8 (2.8%)

  • AF 5 (1.8%)

  • Pneumonia 4

  • Atelectasis 3

  • Urinary Ret 2

  • CVA/TIA 2

  • Readmit 2

  • RLN 2


Fast tracking complications1
Fast-tracking: Do Not NeedComplications

  • Empyema 1

  • CDIFF 1

  • Chylous drainage 1

  • Confusion 1

  • DVT 1

  • Pyelonephritis 1

  • Takeback 1


Fast tracking results4
Fast-tracking: Do Not NeedResults

  • Blood tranfusion = 11 (3.9%)

  • Readmission = 2

    • TIA

    • SQ emphysema


Fast tracking results5
Fast-tracking: Do Not NeedResults

  • Reinsert chest tube:

    • none


Fast tracking conclusions
Fast-tracking: Do Not NeedConclusions

  • Routine use of ICU is not necessary

  • Routine use of labs and xrays is not necessary


Fast tracking conclusions1
Fast-tracking: Do Not NeedConclusions

Protocols may reduce length of stay and not compromise morbidity and mortality


Fast tracking
Fast-tracking: Do Not Need

Look at costs

Sealant costs $800 per dose


Fast tracking sealant
Fast-tracking: Do Not NeedSealant

Bertolaccinii JCTS 2010



Fast tracking rct suction no suction
Fast-tracking: Do Not NeedRCT: Suction / No Suction


Fast tracking rct suction no suction1
Fast-tracking: Do Not NeedRCT: Suction / No Suction


Fast tracking suction no suction
Fast-tracking: Do Not NeedSuction / No Suction

  • Several RCT’s have shown shorter LOS with no suction

  • Level of evidence = 1


Chest tube removal on suction or water seal
Chest Tube Removal Do Not NeedOn suction or water seal?

Martino


Chest tube removal on suction or water seal1
Chest Tube Removal Do Not NeedOn suction or water seal?

  • Level 1 data

  • No difference in CT duration or LOS

  • Suction associated with increased PTX or CXR’s

  • If tube reinserted, double LOS

Martino


Fast tracking chest tube management
Fast-tracking: Do Not NeedChest Tube Management

  • Recommendations (level 1):

    • No suction on drainage system

    • No transition from suction to seal before removal


Fast tracking chest tube management1
Fast-tracking: Do Not NeedChest Tube Management

  • Use suction on drainage system:

    • Empyema

    • Increased postop drainage

    • Pleurodesis

    • Clinically Significant SQ air


Chest xrays
Chest Xrays Do Not Need


Fast tracking daily cxr in icu
Fast-tracking: Do Not NeedDaily CXR in ICU

  • 525 routine daily CXR’s reviewed

  • 89 showed cardiopulmonary disease (12%)

  • 3 (0.006%) required intervention

Silverstein


Fast tracking daily cxr in icu1
Fast-tracking: Do Not NeedDaily CXR in ICU

  • Recommendation:

  • Daily CXR not warranted

  • Order CXR only when clinically indicated


Nebulizer treatments
Nebulizer Treatments Do Not Need

4


Nebulizer treatments1
Nebulizer Treatments Do Not Need

  • 25% of respiratory care procedures delivered were not indicated, whereas 12% of patients were not receiving respiratory care that was indicated

4


Nebulizer treatments2
Nebulizer Treatments Do Not Need

  • 2011 at Cedars Sinai, big push to order nebulizer only for proper indications

  • 60% reduction in nebulizer treatments

4


Nebulizer treatments3
Nebulizer Treatments Do Not Need

  • Not indicated for:

    • routine cases of pneumonia

    • Atelectasis

    • fever

4


European respiratory society nebulizer guidelines
European Respiratory Society Nebulizer Guidelines Do Not Need

  • PCP Pneumonia

    • Nebulizedpentamidine is more effective than placebo but less effective than oral co-trimoxazole (Grade A)

  • Nosocomial pneumonia

    • HHN for treatment of hospital acquired pneumonia (Grade C) No RCT to prove benefit


European respiratory society nebulizer guidelines1
European Respiratory Society Nebulizer Guidelines Do Not Need

  • Surfactant for ARDS:

    • Improves gas exchange (Grade B)

    • RCT showed no improvement in outcome measurements (Grade A)

  • HHN for Pulmonary HTN

    • nebulizedprostacyclin (iloprost) (Grade A)

    • inhaled prostacyclin provide superior physiological outcomes (Grade B)


European respiratory society nebulizer guidelines2
European Respiratory Society Nebulizer Guidelines Do Not Need

  • Bronchoscopy:

    • HHN local anesthesia better than by bronchoscopy (Grade B)

    • HHN to reduce bronchospasm (Grade C)


European respiratory society nebulizer guidelines3
European Respiratory Society Nebulizer Guidelines Do Not Need

  • Lung Transplant:

    • steroids and nebulizedcyclosporin reduce obliterativebronchiolitis because of frequent episodes of rejection in the first 3 months post-transplantation. (Grade C)


Chest physiotherapy
Chest Do Not NeedPhysiotherapy

4


Fast tracking resp treatments
Fast-tracking: Resp Treatments Do Not Need

  • Indications for chest PT:

    • Difficulty expectorating secretions

  • Indications for nebulizer treatments:

    • Wheezing

    • Difficulty expectorating secretions


Chest pt guidelines meta analysis
Chest PT Guidelines: Do Not NeedMeta-analysis

  • Hypercapneic Respiratory

    • Failure (pH 7.25-7.35, CO2 > 50) (Grade A)

  • Secretions (Grade A)

    • IPPB not recommended

    • PEP uncertain

    • Rosièrea, Swiss med 2009


Chest pt hhn guidelines meta analysis
Chest PT / HHN Guidelines: Do Not NeedMeta-analysis

  • Indications for chest PT / HHN:

    • Difficulty expectorating secretions

    • Wheezing

    • Rosièrea, Swiss med 2009



Financial pressures on hospitals
Financial Pressures on Hospitals Do Not Need

  • Decreasing Reimbursement

  • Cost Containment by Hospitals

  • Attempts to Reduce support for Cardio Thoracic Surgery


Revenue for hospital programs
Revenue for Do Not NeedHospital Programs

  • Hospitalization

  • Downstream revenue

    • Lab tests

    • Xrays

    • Referrals to other programs


Profit of surg specialties
Profit of Surg Specialties Do Not Need

Resnick: Ann Surg, 2005


Surgeon s productivity relative value units rvu
Surgeon’s Productivity Do Not Need(Relative Value Units- RVU)

  • Thoracic and Transplant programs were the biggest surgical contributors to hospital profit margin

Resnick: Ann Surg, 2005


Medicare lobectomy profit hospital bed
Medicare Lobectomy Do Not NeedProfit / hospital bed


Medicare lobectomy profit hospital bed1
Medicare Lobectomy Do Not NeedProfit / hospital bed


Medicare lobectomy complications
Medicare Lobectomy Do Not NeedComplications

  • Examples

    • Postop anemia

    • Nodal metastases

  • List everything in discharge summary

  • Work with hospital coders


Best practice after lobectomy
Best Practice after Lobectomy Do Not Need

  • A minimalist approach to postoperative testing is appropriate and cost effective

  • No routine lab tests or xrays are indicated after VATS lobectomy


Best practice after lobectomy1
Best Practice after Lobectomy Do Not Need

  • Work with your hospital to maximize documentation and therefore maximize profitability


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