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Integrated Care In Action Surgery Clinical Program. Disclosures. None pertinent to this presentation No trade names will be used in this presentation. The Principles Of Shared Baselines. Select a high priority care process Generate an evidence-based best practice guideline

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disclosures
Disclosures

None pertinent to this presentation

No trade names will be used in this presentation

the principles of shared baselines
The Principles Of Shared Baselines
  • Select a high priority care process
  • Generate an evidence-based best practice guideline
  • Blend the guideline into the flow of clinical work
  • Use the guideline as a shared baseline with clinicians free to vary based on individual patient needs
  • Measure, learn from and (over time)
    • Eliminate variation arising from the professional
    • Retain variation arising from patients
multi disciplinary colon surgery mdcs background
Multi-Disciplinary Colon Surgery (MDCS) Background
  • Enhanced recovery after colon surgery has not been widely adopted in the United States and Europe despite evidence that postoperative complications and hospital length of stay are decreased.
objective
Objective
  • Evaluate the introduction of a comprehensive care process for an enhanced recovery after colon surgery care process in 8 Intermountain Healthcare community hospitals.
design
Design
  • Quality improvement rather than cost containment was the primary focus.
  • Use of LOS and cost data as quality metrics to assess results of the intended improvement process are well substantiated in the literature.
  • Elements comprising an MDCS care process are not uniformly accepted.
design1
Design
  • Common MDCS elements include:
    • patient education
    • correct peri-operative fluid management
    • optimal pain control with limited opioids
    • thoracic epidural blockade
    • early postoperative feeding
    • aggressive patient ambulation
    • avoiding use of abdominal drains and nasogastric tubes.
implementation
Implementation
  • A central committee composed of general surgeons, colorectal surgeons, operations leaders and data experts reviewed the evidence supporting MDCS.
  • The committee developed a comprehensive MDCS care process with help from nursing, physical therapy, and the pain and medical nutrition services.
implementation1
Implementation
  • In each hospital, an objective review of MDCS literature was presented to surgeons and anesthesiologists in combination with system-wide, hospital, and surgeon-specific baseline data.
  • System-wide and hospital-based leadership teams led by surgeons were essential in implementing the complex MDCS care process.
implementation2
Implementation
  • An electronic self populating dashboard was created from the EDW.
    • Significant resources
  • A postoperative order set was designed to incorporate the essential elements of MDCS.
    • Incorporating process into the workflow
  • A document summarizing the care process was added to each patient’s chart.
    • Education for patients, nursing staff, and physicians.
implementation3
Implementation
  • From inception of the MDCS hypothesis to beginning of implementation took 18 months.
continuous process improvement
Continuous Process Improvement
  • The electronic dashboard made MDCS performance metrics immediately available to physicians and operations leaders and included:
    • patient demographic
    • severity of illness (SOI)
    • clinical and financial outcomes
      • ambulation, diets, bowel activity, etc.
      • LOS, POD, cost
surgeon education and control
Surgeon Education and Control
  • Surgeons had the option of enrolling or not enrolling patients in MDCS.
  • It was expected that this may lead to some degree of selection bias that might confound direct comparison between enrolled and non-enrolled patients; therefore the study population included enrolled and not enrolled patients and was compared to a historical control.
demographic mdcs enrollment comparison data and service population for the 8 community hospitals
Demographic, MDCS enrollment comparison data and service population for the 8 community hospitals
conclusions
Conclusions
  • MDCS was successfully introduced into 8 of the Intermountain Healthcare network of hospitals as indicated by:
    • increasing enrollment rates over time
    • decreasing LOS and POD from the baseline period to the study period
current status and next steps
Current Status and Next Steps
  • Continuing education on patient enrollment
  • Revisiting areas of variation and changing as needed
  • Continued turnaround of data to physicians and clinical team
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