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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

slide2

Presenter DisclosureRob McKenna

The following relationships exist related to this presentation:

Ethicon: Consultant, Speakers Bureau

Covidien: Speakers Bureau

as medical student
As medical student
  • 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
  • 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
  • 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: Protocol
  • 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: Results
  • 282 patients
    • 158 women (56%)
    • 124 men (44%)
  • Mean age 71.2 years
    • Range 46-95 years
fast tracking results1
Fast-tracking: Results
  • 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: Results
  • 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: Results
  • Mean LOS = 3.26 days
  • Median LOS = 3 days
  • Mortality = 1 (0.4%)
fast tracking complications
Fast-tracking: Complications
  • 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: Complications
  • Empyema 1
  • CDIFF 1
  • Chylous drainage 1
  • Confusion 1
  • DVT 1
  • Pyelonephritis 1
  • Takeback 1
fast tracking results4
Fast-tracking: Results
  • Blood tranfusion = 11 (3.9%)
  • Readmission = 2
    • TIA
    • SQ emphysema
fast tracking results5
Fast-tracking: Results
  • Reinsert chest tube:
    • none
fast tracking conclusions
Fast-tracking: Conclusions
  • Routine use of ICU is not necessary
  • Routine use of labs and xrays is not necessary
fast tracking conclusions1
Fast-tracking: Conclusions

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

fast tracking
Fast-tracking:

Look at costs

Sealant costs $800 per dose

fast tracking sealant
Fast-tracking: Sealant

Bertolaccinii JCTS 2010

fast tracking suction no suction
Fast-tracking: Suction / No Suction
  • Several RCT’s have shown shorter LOS with no suction
  • Level of evidence = 1
chest tube removal on suction or water seal1
Chest Tube RemovalOn 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: Chest 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: Chest Tube Management
  • Use suction on drainage system:
    • Empyema
    • Increased postop drainage
    • Pleurodesis
    • Clinically Significant SQ air
fast tracking daily cxr in icu
Fast-tracking: Daily 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: Daily CXR in ICU
  • Recommendation:
  • Daily CXR not warranted
  • Order CXR only when clinically indicated
nebulizer treatments1
Nebulizer Treatments
  • 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
  • 2011 at Cedars Sinai, big push to order nebulizer only for proper indications
  • 60% reduction in nebulizer treatments

4

nebulizer treatments3
Nebulizer Treatments
  • Not indicated for:
    • routine cases of pneumonia
    • Atelectasis
    • fever

4

european respiratory society nebulizer guidelines
European Respiratory Society Nebulizer Guidelines
  • 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
  • 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
  • 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
  • Lung Transplant:
    • steroids and nebulizedcyclosporin reduce obliterativebronchiolitis because of frequent episodes of rejection in the first 3 months post-transplantation. (Grade C)
fast tracking resp treatments
Fast-tracking: Resp Treatments
  • Indications for chest PT:
    • Difficulty expectorating secretions
  • Indications for nebulizer treatments:
    • Wheezing
    • Difficulty expectorating secretions
chest pt guidelines meta analysis
Chest PT Guidelines: Meta-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: Meta-analysis
  • Indications for chest PT / HHN:
    • Difficulty expectorating secretions
    • Wheezing
    • Rosièrea, Swiss med 2009
financial pressures on hospitals
Financial Pressures on Hospitals
  • Decreasing Reimbursement
  • Cost Containment by Hospitals
  • Attempts to Reduce support for Cardio Thoracic Surgery
revenue for hospital programs
Revenue for Hospital Programs
  • Hospitalization
  • Downstream revenue
    • Lab tests
    • Xrays
    • Referrals to other programs
profit of surg specialties
Profit of Surg Specialties

Resnick: Ann Surg, 2005

surgeon s productivity relative value units rvu
Surgeon’s Productivity(Relative Value Units- RVU)
  • Thoracic and Transplant programs were the biggest surgical contributors to hospital profit margin

Resnick: Ann Surg, 2005

medicare lobectomy complications
Medicare LobectomyComplications
  • Examples
    • Postop anemia
    • Nodal metastases
  • List everything in discharge summary
  • Work with hospital coders
best practice after lobectomy
Best Practice after Lobectomy
  • 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
  • Work with your hospital to maximize documentation and therefore maximize profitability