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Definition:

Multimodal care pathways designed to reduce the patients’ stress response to surgery, support their physiologic function, and accelerate the return to normal daily function.

• Pay for volume

• No quality measured

Fee For Service

• Quality Outcome• Process

Improvement

V alue-BasedPayment

• Quality Outcome Data

• Whole system improvement

Pat ient -Cent ered Coordinat ed Care

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ProcedureAdverse Event

RateAverage Added

LOS (days)

Esophagectomy 55% 12

Pelvic Exenteration 45% 11

Pancreatectomy 35% 7

Colectomy 29% 10

Gastrectomy 29% 12

S ch i l l i n g , PL et.al . J Am Co l l S u rg, 20 0 8 No v;2 0 7(5): 69 8 -70 4

$0

$10,000

$20,000

$30,000

$40,000

$50,000

1 2 3

$6,358

$12,802

$42,790

Number of Complicat ions

Additional Cost Per Complication

Additional 10.99 days

One Complication

Additional 5.18 days

Three Complications

Additional 2.59 days

Two Complications

Bo l tz MM, et. al . Am J Med Qu al . S ep -Oct 2 0 12Kassi n , et. al . J Am Co l l S u rg . 2 0 12

www.erassociety.org

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Ped en C, et.al . AAGBI co re to p i cs i n An aesth esi a 2 0 12Ch i ch ester, UK; W i l ey-Bl ackwel l ; 2 0 11:2 8 -4 4

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Bel l amy, MC Br J An aesth 2 0 0 6 ; 9 7(6 ): 755-757Can n esso n , M. J Card i o th o raci c Vasc An esth 2 0 10 ; 2 4 (3):4 8 7-4 9 7

WEIGHT HOURLY REQUIREMENTS

< 10 kg 4 ml/kg

10-20 kg 40 ml + 2ml/kg above 10 k

> 20kg 60 ml + 1 ml/kg above 20 kg

Ho l i d ay et. al . Ped i atri cs 19 57; 19 :8 2 3-32

Mu l l er, et al BJA 2 0 14 , Hah n et al Acta An aesth esi o l S can d 2 0 14L amke et al Acta Ch i r S can d 19 77, Navarro et al Peri o p erati ve Med i ci n e 2 0 15

Bi eg n er/Vacch i an o et al JL AS T 19 9 9

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•Conventional Hemodynamic Variables Misleading In Assessing Volume Status•Lack Of Evidence To Support Use Of CVP

Mari k, et. Al . Ch est, 2 0 0 8 ; 134 :172 -178

N E n g l J Med . 2 0 01Pearse, R, et. al . Cri ti cal Care 2 0 0 5

•GOAL: Adequate Tissue Perfusion

Optimize Intravascular F luid Volume

Optimize Cardiac Output

Optimize Perfusion Pressure

Optimize Tissue Oxygen

Delivery

Preload

Stroke Volume

0

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Ramsi n g h , et. Al . J Cl i n Mo n i t Co mp u t, Dec. 2 0 12Ku p er, et al . BMJ 2 0 11

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