HIMSS Davies Award · Provides support for HIT projects for surgical providers at the operative platform ... epidural catheters vs prior as-needed IV narcotics after staff interview

HIMSS Davies Award Davies Enterprise Committee Site Visit

Duke Health

June 7, 2018

Case Study #1:Improved Surgical Outcomes with Early

Recovery After Surgery Protocols

Dr. Julie Thacker MDChris Vail, PA

Julie K. Marosky Thacker, MDMedical Director, Clinical Research UnitAssociate Professor of SurgeryDivision: Advanced Oncologic and Gastrointestinal SurgerySection: Colorectal Surgery

EDUCATION:MD, Indiana University School of Medicine, 1998 RESIDENCY:General Surgery, University of Utah Health Sciences Center, 1998-2004 FELLOWSHIP:Colon and Rectal Surgery, Mayo Clinic (Minnesota), 2005

PHYSICIAN PROFILE

Christopher Vail, PA-C, MMCiDirector of Clinical Informatics, Duke Surgery & Trauma Physician Assistant

About Christopher:Provider liaison for HIT implementation, maintenance, and optimization for surgical providers in both inpatient and ambulatory practice settings

Provides support for HIT projects for surgical providers at the operative platform level at all OR locations

EDUCATION:Masters of Management in Clinical Informatics Fuqua School of Business, Duke University

PRESENTER PROFILE

CASE STUDY #1: Improved ERAS

PROBLEM

OPPORTUNITY: Can we utilize HIT to improve the clinical outcomes of our colorectal surgery patients to

reduce their length of stay, decrease UTIs and potentially avoid readmissions by providing HIT support across the care continuum for care givers and care

environments

PROBLEM: Colectomy patients have a high rate of readmission and secondary complications such

as UTI related to their surgery.

DGMH10

Slide 5

DGMH10 ? need better problem stateementDr Genie McPeek Hinz, 5/30/2018


Colorectal Surgery –

• What we learned –• Benefit from Standardizing care across the care continuum• Standard education provided consistent messaging

to patients.Reduced variability in care delivery.

Post Protocol Intervention DATA June 2010 to Dec 2010*

Median Avg. LOS: 5 days

30 Day Readmission: 9.8%

UTI Rate: 13%

Pre Intervention DATA 2009-March 2010*

Median Avg. LOS: 7 days

30 Day Readmission: 20.2%

UTI Rate: 24%

*Anesthesia & Analgesia: May 2014 - Volume 118 - Issue 5 - p 1052–1061


PROBLEM

OPPORTUNITY: What tools in Epic will improve the clinical outcomes of our colorectal surgery patients

to reduce their length of stay, decrease UTIs and potentially avoid readmissions by providing HIT support across the care continuum for care givers and care

environments

PROBLEM: Can we use HIT to extend patient care improvements beyond

implementation of a protocol alone?

DGMH10

Slide 7

DGMH10 ? need better problem stateementDr Genie McPeek Hinz, 5/30/2018

Patient identified in Surgical case request as ERAS patient


DESIGN

ERAS Case Identification

Improving care coordination by capturing discrete data of patient surgical status and sharing across the care continuum.

ERAS status in PAT Clinic


HIT

Patient ERAS status evident when in the Pre-Anesthesia testing. Helps to ensure that anesthesia planning is consistent with ERAS process.

ERAS status in Perioperative


HIT

Patient ERAS and Epidural status visually identified on the Perioperative Status board.

Pre Operative ERAS


HIT Other HIT interventions

Improving Patient Education before surgery with ERAS specific written and video content.

ERAS status in Post Operative


HIT

Nursing BPA to add correct Care Plan & Education Template if not already added

ERAS status in PACU


HIT

Nursing orders and new training protocols for increased pain relief via epidural catheters vs prior as-needed IV narcotics after staff interview analysis

ERAS status in Peri Operative


HIT Other HIT interventions

Metric capture of use of Epidurals for ERAS patients increased significantly

DGMH11

Slide 14

DGMH11 Need to update graph, Caitlin is working on thisDr Genie McPeek Hinz, 5/30/2018


Process Measures to Track Use of HIT tools: ERAS for DUH Prostatectomy Go Live September 2017

VALUE

DGMH13

Slide 15

DGMH13 Not this data but the new Cailin data this is just a place holderDr Genie McPeek Hinz, 5/30/2018

CASE STUDY #1: ERAS

VALUE: DUHS Colectomy Average Length of Stay (ALOS)

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00ALOS AND LOS INDEX

ALOS LOS_INDEX Linear (ALOS)

ALOS has dropped from 5 days to 4 days even with LOS index that is higher than LOS consistently

Represents a 28% reduction in ALOS from FY15 to current

Additional ERAS tools

in Epic

DGMH21

Slide 16

DGMH21 need to remove decimal on left sideDr Genie McPeek Hinz, 6/2/2018


VALUE: Colectomy readmission rates across DUHS – includes DRH and DRAHy (Readmission Rate)

FY15‐QTR1, 7.4%

FY15‐QTR2, 16.2%

FY15‐QTR3, 12.7%

FY15‐QTR4, 7.5%

FY16‐QTR3, 8.6%

FY16‐QTR4, 7.1%

FY17‐QTR1, 3.0%

FY17‐QTR2, 12.1%

FY17‐QTR3, 5.8%

FY17‐QTR4, 10.9%

FY18‐QTR2, 7.4%

FY18‐QTR3, 3.5%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%Readmit Rate

Readmit Rate Linear (Readmit Rate)

Additional ERAS tools in

Epic

ERAS for Colectomy implemented at DRH and DRAH in FY17. They saw a similar reduction from average readmission rate of 20% down to 5%.

DUHS overall saw a 50% reduction in readmit rate from FY15 to current

DGMH26

Slide 17

DGMH26 Need help with text box on additional toolsDr Genie McPeek Hinz, 6/5/2018


VALUE: Readmissions

Extension of ERAS Protocols to Other Surgeries


ERAS patient flow + IT interventions

-ERAS patient identified in clinic after discussion with

surgeon-Education materials and

iOS app provided

Case Requested with ERAS ID flag and +/-

epidural needed

ERAS protocols and patient expectations

reinforced during pre-anesthesia testing

Day of Surgery: ERAS patient and anticipated

pain control needs clearly identified on multiple

screens

In the OR: Anesthesia protocols embedded into EHR and standardized orders from surgeon

implemented

PACU: New nursing protocols and orders allow

for increased usage of epidurals for acute pain

control

Post-Op / Floor: Surgical team uses procedure-

based standardized orders to maintain ERAS protocol

Floor Nursing: Use standardized ERAS

patient care plans and education templates to

reinforce patient progress and goals

Discharge: Once the patient has met all care

and education milestones


Lessons Learned:

Extension of ERAS Protocols to Other Surgeries

Constant iterations needed to utilize the EHR to enhance the patient experience at each step of the surgical process

Develop EHR tools for all participants in the patient’s care (e.g., nursing care plans & education templates)


VALUE

Post-Op Colorectal ERAS orders for better Nursing Care

Decreased patient stress, pain, length of stay, complication occurrence, and overall healthcare cost

Median Avg. LOS: 4 days 30 Day Readmission: 7.6%

Documents

HIMSS Davies Award · Provides support for HIT projects for surgical providers at the operative platform ... epidural catheters vs prior as-needed IV narcotics after staff interview