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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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