Optimizing Patients for Surgery Optimizing Patients for Surgery Rl f th PAT i i Rl f th PAT i i Role of the PAT nurse in assessing Role of the PAT nurse in assessing patient risk patient risk Tanya Cowder, RN, CNS Sue Burns, RN Avis Hayden, PhD
Optimizing Patients for SurgeryOptimizing Patients for Surgery
R l f th PAT i iR l f th PAT i iRole of the PAT nurse in assessing Role of the PAT nurse in assessing patient riskpatient risk
Tanya Cowder, RN, CNSSue Burns, RN
Avis Hayden, PhDy ,
Southwestern Vermont Medical C tCenter
•3,100 surgeries per year•35 surgeons 2 PAT nurses•35 surgeons, 2 PAT nurses•80% ambulatory care; 20% inpatient•Physician affiliation DHMC
Objectives for Today:Objectives for Today:
•Factors leading to change•Factors leading to change•Key elements of new processy p•Expanded role of PAT nurse•Outcomes, data•Next steps•Next steps
InterviewsInterviews•Chief Medical Officer•Patient Safety Specialist•Anesthesiologists•Anesthesiologists•Internists & PCP’s•Surgeons•Nurses•Nurses•Support Staffpp
Challenge #1:Challenge #1:
RISK IDENTIFICATION NOT RELIABLE
••Not well definedNot well defined
••No double checkNo double checkNo double checkNo double check
80% cases identified(too low)
Sample of 128 elective cases Mar, Apr 2011
Challenge #2:Challenge #2:
Q ti bl lQ ti bl lHIGH RISK PATIENTSDID NOT RELIABLY GET MEDICAL EVAL
••Questionable valueQuestionable value
••Not enough timeNot enough timeGET MEDICAL EVAL
••Unclear expectationsUnclear expectations
75% got evaluation(too low)
Sample of 128 elective cases Mar, Apr 2011
Challenge #3:Challenge #3:
HIGH RISK PATIENTS UNDERIDENTIFIED
••Identification not Identification not reliablereliable
••If missed, not detectedIf missed, not detected
Only 9.8% identified (too low)
Data from earlier phase of project, collected 2009
Summary:Summary: Develop reliable process for:Develop reliable process for:
Ri k id tifi ti•Risk identification
•Medical evaluation
•FOCUS: Timely flow of i f tiinformation
Change #1: Define High RiskChange #1: Define High Risk
• Polypharmacy (7 +)• Polypharmacy (7 +) • Active cardiac disease • Poorly controlled hypertension• Diabetes requiring medication• Diabetes requiring medication• Sleep apnea• Anticoagulation• If clinical intuition raises the• If clinical intuition raises the
question
Change #2: Booking ReportChange #2: Booking Report
DATE OF DATE OF SURGERYREPORT
BOOKINGREPORT
RN VERIFY risk category
RN & Anesthesia UPGRADERN & Anesthesia UPGRADErisk category based on assessment
of patient history
Change #5: Medical EvalChange #5: Medical Eval
M di l bl• Medical problems• Medication list• Would delaying the procedure allow to better control any of theallow to better control any of the following:
H A1C 7• HgA1C over 7• Poorly controlled hypertension or heart disease• Active infections• Sleep apnea• Anticoagulant therapy
Change #6: Booking ScriptChange #6: Booking Script
•Urgent?•Urgent? Elective?
•High Risk? Normal Risk?Normal Risk?
•If High Risk, gname of PCP
Change # 7: Booking Window•High Risk PatientsHigh Risk Patients
Optimal interval 14 days
All Oth P ti t•All Other Patients Minimal interval -- 7 days
Process MapsProcess Maps
Decision for
surgery
Complete risk form
Call OR to schedule case;
(risk score)
Complete H&P, consent, orders
Fax to PAT
Schedule PAT appt< 5
Schedule medical evaluation with PCP or specialist
> 5
Decision AlgorithmDecision AlgorithmDECISION TO PERFORM SURGERY
URGENT OR "ADD ON" ELECTIVE
Based on medical need
Booking < 7 days
Requires call to anesthesia
NORMAL RISK HIGH RISK
Based on assessment of i di l di i
Based on assessment of patients medical conditionanesthesia patients medical condition patients medical condition
Medical Evaluation Completed?
NO NO
Booking > 7 days
Allow time for Anesthesia,
RECOMMENDED BOOKING INTERVAL
Booking > 14 daysYES
Allow time for Anesthesia,
RECOMMENDED BOOKING INTERVAL
,PAT review PAT review & medical
evaluation
Booking < 14 days
Short Notice or Convenience
Booking < 7 days
Short Notice or Convenience
Booking < 7 days
Exceptions: ESWL, Dental, Short Notice or ConvenienceBooking
Condenses time for Anesthesia, PAT review
Condenses time for Anesthesia, PAT review
Short Notice or Convenience BookingPort-A-Cath, Pacemakers,
ENT cases < 16 yo
Condenses time for Anesthesia, PAT review
Challenge #1Challenge #1
RISK IDENTIFICATION NOT RELIABLE
SIMPLIFYDEFINITIONS, GIVE FEEDBACK
100% cases identified(88% surgeon, 12% PAT nurse)
80% cases identified(too low)
Sample of 128 elective cases Mar, Apr 2011; project data 2012.
)
1.2UCL=1.129
Hit or Miss FAX
Patient Risk Identification, Surgeons
1.0
0.8
_X=0.88
77%
0.6
0.4
Rat
e LCL=0.63477%
0.2
0.0
14-S
ep
17-A
ug20
-Jul
22-Ju
n
25-M
ay
27-A
pr
30-M
ar2-M
ar3-
Feb
6-Jan
9-De
c
11-N
ov
Week Ending
Challenge #2:Challenge #2:
HIGH RISK PATIENTSDID NOT RELIABLY GET MEDICAL EVAL
WORKFLOW CHANGE“HARD STOP”
GET MEDICAL EVAL
100% got evaluation75% got evaluation(too low)
Sample of 128 elective cases Mar, Apr 2011; project data 2012
Challenge #3Challenge #3
HIGH RISK PATIENTS UNDERIDENTIFIED
RELIABLE PROCESS CLEAR EXPECTATIONS
Now 26% identifiedOnly 9.8% identified (too low)
Data from earlier project collected 2009; new project data 2012
1.0 EXISTING NEW
Proportion of High Risk Patients Identified in our Surgical Population
0.8
0 60.6
0.4
Perc
ent
_X=0 26
UCL=0.451
18%
0.2
0.0
X=0.26
LCL=0.071
14-S
ep
17-A
ug20
-Jul
22-Ju
n
25-M
ay
27-A
pr
30-M
ar2-M
ar3-
Feb
6-Jan
9-De
c
11-N
ov
Week Endingg
Optimizing Patients for SurgerySurviellance of High Risk Patients
Comparison 2009 and 2012
1600
1400
1200 CASES MISSED high risk 26%
1000
800
Case
s normal risk
high risk 9.8%
normal risk
600
400
200
Year 2012 (n=1431)2009 (n=1338)
200
0
Data Sources: PICIS Booking Data/Loomis/Reed
Issues Still to be Addressed:Issues Still to be Addressed:
• ClinicalClinical• Anticoagulation **• Beta blockersBeta blockers• Poorly controlled diabetes• Sleep apnea **• Obesity
• Process• Post op co-management• Short notice booking
SummarySummary
• Identified a problem•Identified a problem•Interviewed key stakeholders•Reviewed literature•Developed a new process•Developed a new process•Used data to keep the process on track
•After 1 yr – reliable processAfter 1 yr reliable process
Questions Contact emails:[email protected]@phin.orgy @p g