Standardization improves outcomes
Almost a decade ago, the Department of Surgery began moving its surgical care into a value-based model, focused on improving patients’ health through evidence-based, cost-effective methods. This approach — almost certain to remain the trend in U.S. health care — continues to yield benefits for the department’s surgical patients and promises to improve care for years to come.
Over the past year, the department has focused on standardizing care pathways, developing patient safety and quality improvement projects in data-determined areas of deficiency, and reducing operating-room costs.
The colorectal surgery section and urology division have led the way in establishing standard enhanced recovery after surgery (ERAS) protocols that prescribe exact steps for patients and caregivers — from preparation at home through the hospital stay and recovery periods. The results have been a dramatic reduction of surgical site infections (SSIs) in patients who have part of their colon removed and a decreased rate of deep-space infections for patients who have had all or part of their bladders removed.
“Transplant surgeons recently implemented an ERAS protocol for their living kidney donors, and hepatobiliary-pancreatic surgeons have begun using a protocol for patients undergoing pancreas cancer surgery,” says Dee Dee Epstein, RN, BSN, patient safety nurse coordinator. “These pathways aim to decrease pain and length of stay, improve recovery and reduce readmission.”
To further improve patient care, each division and section reviews metrics from internal and external quality-reporting systems: the Washington University event-reporting system, Barnes-Jewish Hospital cost data, the Vizient reporting system for academic medical centers, and the American College of Surgeons National Surgical Quality Improvement Program® (ACS NSQIP®). These metrics have led to the SSI reductions and to the procedural change of reporting radiology and lab results directly to the surgeon, instead of sending reports through specialists.
A yearlong effort to reduce operating room costs helped the hospital save millions of dollars over the past year.
“We achieved agreement to use one type of stapler, implant and other disposable items after asking our surgeons to compare the many existing alternatives,” says Gerald Andriole, MD, vice chair for patient safety and clinical effectiveness. “This was the low-hanging fruit; next year it will be a little more challenging.”
Highlights
IMPROVED METHODS AND STANDARDIZATION in surgery scheduling could yield big benefits for the Department of Surgery, its patients and other surgical areas.
Transplant, cardiothoracic, and plastic and reconstructive surgeons are piloting the project with the support of Jackie Martin, MD, vice president of perioperative services at Barnes-Jewish Hospital. Surgeons use an electronic scheduling form that requires details about the patient and surgery: for example, whether the patient is healthy or sick, obese, or has adhesions from previous surgeries, or whether any blood work or special equipment is needed for the surgery.
The information goes to the entire operating-room team, including nurses, anesthesiologists, central sterile supply staff and residents.
“In the past, nurses would have to read surgeons’ minds to know that a special piece of equipment was needed for a specific patient,” says Gerald Andriole, MD, vice chair for patient safety. “The new scheduling process enables the operating room to be much better prepared for surgery.”
Martin plans to use the scheduling system as a best practice that other clinical care areas such as otolaryngology, neurosurgery, and obstetrics and gynecology could adopt.