When a Florida healthcare system desired to standardize perioperative protocols, they engaged their existing anesthesia partner, TeamHealth, to lead implementation of a perioperative care pathway that would standardize clinical care and reduce patients’ use of narcotics.
Partnership
- Facility: A healthcare system in Florida, which provides care to over 40,000 patients annually
- Services: Anesthesiology and Emergency Medicine
The Challenge
Targets defined by the Centers for Medicare and Medicaid Services (CMS) and National Health Care Priorities for the total knee and hip arthroplasty surgical patient population were falling short in this health system. Extended length of stay, readmissions and complications were impacting the quality of care, as well as the patient experience. A gap analysis, conducted in 2021, revealed a lack of standardization around patient education, pain management and opioid-sparing techniques and an absence of standard preoperative, intraoperative and postoperative protocols.
The Solution
The hospital’s Chief Quality Officer assembled a Steering Committee that would define the initiative’s desired goals, along with the plan to build consensus among key stakeholders. TeamHealth Anesthesiology was enlisted as a foundational stakeholder on the committee, able to provide recommendations based on national best practices and build consensus toward the goals across a diverse set of stakeholders.
In July of 2021, the Performance Improvement Consultants (PIC) team made an on-site visit to begin the process and attend the first Steering Committee meeting. Valuing our partnership, we were invited to attend bi-weekly meetings throughout the planning and implementation processes. Sub-workgroups assembled to address specific facets, such as patient education, clinical recommendations and quality measures. Under Dr. Staggenborg’s leadership, the anesthesiology department eliminated barriers to achieving the initiative’s goals. In the physician oversight group, Dr. Glance helped guide the clinical decision-making process in establishing standardized protocols. The close working relationship of all involved over the two-year evolution ensured the successful launch and sustainment of the initiative.
Solution: Best Practices
The best practices implemented were tailored to these Ortho DRGs: 461, 462, 466, 467, 468, 469, 470. They were gleaned from current guidance from the Enhanced Recovery After Surgery (ERAS) Society. Best practices included:
- Preoperative physiotherapy
- Total joint class and standardized patient education
- Nutritional guidelines
- PONV prophylaxis
- Multimodal pain management
- Avoid opioids where possible
- Spinal or general anesthesia where appropriate
- Goal directed fluid therapy
- Early ambulation postoperatively
These multi-disciplinary best practices support patient optimization before surgery and standardized care delivery that is patient-centered, driving quality and improved patient outcomes.
Solution: Change Management
Successful implementation of any robust initiative requires effective change management. Buy-in across clinical departments is fundamental, and it’s critical to identify key influencers. The facility identified the anesthesia team as an engaged and influential group. The partnership between anesthesia and the facility helped set expectations for the program. As key perioperative stakeholders, the team was also fundamental to reducing clinical protocol variation. In addition, other stakeholders viewed TeamHealth anesthesiologists and anesthetists as subject matter experts, safety keepers and valued leaders, which helped solidify the best practice recommendations from the Steering Committee. All of these factors helped the team effectively manage the changes needed to plan, implement and sustain the care pathway.
“All [the surgeons] are very happy with pain scores and outcomes since starting this program. It has made our group more uniform in the blocks we perform as well, which reduces block variability and thus has improved surgeon satisfaction.” – Dr. Ryan Glance
The Results:
The collaborative effort yielded an ongoing program to standardize care and improve quality. The initiative officially launched in October 2022, and TeamHealth continued to partner closely with the system to ensure its sustainability for another 11 months. Efforts to improve and maintain consistency in the quality of care are ongoing. Results to date include:
- Opioid-Sparing Care Pathway (total knee & total hip) implemented in October 2022.
- Reduced LOS O:E Snapshot October ’22 (1.13) to November ’22 (0.34) Top Quartile (0.94)
- SSI Hips Zero, month over month
- % Complications of care Zero (1 of 2 sites)
- 30 Day Readmissions Zero (1 of 2 sites)
- Reduced variation in anesthesia practice by implementing standardized order sets for orthopedic patients following the Opioid Sparing Care Pathway.
- The initative was accepted and adopted by the orthopedic surgeons.
- Improved and maintained top box HCAHPS score for would recommend and overall rating.
In September 2023, the program leadership officially transferred to the boots-on-the-ground anesthesia team and facility. However, TeamHealth’s national leadership, PIC team and Quality team will continue to work closely with the facility to ensure the ongoing success of the Opioid-Sparing Care Pathway. Future evolutions of the initiative may include expansion to other surgical procedures, collection of comprehensive opioid-use data and planned events to enhance compliance.
The Conclusions
Over two years, TeamHealth and the facility implemented and have sustained an Opioid-Sparing Care Pathway Initiative that addressed unique challenges. The success of this initiative highlights the benefits of having close partners with the breadth and depth of experience to rise to the challenge and bring innovative ideas to the table. TeamHealth is committed to supporting our client partners and enhancing care delivery. Connect with us to learn more about our services and partnerships.
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