Hospital Quality Institute Vanguard Award 2017

Contact Persons:

Zed Reagan, MD Anesthesiologist/Physician Quality Advisor [email protected]

Amber Holmer Senior QI Specialist RN, BSN Quality Improvement Department [email protected]

Title of Application:

Reducing harm through the institution of a clinical pathway for colorectal , Enhanced Recovery at Cottage Health (ERACH)

Topical Area of Focus:

Patient Safety and Performance Improvement

Brief Statement by an executive leader in support of the application:

On behalf of Cottage Health, I am honored to support this Vanguard application for the Enhanced Recovery pilot project. While Santa Barbara Cottage was named a meritoriously performing American College of Surgeons National Surgical Quality Improvement Program hospital in 2015, we knew there were still opportunities to further strengthen our surgical program and provide safer and more effective care. I applaud the efforts of the team members and especially initial physician for their leap of faith and hard work to change practices, closely monitor and adapt as necessary. We now have surgeons eager for the programs expansion. This pilot shows the power of a small test of change and a dedicated team that was able to persevere through an Epic go-live and demonstrate remarkable improvement.

Sharon Lutz, Ph.D. Vice President Quality Support Services, Cottage Health

Executive Summary

Cottage Health is a not-for-profit hospital system that includes Santa Barbara Cottage Hospital, Cottage Children's Medical Center, Cottage , Santa Ynez Valley Cottage Hospital, and Goleta Valley Cottage Hospital. The top goals of 2016 clearly defined a hospital wide goal to reduce patient harm. One of the identifiable patient harms was surgical site infection in colorectal surgery. While the idea of enhanced recovery has certainly gained traction in Europe and many large institutions across the country, it had not been accepted in the community of practice around Santa Barbara. As it became clear that the results of this pathway had significant potential to reduce patient harm and

improve our delivery of care, it became clear to us that we needed to develop our pathway at Cottage Health.

First steps included collection of data for our baseline. In the year preceding this initiative, our SSI rate for elective colon resections by a single surgeon was 16.9%, our length of stay was 7.5 days, and our readmission rate was 7.9%. We began our pathway in June 2016. During the pilot program, our surgical site infection rate was 2.3%, our readmission rate was 4.5%, and our length of stay was 4.5 days. Since the pilot has ended we have been able to sustain these improvements SSI 2.4%, LOS 4.9 days and readmission 7%.

Background and Relevance

Despite significant improvements in the past 20 years in surgical technique, anesthesia safety, and preoperative optimization, colorectal surgery remains as a field with a high level of morbidity related to the surgical procedure. Due to the pioneering efforts of Dr. Kehlet, MD in Europe over the past thirty years, our views of the standard work of colorectal surgery were changing dramatically. Those willing to break tradition and change decades-held notions were handsomely rewarded with an improvement in patient outcomes. As we reviewed our NSQIP data in spring 2016 we discovered that while we were in the “no different from other hospital cohort” on many measures related to colorectal, we were in the 10th decile for colorectal SSI. While many studies have certainly established “cost” of a surgical site infection, we were alarmed by the patient harm. Most studies of enhanced recovery pathways suggest that our infection rate could be lowered by 50% or more. In that regard alone, this performance improvement project easily aligned with our top institutional goals and became a top priority for 2016.

III. Describe the effort, including the scope, process, strategies and tactics utilized, challenges encountered and how they were addressed.

Our first effort was to partner with a colorectal surgeon who was willing to redefine a career of practice in the spirit of this effort. We formed a committee comprising of an anesthesiologist, surgical resident, preoperative nurses, floor nurses and quality support staff. We starting meeting in early 2016. We designed a pilot program to run for four months, June 1, 2016 to September 30, 2016. In anticipation of this pilot, we developed our pathway from the literature, taking into consideration some of the constraints and standard practices of our hospital system. We developed a comprehensive preoperative education packet. In-service education was given to both the preoperative and postoperative nurses regarding the changes in practice and their involvement. Data tracking efforts were somewhat stalled by a hospital wide change in electronic medical records, but we designed a highly reliable paper tracking system.

A Narrow Project Scope

 One surgeon

 Four months

 All patients followed for 30 days after surgery

 The scope was intentionally small, a small test of change

Process Improvement

Scheduling At our hospital patients are seen the day before surgery. Due to the expectation of preoperative optimization, this was changed for these patients to at least seven days.

Preoperative Interview The pathway was discussed at length with the patient in the preoperative visit and the patients were given a packet of reference information to read before surgery

Day of Surgery Improving the preoperative process of allow for more than 7 day preoperative visit, preoperative medications, fasting guidelines.

Intraoperative Anesthesiologists and OR Nurses were aware of the pathway and dedicated to data collection and following it. If elements of the pathway were not followed, explanations were noted.

Postoperative Expectation of patients out of bed within six hours of surgery, walking QID. Developed a tracking system for the patients to keep regarding activity.

Post Discharge Patients were followed for thirty days to capture SSI and readmission data.

Challenges Encountered and How They Were Addressed

As with any improvement project at a large institution, the challenges were many.

Challenge #1

Having the patients arrive at least seven days preoperatively. This was a big change not only for the hospital but also the surgery scheduler at the surgeon’s office.

How we addressed:

Developed an easily identifiable orderset that notified hospital scheduling that an enhanced recovery patient was coming, this allowed scheduling a week before surgery. This also notified the preoperative staff that a longer visit was required for the education of these patients.

Challenge #2

Electronic Medical Record Transition effectively shuttered all new operations on the eve of the pilot.

How we addressed:

A highly identifiable (bright neon green) paper trail was devised to keep track of the data and documentation of the project. Quality personnel were responsible for picking up the data sheets off of the unit and entering the data into a research database. At the end of the pilot we were able to track patients through our MIDAS database.

Challenge #3

Physician Engagement/Change of Practice

How we addressed:

This project undermines years of taught and practiced behavior. By establishing our case with the evidence, the physicians were willing to suspend and participate. We presented at the surgical department meeting, the medical advisory panel, the operating room committee, and the department of anesthesiology. We advertised everywhere we could, took questions and feedback along the way. By managing this project on a small scope we were able to demonstrate success in our hospital system in a controlled manner, addressing the change of practice ideals.

Challenge #4

30 day follow-up proved difficult by phone.

How we addressed:

This problem required many attempts at phone calls and emails. For patients we could not get ahold of, we would use their follow-up chart notes as proxy for post-op complications.

Challenge #5

Identifying ERACH patients throughout the care continuum

How we addressed:

Preoperative orderset was flagged. Chart was physically flagged. Patient was informed and educated.

Challenge #6

Readmission rate remains at 7%, no significant change from baseline

How we are addressing:

As we have made great strides in the quality of our surgical recovery, the length of stay and surgical site infection, our readmission rate has remained steady. We have changed the paradigm of when patients go home (much earlier) and thus must reset our ability to detect problems earlier. As we get more comfortable with the pathway, it seems that our ability to detect the outliers will become more adept. At this point we can be confident to say that this steady readmission rate should at least inform us that we are not trading harms.

Describe the results of the efforts

Measure 1 – Surgical Site infection

When beginning we had a SSI of 17% which statistically was in the ‘no different’ category for nationwide colorectal surgery. Figure one demonstrates our SSI rate for 2015-2017.

Measure 2 – Length of stay

Our average length of stay for colorectal was 7.5 days when the project started. Since June 2016 when we began our pilot, length of stay has reduced to 4.9 days.

Measure 3 – Readmission

Our baseline readmission rate for colorectal surgery was 7.4% preceding the pilot. During the pilot our readmission rate was 4.5%. This has bounced back to baseline requiring us to look at the data and ask why. As length of stay has gone down, we need to learn the early signs that will require readmission. This will require further study.

Discuss the significance of the results. How do the results demonstrate outstanding achievement?

The results of this project were an outstanding reduction in the number of patient harms at our hospital. This project was the collaboration of many departments to develop a standard and consistent path for patients through our hospital. This path allowed for the education of patients preoperatively so

that a shared expectation of care could be communicated in advance. We did not specifically follow patient experience, but I cannot imagine this is not an improvement.

Additionally we have demonstrated that these clinical pathways can improve our care and are not “cookbook” medicine. Success on these measures has given more power and validity to further discussions in other areas.

Sustainability and Scalability

We have successfully our improvements with our one, busiest surgeon. Our expansion has been planned for many months but has hinged on the availability of an orderset that needed to be built in our new electronic medical record. A standardized electronic orderset is now available, and will serve to open this pathway all surgeons preforming elective colon resections. We will be monitoring the data carefully to ensure that scaling the process does not diminish it. Our hope is that awareness of the pathway and compliance might improve with broad implementation of ERACH. This will become the new standard of care and all staff will be familiar with it. We are exploring the possibility of joining the AHRQ/ACS program for enhanced recovery beginning July 2017. This fits well with our expansion to the entire colorectal population at our hospital.

Our preoperative nurses have taken great pride in their involvement in this project. They are thoroughly engaged and continue to help and improve the process. Postoperatively most of the care has come to be standard of care in bits and pieces. They have shown great resilience in their ability to embrace these changes.

A dialogue has been developed between the departments of care around elective surgery. This dialogue is absolutely crucial to further endeavors to improve care to our surgical patients.

Reducing patient harm through the institution of a clinical pathway for colorectal patients, Enhanced Recovery at Cottage Health (ERACH)

Reducing patient harm through the institution of a clinical pathway for colorectal patients, Enhanced Recovery at Cottage Health (ERACH)

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1 J Am Coll Surg. 2013 Dec; 217(6): 10.1016/j.jamcollsurg.2013.07.403.

2 Cohen, M. E., Bilimoria, K. Y., Ko, C. Y., Richards, K., & Hall, B. L. (2009). Variability in length of stay after colorectal surgery: Assessment of 182 in the national surgical quality improvement program. Annals of Surgery, 250(6), 901-907. DOI: 10.1097/SLA.0b013e3181b2a948 Reducing patient harm through the institution of a clinical pathway for colorectal patients, Enhanced Recovery at Cottage Health (ERACH)