A perioperative consult service results in reduction in cost and length of stay for colorectal surgical patients: evidence from a healthcare redesign project.

BACKGROUND: A major restructuring of perioperative care delivery is required to reduce cost while improving patient outcomes. In a test implementation of this notion, we developed and implemented a perioperative consult service (PCS) for colorectal surgery patients. METHODS: A 6-month planning process was undertaken to engage key stakeholders from surgery, nursing, and anesthesia in a healthcare redesign project that resulted in the creation of a PCS to implement a coordinated clinical pathway. After Institutional Review Board (IRB) approval, data were collected for all elective colorectal procedures for three phases: phase 0 (pre-implementation; 1/2014-6/2014), phase 1 (7/2014-10/2014), and phase 2 (11/2014-10/2015). Length of stay (primary endpoint; LOS), total hospital cost, use of clinical pathway components, markers of functional recovery, and readmission and reoperation rates were analyzed. Outcomes and patient characteristics among phases were compared by two-tailed t tests and Wilcoxon rank-sum tests. Categorical variables were analyzed by chi-square and Fisher's exact tests. RESULTS: We studied 544 patients (phase 0 = 179; phase 1 = 124; phase 2 = 241), with 365 consecutive patients being cared for in the redesigned care structure. Median LOS was reduced and sustained after implementation (phase 0, 4.24 days; phase 1, 3.32 days; phase 2, 3.32 days, P < 0.01 phase 0 v. phases 1 and 2), and mean LOS was reduced in phase 2 (phase 0, 5.26 days; phase 1, 4.93 days; phase 2, 4.36 days, P < 0.01 phase 0 v. phase 2). Total hospital cost was reduced by 17 % (P = 0.05, median). Application of clinical pathway components was higher in phases 1 and 2 compared to phase 0 (P < 0.01 for all components except anti-emetics); measures of functional recovery improved with successive phases. Reoperation and 30-day readmission rates were no different in phase 1 or phase 2 compared to phase 0 (P > 0.15). CONCLUSIONS: Restructuring of perioperative care delivery through the launch of a PCS-reduced LOS and total cost in a significant and sustainable fashion for colorectal surgery patients. Based on the success of this care redesign project, hospital administration is funding expansion to additional services.

Predicting case volume from the accumulating elective operating room schedule facilitates staffing improvements.

BACKGROUND: Precise estimates of final operating room demand can only be made 1 or 2 days before the day of surgery, when it is harder to adjust staffing to match demand. The authors hypothesized that the accumulating elective schedule contains useful information for predicting final case demand sufficiently in advance to readily adjust staffing. METHODS: The accumulated number of cases booked was recorded daily, from which a usable dataset comprising 146 consecutive surgical days (October 10, 2011 to May 7, 2012, after removing weekends and holidays), and each with 30 prior calendar days of booking history, was extracted. Case volume prediction was developed by extrapolation from estimates of the fraction of total cases booked each of the 30 preceding days, and averaging these with linear regression models, one for each of the 30 preceding days. Predictions were verified by comparison with actual volume. RESULTS: The elective surgery schedule accumulated approximately three cases per day, settling at a mean ± SD final daily volume of 117 ± 12 cases. The model predicted final case counts within 8.27 cases as far in advance as 14 days before the day of surgery. In the last 7 days before the day of surgery, the model predicted the case count within seven cases 80% of the time. The model was replicated at another smaller hospital, with similar results. CONCLUSIONS: The developing elective schedule predicts final case volume weeks in advance. After implementation, overly high- or low-volume days are revealed in advance, allowing nursing, ancillary service, and anesthesia managers to proactively fine-tune staffing up or down to match demand.

Automated near-real-time clinical performance feedback for anesthesiology residents: one piece of the milestones puzzle.

BACKGROUND: Anesthesiology residencies are developing trainee assessment tools to evaluate 25 milestones that map to the six core competencies. The effort will be facilitated by development of automated methods to capture, assess, and report trainee performance to program directors, the Accreditation Council for Graduate Medical Education and the trainees themselves. METHODS: The authors leveraged a perioperative information management system to develop an automated, near-real-time performance capture and feedback tool that provides objective data on clinical performance and requires minimal administrative effort. Before development, the authors surveyed trainees about satisfaction with clinical performance feedback and about preferences for future feedback. RESULTS: Resident performance on 24,154 completed cases has been incorporated into the authors' automated dashboard, and trainees now have access to their own performance data. Eighty percent (48 of 60) of the residents responded to the feedback survey. Overall, residents "agreed/strongly agreed" that they desire frequent updates on their clinical performance on defined quality metrics and that they desired to see how they compared with the residency as a whole. Before deployment of the new tool, they "disagreed" that they were receiving feedback in a timely manner. Survey results were used to guide the format of the feedback tool that has been implemented. CONCLUSION: The authors demonstrate the implementation of a system that provides near-real-time feedback concerning resident performance on an extensible series of quality metrics, and which is responsive to requests arising from resident feedback about desired reporting mechanisms.

Novel use of electronic whiteboard in the operating room increases surgical team compliance with pre-incision safety practices.

BACKGROUND: Despite evidence that use of a checklist during the pre-incision time out improves patient morbidity and mortality, compliance with performing the required elements of the checklist has been low. In an effort to improve compliance, a standardized time out interactive Electronic Checklist System [iECS] was implemented in all hospital operating room (OR) suites at 1 institution. The purpose of this 12-month prospective observational study was to assess whether an iECS in the OR improves and sustains improved surgical team compliance with the pre-incision time out. METHODS: Direct observational analyses of preprocedural time outs were performed on 80 cases 1 month before, and 1 and 9 months after implementation of the iECS, for a total of 240 observed cases. Three observers, who achieved high interrater reliability (kappa = 0.83), recorded a compliance score (yes, 1; no, 0) on each element of the time out. An element was scored as compliant if it was clearly verbalized by the surgical team. RESULTS: Pre-intervention observations indicated that surgical staff verbally communicated the core elements of the time out procedure 49.7 ± 12.9% of the time. After implementation of the iECS, direct observation of 80 surgical cases at 1 and 9 months indicated that surgical staff verbally communicated the core elements of the time out procedure 81.6 ± 11.4% and 85.8 ± 6.8% of the time, respectively, resulting in a statistically significant (P < .0001) increase in time out procedural compliance. CONCLUSION: Implementation of a standardized, iECS can dramatically increase compliance with preprocedural time outs in the OR, an important and necessary step in improving patient outcomes and reducing preventable complications and deaths.