A quality bundle created for colorectal surgical patients has proved so successful that it is being expanded to other units at Johns Hopkins University Hospital in the hopes that the financial and clinical benefits can spread to other specialties.
The positive outcomes experienced by the quality improvement program are outlined by an article in press with the Journal of the American College of Surgeons.1 Some of the items used in the bundle have been studied and reported on separately as part of Enhanced Recovery Programs (ERPs). Such protocols call for patients to be allowed to continue imbibing clear fluids until just before surgery, encourage patients to eat and move very quickly after surgery ends, and try to limit the use of narcotic pain medications in order to achieve that early ambulation. The findings of those who have used these protocols have included shorter inpatient stays, lower costs, higher patient and provider satisfaction, and lower complication rates.
This allows patients to continue to hydrate until very close to surgery, gets them up and moving more quickly, and limits the use of narcotics as much as possible. All have been found to reduce the length of stay for patients, as well as improve patient satisfaction scores.
The new program melds some of these same elements with other items, including improved communication efforts, leadership support, and the very culture of the organization, says Elizabeth Wick, MD, FACS, the lead author of the study.
The paper outlines how the project brought together a multidisciplinary team to create a pathway based on existing best practices in the literature. They trouble-shot based on feedback from frontline staff, making changes quickly as problems were reported. A big part of the project was to include patients and their families in education and care, and to provide physicians and their staff with set goals for metrics they wanted to change. For example, surgical site infection rates for 2014 had a goal of 12% — down from an existing 18.8%. The entire pathway was put on a bulletin board for patients to see, the study notes.
Patients received mechanical bowel preparation including antibiotics, chlorhexidine bathing prior to surgery, and preoperative prophylaxis for venothromboembolism (VTE). Patients who smoked received smoking cessation counseling. On the day of surgery, they were allowed to drink clear fluids until two hours prior to surgery. On recovery, patients are encouraged to resume eating and walking much more quickly than previously. Narcotic pain medications are used sparingly. Patients deemed at risk are given continued VTE prophylaxis.
The results of the pathway were significant. Within 11 months, the study reports, patient stays were two days shorter, with the associated costs declining by almost $2,000 to $9,036. Surgical site infections declined by more than half to just 7.3%, about 5% less than the goal. And Wick says the entire culture and values of the organization seemed to shift. Things became much more patient-focused as a result, and trust between staff members grew.
Staff that had shifted between units now stayed together, building rapport that did not exist before. Accountability increased as the key metrics were available for all to see on an electronic dashboard that was kept up to date with information on length of stay, surgical site infection rates, and patient satisfaction scores, she says.
Patients loved the new pathway, too, with results improved most in the areas of staff communications regarding medications, responsiveness to patient requests, and dealing with issues of pain management. Wick thinks this is one of the few quality improvement programs showing a valid clinical intervention that also has positive benefits for patient satisfaction.
Other beneficial results include a drop in urinary tract infections from 4.1% to 1.6%, less VTE, with pre-intervention rates of 3.5% and post-intervention rates of 1.6%, according to the study.
None of what they did was “new,” per se, Wick says. It was all best practices. But it was that they rolled it all together that made such a difference, she says. “We had best practices in surgical site infections, best practices in DVT prophylaxis, best practices in building a patient-centered culture and teamwork and communication. Together it all made a difference.”
The changes in culture were actually easier than one might think to bring about. Doctors respond to data, so having the data on key metrics front and center in front of those physicians on an electronic dashboard was a way to bring it home to them that their actions had consequences.
In addition, having an “executive partner” from leadership who was a visible champion for the project also helped. “We worked on improving the culture and communication for three years,” she says. They had started as part of a unit-based safety program related to surgical site infections, and continued with this colorectal surgery project. “We saw improvement right away, and that was a key contributor.”
Wick notes that with success comes buy-in. So when you have it, put it up in front of the key stakeholders on a dashboard and celebrate it. They included volume of surgery, length of stay, infection rates, rates of epidurals, how many patients were getting out of bed early.
Initially, the data were aggregated, and physicians were uninterested in having individual information. They feared there was no way to stratify for their case mix. However, since then they have started to pass out individual provider information, and Wick says it will be interesting to see if that leads to further improvements or changes in individual practices.
The initial program was done with high volume surgeons. Since then, it has expanded to all the gastro-intestinal surgery done at Hopkins. It is now spreading further to gynecological oncology and liver surgery. “So far, we are seeing the same kind of results,” she says.
There have been changes to the program. At first they tried to completely cut out the use of narcotics in epidurals, but feedback was that it wasn’t working. Now they are more judicious in their use, but do not ban it altogether. What they use for pain medications has also changed over time. “I think if we were starting over we wouldn’t be so militant about our ideas.”
She thinks, too, that one reason this project had such great success so early is that they had been working together for some years on another project and had seen success already. “We knew the people involved, we knew who we had to have on board.” If you do not have that experience, you might not have that instant success, she says. But do not let that upset you. “Get people together and engaged. Once you do that, things will flow more easily.”
She has one key recommendation, too: Make sure no one on the team stakes a claim to anything the team should own. “I have seen a lot of instances where both anesthesia and surgery are trying to own the perioperative home. That is not a way to have an easy win that can bring the team together. This has to be a collaboration between all members of the team, and everyone has to have the proverbial skin in the game. We all bring value, and we all have to recognize what we each can do for the process, and then we all have to be equally rewarded. This would not have worked if we were not a collaborative unit. If you do not have that, start with something smaller and build it first. Then you can do something bigger like this.”
For more information on this topic, contact Elizabeth Wick, MD, FACS, associate professor of surgery and oncology at Johns Hopkins University School of Medicine, Baltimore, MD. Email: [email protected].
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Wick EC, Galante DJ, Hobson DB et al. Organizational Culture Changes Result in Improvement in Patient-Centered Outcomes: Implementation of an Integrated Recovery Pathway for Surgical Patients. Gregory A. Freeman [email protected] (770) 998-8455 . In press.
