A Hospital-Based Preoperative Clinic: Patient Optimization with Enhanced Recovery After Surgery and Strong for Surgery

General Information 

Institution Name: CHRISTUS St. Michael Health System

Submitter Name and Title: Dawn Davis, MSN, RN, NP-C; Vickie Hurst, BSN, RN-BC; Benjamin DuBois, MD, FACS; Christy Mills, DNP, RN, CPHQ, HACP; and Jessica Davis, RN, SCR

Name of the Case Study: A Hospital-Based Preoperative Clinic: Patient Optimization with Enhanced Recovery After Surgery and Strong for Surgery

What Was Done? 

Global Problem Addressed 

With traditional perioperative care, day-of-surgery cancellations and surgical complications can result from multiple factors, including poor blood sugar control, inadequately managed disease processes, frailty, poor nutrition, smoking, delirium, and unaddressed medications.

Identification of Local Problem 

In 2016, American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) data for colorectal surgery at CHRISTUS St. Michael Health System (CSMHS) demonstrated an overall occurrence rate of 32.7 percent, an average length of stay of 7.4 days, and average variable costs of $6,346 (which include lab, radiology, pharmacy, and supplies). In the ambulatory care unit, blood sugar control (blood glucose < 200 mg/dl) on the day of surgery was 87.7 percent, and the day-of-surgery cancellation rate was 4.9 percent.

To improve patient outcomes, we initiated a nurse practitioner (NP)-driven, hospital-based preoperative clinic built on the basis of Enhanced Recovery After Surgery (ERAS) and Strong for Surgery (S4S) guidelines. In the preoperative clinic, the NP captures ACS NSQIP variables, identifies patient risk factors for S4S, and follows ERAS guidelines on appropriate patients. Our goal is to enhance the surgical care of the patient, reduce the length of stay without increasing readmissions, minimize postoperative complications, decrease health-related costs, and increase patient quality of life/satisfaction.

How Was the Quality Improvement (QI) Activity Put in Place? 

Context of the QI Activity 

CSMHS is a faith-based, community, not-for-profit, 354-bed acute care facility located in Texarkana, TX. The service area is predominately rural and serves 13 counties in Northeast Texas, Southeast Oklahoma, and Southwest Arkansas.

The Quality Department team for CSMHS attended the annual ACS Quality and Safety Conference, and through the conference sessions we gained a better understanding of ERAS principles and S4S guidelines. We brought these concepts back to our community and began to implement these two programs within our hospital.

We gathered information on successful ERAS programs across the nation, and in 2016, a colorectal ERAS program was approved as a process improvement project for our hospital. It became apparent to us, through this project, that using a preoperative clinic within the hospital would serve as a gateway for the ERAS program and would also help to ensure the principles were properly implemented. Once the original S4S guidelines were published, they were added to our program and the preoperative clinic was underway.

Planning and Development Process 

We introduced the ERAS principals to the team at our initial meeting in September 2016. Shortly after this meeting, we began to develop the ERAS algorithms and measurements. We completed the preoperative, intraoperative, and postoperative algorithms by February 2017.

We hired our preoperative clinic nurse practitioner in early 2017, and by April 2017, we began piloting ERAS on colorectal surgeries. We also introduced the nutrition, blood sugar, medication, and smoking S4S checklists to the team and finalized our program logo and education booklet. During this time, our Surgeon Champion (SC) began providing education on ERAS and S4S guidelines to the community surgeons and hospital staff.

Our “go live” date occurred in June 2017, with ERAS colorectal and the first four checklists for S4S. We began to track the ACS NSQIP/ERAS variables for colorectal surgery. When the ACS began using the S4S checklists for delirium, prehabilitation, safe and effective pain control, and patient directives, we added those to our practice as well.

Early in 2018, we began planning for ERAS orthopaedic surgeries and for the integration of ERAS with the Improving Surgical Care and Recovery (ISCR) program. By October 2018, we implemented orthopaedic ERAS /ISCR on knee replacement, hip replacement, and hip fractures. The team is currently in the implementation stage of the ERAS/ISCR gynecology guidelines.

Description of the Quality Improvement Activity 

In preparation for implementation, the Surgeon Champion provided education to the community surgeons and select hospital staff. The clinical education department provided house-wide education, and all nursing associates were required to complete online education modules on care provided to the ERAS patient. We also developed and implemented our data collection methods.

We created ERAS education booklets for patients and their family members. These booklets were distributed to physician offices where education is initiated. Booklets are also provided in the preoperative clinic. The NP is in charge of educating the patient on preoperative, postoperative, and discharge instructions, as well as applying the S4S checklists to each patient.

The pre-and postoperative ERAS orders are written by the surgeon/ anesthesiologist and carried out by the nursing staff.

Date when the QI activity was first implemented:

Our “go live” date for the colorectal ERAS program and S4S checklist was June 2017.

Resources Used and Skills Needed

We used a multidisciplinary team approach, including staff from:

• Administration
• Anesthesia
• Case Management
• Clinical Informaticist
• Critical Care
• Dietary
• Marketing
• Nurse Educator
• Nursing Postoperative
• Pharmacy
• Physician Office Staff
• Physical Therapy
• Quality Outcomes
• Respiratory
• Risk Management
• Surgeon Champion
• Surgical Services

Cost 

No additional costs or funding beyond normal hospital operations were necessary to implement and maintain the QI program.

What Were the Results?

Overall Results 

We obtained data using the ACS NSQIP database. Additional information was obtained during the preoperative visit, hospital stay, and postoperative phone calls (done two months after the surgical procedure).

Analysis of colorectal ERAS data for one year indicated a decreased length of stay from 7.3 days to 5.2 days. The average variable costs were reduced from $6,346 to $4,359. Postoperative occurrences as defined by ACS NSQIP have decreased from 32.7 to 19.6 percent.

S4S data for one year indicates that blood sugar control (blood glucose <200 mg/dl) on the day of surgery has improved from 87.7 to 95.6 percent. Patient- reported smoking cessation rates are 18.5 percent two months after surgery.

Since implementation of our preoperative clinic, day of surgery cancellations have decreased from 4.9 to 0.95 percent.

In addition to the processes outlined above, we assess the nutritional needs of our patients and, when appropriate, place patients on an immunomodulating supplement; we consult a registered dietitian as needed. We provide counseling and documents for completion of advanced directives/medical power of attorney to 100 percent of patients in the preoperative clinic. We also provide diabetic and smoking cessation counseling, screen for delirium, and recommend consults as necessary from physical therapy, cardiology, pulmonology, and case management.

Setbacks

Upon evaluation of our implementation process, the main barriers we encountered were a slow-changing culture and time-consuming data collection. Constant teamwork, communication, and surgeon engagement have been key for culture change. The progress made creates a smoother path for our future ERAS programs. A Clinical Data Analyst was added to our team to support data collection and abstraction.

Strong support from our Surgeon Champion and leadership team contributed to our success. We also have an engaged multidisciplinary ERAS team.

Communication was key, and was accomplished using frequent ERAS meetings, operating room information boards, memos to the surgeons, and online staff education.

Cost Savings

There was no additional money invested in implementing this QI project. Cost savings data has not been finalized at this time.

Tips for Others 

Key components for successful implementation include:

• Strong support from the Surgeon Champion, senior leadership, and frontline management is necessary.
• Engaged team members and clear communication are crucial for success.
• Keep it simple. Use S4S checklists and ERAS principles to guide your data collection. Begin by tracking data your hospital can easily collect and build from there. Even if the data are not as positive as expected, the information highlights the areas that need improvement and can help you form a plan.
• Don’t reinvent any wheels. Use the resources available through the American College of Surgeons and other facilities that have already implemented the programs.