CLINICAL INTEGRATION

“THE RIGHT CARE, IN THE RIGHT SETTING, AT THE RIGHT TIME”

CME JUNE 2014

Pre-Operative EvaluationsOctober 2013 – August 2014

Preoperative Evaluations: WORK GROUP Executive Sponsor

o Dean Danner Sr. VP and ACI Chief Operating Officer Core Work Team

o John Wheat, D.O. Primary Care Physiciano Kristen Rahn, M.D. Primary Care Physiciano Erik Anderson, M.D. Primary Care Physiciano Gary Sweet, M.D. General Surgeryo Timothy Logemann, M.D. Cardiovascular Associateso Dean Kellner Central Wisconsin Anesthesiology o William Holm, M.D. Anesthesiologisto Aaron Anderson, M.D. Anesthesiologisto Nathan Grabher, M.D. Anesthesiologisto Jennifer Baumann Clinical Integration Project Coordinator

Supporting Work Teamo Carrie Murray Patient Centered Medical Homeo Gregory Sewall, M.D. ENTo Tristan Laszewski IT/EPICo Andrea Blaubach Fiscal Serviceso Susan Courtney MHC Quality Serviceso Angela Guden, CRNA MHC Anesthesia

Preoperative Evaluations: GUIDING PRINCIPLES

Patient Centered

System-Wide Approach

Physician Compact

Preoperative Evaluations: OBJECTIVE

Pre-operative visits are conducted in a timely manner to provide standardized, essential, evidence-based, preoperative information to anesthesia and surgical care teams.

Preoperative Evaluations:OPPORTUNITIES FOR IMPROVEMENT

Wide Variation in Care Inconsistent pre-operative information and process flow between clinics and providers No consistent, documented evidenced–based pathway guiding appropriate care Unnecessary or duplicated tests Incomplete information, increased cost, inconvenience for patients Out-of –System evaluations add variation, complexity to process

Expertise alignment with Severity of Care No process to evaluate appropriate preoperative work-up based on surgical risk Non-complex cases H&P could be conducted at the time of the surgical consult

Non-Integrated Process Difficultly with Timeliness/Access of H&P visit in Primary Care Inefficient for providers and patients Communication difficulty/gap between involved specialties

Expertise Alignment with Severity of Care

Risk Assessment Tool

Surgical Groups performing low risk Evaluations

Wide Variation in Care and Process

Evidence Based Epic Template

Standardized clinic work flow and provide guideline based evaluations

Suboptimal Integration and Access

ACI Pre-Operative Clinic Integrated with Anesthesia

• Out-Of-System patients

• High surgical risk procedures

Preoperative EvaluationsOPPORTUNITIES FOR IMPROVEMENT

OctoberNovember

January

December

May

February

March

April June July August

2013 2014

Workgroup representing all stakeholders to improve the HnP process.

Communicate with Primary Care, Anesthesia and Surgical Sites.

Develop Epic template based on ICSI guidelines

Implement Risk Algorithm Tool and Evidence Based Guidelines at Clinic and Surgical Sites.ACI

Preoperative HnP Clinic

Assess and Improve

Assess and Improve

Preoperative Evaluations: TIMELINE

Pilot: Risk Algorithm

Pre-Operative Evaluations: SURGICAL ASSESSMENT TOOL

Will patient be admitted Post-op for greater

than 24 hours?

Is patient scheduled for a minor OP

surgery under MAC anesthesia?

Surgeon refers directly to Pre-Op Visit for specific

concerns.

Yes

No

No

Yes

Yes

Refer to Pre-Op

Visit

Proceed to scheduled surgery without further work-up.

Surgeons H&P should be completed and will satisfy requirement.

NoDeveloped by Dr. William J. Holm with the support of CWA

and in collaboration with the AWH Pre-Op Workgroup

Pre-Operative Evaluations: SURGICAL ASSESSMENT TOOL

No

No

Yes

Yes

Refer to Pre-Op

Visit

Age 12 months or less? (If of premature birth –

24 months or less)

Does the patient have insulin corrected diabetes?

Is patient on anti-coagulant therapy or

blood thinning drugs?

No

Developed by Dr. William J. Holm with the support of CWA and in collaboration with the AWH Pre-Op Workgroup

Pre-Operative Evaluations: SURGICAL ASSESSMENT TOOL

No

No

Yes

Yes

Refer to Pre-Op

Visit

Greater than three positive answers on Pre-Op

Assessment Survey?

Any positive answers on Pre-Op Assessment

Survey?

Proceed to scheduled surgery without further work-up.

Surgeons H&P should be completed and will satisfy requirement.

Has patient completed therapy or is

established with a PCP & has been seen in the

last year?Yes

No

Developed by Dr. William J. Holm with the support of CWA and in collaboration with the AWH Pre-Op Workgroup

Pre-Operative Evaluations: PATIENT ASSESSMENT TOOL

Assessment Survey1. Patient is either Male, over 50 or Female, over 60? Yes⃝ No⃝2. Patient has a BMI of greater than 35? (?) Yes⃝ No⃝3. History of severe Gastro Esophageal Reflux Disease (Heartburn)? Yes⃝ No⃝ - continue current drug therapy through day of surgery.4. History of Pulmonary Disease or related (ie. COPD, Asthma)? Yes⃝ No⃝5. History of Obstructive Sleep Apnea (Excessive Snoring)? Yes⃝ No⃝6. History of Hypertension (High Blood Pressure)? Yes⃝ No⃝ - continue current beta blockers, hold ACE inhibitors and diuretics for the day of surgery.7. History of Coronary Artery Disease (Heart Attack or Blockage of Arteries in the Heart)? ⃝Yes No⃝

Pre-Operative Evaluations: PATIENT ASSESSMENT TOOL

Assessment Survey (Continued)8. History of other Heart Disease? Yes⃝ No⃝ - cardiomyopathy, arterial fibrillation, other arrhythmia, pacemaker or AICD.9. History of High Cholesterol? Yes⃝ No⃝10. History of Endocrine Disease, Diabetes, Hyper/Hypothyroid or related?

Yes⃝ No⃝11. History of Renal Disease (Kidney Failure)? Yes⃝ No⃝12. History of Hepatic Disease or Chronic Hepatitis or other Liver Problems?

Yes⃝ No⃝

Pre-Operative Evaluations: PATIENT ASSESSMENT TOOL

Assessment Survey (Continued)13. History of Alcohol Abuse or Illicit Drug Use? Yes⃝ ⃝No14. Does the patient get winded when climbing just one flight of stairs?

⃝Yes No⃝NOTES:

TOTAL NUMBER

OF YESANSWERS

If total is greater than three

Refer to Pre-Op

Visit

Developed by Dr. William J. Holm with the support of CWA and in collaboration with the AWH Pre-Op Workgroup

Class IEmergency Surgery OR

Active Cardiac Conditions Evaluate, Manage First

Low-Risk Surgery OR

No Clinical Risk Factors OR

Preoperative EvaluationsCARDIOVASCULAR

Preoperative Evaluations:CARDIAC RISK INDEX

• Hx of ischemic heart disease• Hx of compensated or prior HF• Hx of cerebrovascular disease• Diabetes mellitus• Renal insufficiency

Lee et al. Circulation 1999

Preoperative Evaluations:GUIDELINE: ELECTROCARDIOGRAM

ICSI EKG Guidelines Perform EKG for all patients age 65 and older within

one year prior to procedure

EKGs not indicated, regardless of age for patients having cataract surgery

EKGs not recommended for patients undergoing other minimal risk procedures unless medical history/assessment indicate a high risk patient.

Preoperative Evaluations:GUIDELINE: ELECTROCARDIOGRAM

ICSI EKG Guidelines

Preoperative history and physical examination

Signs or symptoms of cardiovascular disease

No Signs or symptoms of cardiovascular disease

Electrocardiography

High Risk Surgery Low Risk Surgery Intermediate Risk Surgery

At least 1 Clinical Risk Factor ** Cerebrovascular disease Congestive heart failure Creatinine level >2.0 mg per dL

(176.80 umol per L) Diabetes mellitus requiring

insulin Ischemic cardiac disease Suprainguinal vascular surgery,

intrathoracic surgery, or intra-abdominal surgery

No Clinical Risk Factors **

NO Electrocardiography

Class I - NONE

Class IIaPts with > 3 RFsFunctional Capacity < 4 METsVascular Surgery

Preoperative EvaluationsNON-INVASIVE STRESS TESTING

JACC 2009

Exercise Echo if normal LV

Or MIBI

Preoperative EvaluationsWHICH STRESS TEST ?

ABLE TO EXERCISE?

YES NO

Pharmacologic

Stress Imaging

JACC 2009

Preoperative EvaluationsANTICOAGULATION BRIDGING

THERAPYRecent Stentingo Aspirin 81 mg should be continued.o Patients anticipating “necessary elective” surgical procedures that

meet the following criteria may hold their medications based on the following recommendations:

• > than 2 weeks post angioplasty• > than 4 weeks post bare metal stent• > 6 months post drug eluding stent (DES)

o Clopidegrel should be stopped 5 days before procedureo Prasugrel should be stopped 7 days before procedureo Ticagrelor should be stopped 5 days before procedureo Medications should be resumed 48 hours post-surgery, if there are

no signs of active bleeding.

Preoperative EvaluationsANTICOAGULATION BRIDGING

THERAPYAtrial Fibrillationo Use the CHADSVASC risk calculatoro Use the online creatinine clearance calculatoro Briding therapy is recommended for patient with the

following:• CHADS 2 > 4 or CHADSVASC of 6• Prior CVA or TIA• Mitral valve stenosis• Prior embolic event• Intra-cardiac thrombus

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Preoperative Basic Health Assessment

MEDICAL HISTORY

Preoperative Basic Health Assessment

PHYSICAL EXAMINATION

Indication for surgical procedure Weight, height and body mass index Allergies and intolerances to medications, anesthesia or other agents (specify reaction type)

Vital signs Blood pressure Pulse (rate and regularity) Respiratory rate

Known medical problems Cardiac Surgical history Pulmonary Trauma (major) Other pertinent exam Current medications (prescription, over-the-counter medications, herbal and dietary supplements)

Risk factors for development of surgical site infections (e.g., smoking, diabetes, obesity, malnutrition, chronic skin disease) Basic nutritional assessment – lab verification reserved for those patients felt to be at risk. Focused review of issues pertinent to the planned anesthesia and procedure Current status of pertinent known medical problems Cardiac status Pulmonary status Functional status (ability to perform at four or more

METs) Hemostasis status (personal or family history of

abnormal bleeding) Possibility of severe (symptomatic) anemia Possibility of pregnancy Past personal or family history of anesthesia

problems Smoking, alcohol history and illicit drugs

Preoperative Evaluations:GUIDELINE: LABORATORY TESTS

Coagulation Studies Patient has a known history of coagulation abnormalities or recent history suggesting coagulation problems or is on anticoagulants.

Patient needs anticoagulation postoperatively (where a baseline may be needed.

Hemoglobin Patient has a history of anemia or history suggesting recent blood loss or anemia.

Potassium Patient is taking one or more of the following: Digoxin Diurectics ACE inhibitors Angiotension Receptor Blockers

Pregnancy Test Patient is of child-bearing age and: Is sexually active and history suggest possible

pregnancy, e.t. delayed menstruation Patient is concerned about possible pregnancy Possibility of pregnancy is uncertain

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Considerations For Medications Discontinued Pre-Operatively

  Medications that do not contribute to the medical homeostasis of the patient should be discontinued in preparation for surgey

DRUG TYPE DRUG/DRUG CLASS CONSIDERATIONS

Anticoagulant/Antiplatelet Aggrenox Stop at least seven days before surgery

Aspirin Stop at least five days before surgery

Cilostazol Stop three days before surgery

Dabigatran Stop two days before surgery (CrCl >/= 50 mL/min.)Stop five days before surgery (CrCl < 50 mL/min.)

Plavix Stop at least five days before surgery – may need to hold elective procedures off for at least six months after stent

Ticlopidine Stop at least five days before surgery

VKA (warfarin) Stop at least five days before surgery.

Cardiovascular ACEI/ARB Hold morning of surgery/suspend for 1 dosage interval before surgery. If drug already taken, watch blood pressure closely at induction.

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Diabetes Oral agents Hold morning of surgery/while nothing by mouth Metformin Hold at least 24 hours before surgery to prevent lactic

acidosis

Endocrine Hormone therapy (estrogen)

Stop four weeks before surgery if ableIf unable to stop, ensure adequate venous thromboembolism prophylaxis perioperatively Weigh risk of symptoms/unwanted pregnancy vs. risk for developing clot.

Herbals All types Stop at least one week before surgery. Many prolong bleeding time/increase blood pressure. Inadvertent omega-3 administration day of surgery is not a contraindication to surgery.

Considerations For Medications Discontinued Pre-Operatively

  Medications that do not contribute to the medical homeostasis of the patient should be discontinued in preparation for surgey

DRUG TYPE DRUG/DRUG CLASS CONSIDERATIONS

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Considerations For Medications Discontinued Pre-Operatively

  Medications that do not contribute to the medical homeostasis of the patient should be discontinued in preparation for surgey

DRUG TYPE DRUG/DRUG CLASS CONSIDERATIONSEndocrine Hormone therapy (estrogen) Stop four weeks before surgery if able

If unable to stop, ensure adequate venous thromboembolism prophylaxis perioperatively Weigh risk of symptoms/unwanted pregnancy vs. risk for developing clot.

Herbals All types Stop at least one week before surgery. Many prolong bleeding time/increase blood pressure. Inadvertent omega-3 administration day of surgery is not a contraindication to surgery.

NSAID Non-COX selective Short-acting (ibuprofen, indomethacin, etc.) – stop one day before surgery. Long-acting (naproxen, sulindac, etc.) – stop three days before surgery.

Osteoporosis Raloxifene Stop at least one week before high risk venous thromboembolism procedures.

Alendronate Stop perioperatively due to difficult administration during hospitalization.

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Considerations For Medications Continued Pre-Operatively

  “Medications contributing to the patient’s current state of homeostasis should be continued.”

DRUG TYPE DRUG/DRUG CLASS CONSIDERATIONS

Cardiovascular Beta-blockers Continue if patient has been taking Consider initiating if patient has high CV risk (ACC/AHA guideline)

Clonidine Continue – utilize patch formulation if anticipate extended NPO status

Calcium channel blockers

Continue pre-operatively(Consider holding if left ventricular dysfunction)

Statins Continue if patient taking chronically Consider initiating if patient has high CV risk (ACC/AHA guideline)

Anti-arrhythmics Continue preoperatively

Diabetes Insulin Decrease basal/long acting insulin by up to 50% Cover with sliding scale, short-acting insulin

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Considerations For Medications Continued Pre-Operatively

  “Medications contributing to the patient’s current state of homeostasis should be continued.”

DRUG TYPE DRUG/DRUG CLASS CONSIDERATIONS

Endocrine Thyroid replacement Continue preoperatively

Corticosteroid therapy Continue – add stress dosing if > 5 mg prednisone per day (or equivalent) in six months prior to surgery, or on chronic therapy

HIV All types Continue – if necessary to discontinue, re-initiate all medication at the same time

Neuro/Psych All types Continue pre-operatively; With exception of MAO Inhibitors. (Consult with Anesthesia)

Osteoporosis Tamoxifen May increase risk of deep vein thrombosis – Discuss with oncologist before decided to stop medication preoperatively

Rheumatology All types Continue –per-operatively.Anecdotal evidence of increased wound infections/delayed healing.

Preoperative Evaluations:AIMS and MEASURES

Increase the percentage of COMPLETE preoperative history and physical examination obtained for patients two years of age and older undergoing elective, non-high-risk surgery and eliminate diagnostic tests performed without clinical indications.

Increase the percentage of patients two years of age and older undergoing elective non-high-risk surgery who receive appropriate management of stable comorbidities prior to procedure.

Eliminate canceled or delayed elective, non-high-risk surgical procedures for patients two years of age and older due to incomplete preoperative history and physical examination and ineffective communication between clinics.

Fiscal Implications

Preoperative Evaluations:Summary

o All: Review/Familiarize with ICSI guidelines. Provide insight on areas of input and communicate with Work Group or

others involved in process.o Surgical Groups:

Incorporate Preoperative assessment tool and identify lower risk surgeries that may not need separate evaluation and perform at time of surgical consult/scheduling.

When separate evaluation needed, allow guidelines to direct preoperative testing at time of evaluation.

o Primary Care: Trial use of SmartSet / Template, give constructive feedback and move

towards standardizing visits around a set of guidelines.o Anesthesia:

Serve greater role in consulting, communication with surgical teams and primary care in guiding pre-operative management.

Preoperative Evaluations:Implementation Plan

o Surgical Groups: Operations/Board meetings: introducing Pre-Operative Assessment tool

and asking to incorporate into work flow Monitor trend/number of Pre-operative Evaluations that can be done at

time of consultation.o Primary Care:

Operations meetings. Managers, Super-Users, and Epic Trainers trained on use of template to

provide on-site physician support. Identification of upcoming pre-ops and use of tools on subsequent visits.

o Anesthesia: Collaborating with Anesthesia Department, PARC, other surgical centers

to adapt current guidelines in their protocols. Monitoring process with subgroup focused on aims/measures listed above.

Pre-Operative Evaluations: Dr Joseph F Smith Medical Libraryo Select Staff Pickso Select Aspirus Guidelines

• Preoperative Evaluation Section Presentation ICSI Guidelines Patient Risk Assessment Tools Epic Tip Sheet ACVA Protocol for Bridging Therapy

CLINICAL INTEGRATION

“THE RIGHT CARE, IN THE RIGHT SETTING, AT THE RIGHT TIME”

CME JUNE 2014

Pre-Operative Evaluations: October 2013 – August 2014