Preoperative evaluation clinics proving their worth

The rise of pay-for-performance programs in healthcare has necessitated that hospitals seriously examine how to reduce surgical complications, one of the key metrics being tied to reimbursement.

Typically, preadmission testing is done a few days before an elective surgery. Identification of comorbidities this close to the procedure greatly reduces the ability of the surgeon to take steps to mitigate the risks these may entail. This is also the point where it is hugely inconvenient for patients, and costly to hospitals and surgeons, to cancel surgery so corrective action can be taken.

Enter the preoperative evaluation clinic (PEC), a rapidly emerging strategy of assessing patients three, four or more weeks prior to surgery. Many of the PECs currently focus on orthopedics and, more specifically, total joint replacement. The Comprehensive Care for Joint Replacement (CJR) model, an alternative Medicare payment method launched last April, financially rewards hospitals for improving patient outcomes. I recently had the opportunity to visit three forward-thinking institutions that have established a PEC for an up-close look at how they’re structured and staffed, and if they can report any ROI for their efforts. The answer to the latter question is an unequivocal yes. When it comes to PECs, early results suggest that what’s best for patients is also good for the bottom line—and this applies regardless of the prevailing reimbursement model (none of the three clinics I visited were subject to the CJR mandate).

Common attributes of the three PECs include:

• Patient flow algorithm facilitated by a nurse navigator
• Evaluation of patients for anemia, cardiac conditions, diabetes, dentation, nutritional status, renal insufficiency and sleep apnea
• Geriatric assessment on elderly patients
• Internist clears patients for surgery
• Patients engaged in their care and share in decision-making
• Educational instruction to patients and families to set expectations

Among the first to take the leap of faith was Dixie Regional Medical Center (part of Intermountain Healthcare) in St. George, Utah, which has a gorgeous PEC intentionally designed for this purpose. The clinic, restricted to patients of employed physicians, has a team (nurse navigator, social worker, physical therapist and internist) that evaluates patients utilizing a twelve-system assessment. If additional testing is needed based on the assessment, it’s coordinated through the PEC. All caregivers discuss and establish a plan of care for each patient seen, including suggestions for post-procedure care. Patient-specific calendars serve as reminders for the patients of key events (e.g., surgical scrub preparation and when different medicines start and stop) and who and when to call postoperatively is color-coded red, yellow or green based on the severity of symptoms. Across PECs, the standard role of nurses—preadmission history and physical, patient education, medication reconciliation and communication with the rest of the care team—remains unchanged, but happens well in advance of surgery.

At Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire, the PEC is run out of an orthopedic surgeon’s office with an embedded internist who sees patients preoperatively and also rounds on them postoperatively. During assessments, patients can point to their discomfort level on an “arthritis ladder” (minor to debilitating joint pain) that corresponds to their treatment options. Once the internist clears the patient for surgery, the surgery is scheduled. Currently, only one surgeon in the group sends patients through the clinic.

The third PEC occupies a small space within the preadmission testing area at St. Luke’s Medical Center in Boise, Idaho. Here, a predefined algorithm identifies high-risk patients who need to be seen at the clinic; everyone else goes through traditional preadmission testing. St. Luke’s clinics and orthopedics/internal medicine hospitalists are also using best practices and care maps, based on clinical practice guidelines of the American Academy of Orthopaedic Surgeons. Best evidence from these guidelines gets incorporated into clinical care pathways to improve patient outcomes.

One of the big rewards, cited by all three clinics, is a decrease in same-day surgery cancellations. All three PECs report higher HCAHPS scores, and there is also some evidence of reduced rates of complications and readmissions, and shortened lengths of stay.

The shared decision-making with patients is critical. Nurses ensure patients have realistic expectations of surgery (e.g., they won’t be totally pain-free) and understand they’ll be discharged home (if possible) rather than to a skilled nursing or rehab facility where their infection risk would be higher. They “get” that they won’t get better postoperatively no matter how well the surgeon replaces their joint if they don’t play an active role in their own recovery process.

But establishing a PEC is clearly not a slam-dunk proposition. Three main hurdles need to be cleared—where to find space, how to pay for it (one of the PECs bills the preoperative assessment as an office visit and the other two bill only for required tests and lab work), and how to get the buy-in of surgeons. Nurses have an enormous opportunity to help patients recognize that when a surgery is delayed it truly is with their best interests in mind.

About the Author: Kim Wright, R.N.
Kimberly Wright, AVP Clinical Data Solutions, HealthTrust

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