#LeadingVBHC – We talked to Barbara Slawski, MD from MCW after her presentation, Fundamentals of Preoperative Testing.
Dr. Brian Cunningham: Here at the first annual Interdisciplinary Conference on Orthopedics and Value Based Care. We have the pleasure of being joined today by Dr. Barbara Slawski at the Medical College of Wisconsin, Professor of Medicine and generally the boss of perioperative optimization. I’m subbing in for Ms. Bolley.
We’re very grateful for a few minutes of your time. We listened to a fantastic presentation on some of the mechanics of perioperative optimization. One of the things that I thought was very interesting is you guys have been working on a multidisciplinary group, including medicine, anesthesia, orthopedics, looking at how to create a little bit more of a streamlined process. Can you elaborate on that for us?
Slawski: Sure. For several years, we’ve had a somewhat curtailed process for the care of hip fracture patients that started in the emergency department and went till discharge but really only involved internal medicine and orthopedic surgery that defined, for example, what lab tests patients would have and who cared for the patient in the hospital. We found more and more that wasn’t really enough to take care of the whole patient and that we really needed a collaborative, multidisciplinary process that involved the whole care of the patient, that was centered around the patient rather than around providers.
We got together a working group that involved anesthesiology, internal medicine, surgery, administration, and was facilitated by someone outside those groups to help us develop this comprehensive pathway, from admission to discharge, that included every aspect of care for those patients.
Cunningham: Fascinating. It sounds like that’s one way that would be extremely effective at generating value for the organization as well as the patients. Did you guys examine any metrics on how often cases were cancelled or how efficiently care was received pre and post?
Slawski: We’re just getting ready to implement the final …
Slawski: … phase of this protocol …
Cunningham: Okay, great.
Slawski: … so we’ll have post metrics coming up. It’s hard for us to actually measure cancellations at our facility because of a number of administrative reasons. It’ll be interesting. We’ll be able to pull those metrics after we implement. What we do know is that there’s a lot of provider dissatisfaction associated with cancellations and with the whole process of care. One of our goals in doing this is to, for example, change, when one team says a patient’s ready to get to the operating room and they get transported there the morning of surgery, to have another team not see the patient and say, “Well, they’re not ready to go,” then have them get back to the floor for additional diagnostic testing or an intervention.
What we need is a group of providers, even though they’re from different disciplines, that are all on board together, who are able to take care of a patient collaboratively and get the patient through the system efficiently and safely.
Cunningham: Did you guys do anything in that to investigate or evaluate how handoffs work? I know that’s one of the challenges of the medicine, is we’ve come from a time when people were taking call for days on end to a time where, I don’t want to call it shift work, but defined periods of work have made that difficult.
Slawski: What we did was talk to each other about how handoffs work.
Cunningham: Oh. Innovative solution.
Slawski: I know.
Cunningham: I like it.
Slawski: It was interesting. One team might think that their handoffs work completely well.
Cunningham: Fantastic, yeah.
Slawski: When you hear from other teams about how user unfriendly your system is, you find out. For example, one of our solutions to this was a pager group that includes all disciplines. We have a hip fracture pager group that we’re implementing, that you can page the hip fracture paging group, and the orthopedic surgeon, anesthesiologist, and internist on call at the same time responsible for hip fractures all get that page. It might say, “This patient is ready to proceed to the operating room,” and everybody knows.
Cunningham: My gosh. That sounds amazing.
Slawski: Or it might say, “Internal medicine needs to talk to anesthesia about hip fracture patient x.”
Slawski: We all can communicate well.
Cunningham: Yeah. It facilitates communication and expedites care, obviously. Interesting. Do you guys have a time goal for hip fractures at your institution? Six hours? 24 hours? 48 hours?
Slawski: Ideally, this would be 24 hours. Ideally, it would be as fast as possible from ED to OR. Realistically, I don’t think we’ll get from ED to OR in every case. When you look at the literature across the nation, I’ve averaged this up across articles, even among groups that think they’re going straight to the ED to the OR, or as fast as possible, it’s 2.4 days when you look at the literature.
Slawski: Among groups who think that they’ve improved care dramatically to go to the OR right away, they’re getting there in two days …
Slawski: … and decreasing their time from somewhere around four days. We really need to get patients to the operating room quickly.
Cunningham: Got it. Is this just totally crazy to think that there may be some role for not having any medical optimization for a hip fracture patient and just literally taking them to the OR?
Slawski: I think that is a little crazy. There have been studies that show … There was a study published several years ago that showed that patients with major abnormalities before going to the operating room had worse outcomes then patients who had what were defined as minor abnormalities. There are some things I think we do need to optimize or improve on before patients go to the operating room to make it more safe. The concept, though, that we don’t have to make patients perfect before they go to the operating room to have them get through the surgical experience safely for a hip fracture surgery is well taken, as opposed to an elective surgery case where we have time and it’s reasonable to say, “This is an elective surgery. We don’t want to do you any harm.”
Cunningham: I think that’s the interesting thing. Our literature, there is this sense that it has to be one hour and that patient would have the best possible outcome compared to someone that spent two days, but we don’t really have a sense of, from a medical standpoint or an optimization standpoint, where is that balance? Is two days with optimization better than one day with one study? I think that’s really where from an orthopedic standpoint we’re struggling.
The perioperative home concept to me is really what you guys are doing at MCOC on a national level of anesthesia and medicine, orthopedics, getting everyone on the same page, getting everybody together. I think it’s phenomenal what you guys have been able to achieve. I’m really excited to see how it goes.
Any other thoughts on the idea of … Outcomes have been pervasive in orthopedics as far as patient-reported outcomes. Any thoughts on how that concept could be applied to the perioperative surgical home or the medical preoperative optimization side?
Slawski: We’ve been looking at a long time … We have a co-management group that sees not just orthopedic surgery but plastics and so on. What we do are follow just basic outcomes like mortality, length of stay, readmissions, and we compare before we co-managed patients to after we co-managed and look at just what the trends and those data are. I think those are very reasonable goals when we’re collaboratively caring for patients, saying, “How well are we doing in unison?”
Cunningham: Fantastic. This isn’t breaking news, but humongous Packers fan. Probably totally stressed out, can’t concentrate on anything right now. First of all, who’s your favorite player?
Slawski: I’d have to say Rogers.
Cunningham: Yeah, Rodgers, of course. I don’t even like the Packers and he’s my favorite player. Thoughts about the game? Give me your overall gestalt.
Slawski: My biggest worry is that I’m going to be on a plane during the game and I have to figure out how to be able to watch it.
Cunningham: Have you thought about changing your flight? Honestly, I feel like that’s very reasonable.
Slawski: I did think about it. I really honestly did think about that.
Cunningham: I love it.
Slawski: Because I’ve thought about, well, I have a stopover in Phoenix and I’ll be able to watch it for 30 minutes, but I’ll be on the flight for the last part of the game. What I did realize is that everybody else on my flight will be flying into Milwaukee, and someone will have figured out how to be watching the game.
Cunningham: That’s true. If you’re going to pick her up at the airport tonight and she’s not on the plane from Phoenix, you know that the game, it was too close. You couldn’t leave.
Slawski: Right, exactly. It’ll be a good game regardless.
Cunningham: Fantastic. Thank you very much for the few minutes and joining us.
Slawski: Thank you.
Cunningham: One of the real bright stars in perioperative management. Fantastic to see what happens at MCOC. We’re all I think very much looking forward to it.
Slawski: Thank you.