The Benefits of Enhanced Recovery Pathways in Perioperative Care

Introduction Chronic Obstructive Pulmonary Disease (COPD) is a leading cause of morbidity and mortality globally, and rural patients are at higher risk for poor COPD health outcomes. The United States National Institutes of Health (NIH) has issued a call for innovative care delivery models to address this gap in COPD care quality in rural communities. This paper explores the perspective of healthcare teams at two rural VA medical centers sustaining an innovative interprofessional COPD care delivery model, COPD Coordinated Access to Reduce Exacerbations (CARE). Methods This qualitative evaluation was conducted at two rural VA medical centers in the Southeast and Midwest regions of the US. Eleven semi-structured interviews with diverse clinical stakeholders were conducted including: facility leaders, hired pharmacists, clinical pharmacists, nurse care managers, primary care providers, and referral champions. The Practical Robust Implementation and Sustainability Model (PRISM) was applied to develop interview guides and informed data analysis. Interviews were transcribed and a mixed inductive-deductive approach was used for data analysis, involving iterative coding and consensus-building among five evaluators to identify emerging themes. Results Five overarching themes emerged as key facilitators of COPD CARE sustainment including (1) leadership support, (2) value alignment, (3) service institutionalization, (4) service adaptation, and (5) interprofessional collaboration. Notably, clinical pharmacists were described as filling care gaps in these under-resourced facilities. Conclusion This evaluation demonstrated the impact of clinical pharmacists serving as prescribers in improving COPD management in rural settings. The sustainment factors identified can be utilized to inform the expansion of similar, team-based healthcare programs across rural settings.

Use of Transversus Abdominis Plane (TAP) Blocks for Pain Management in Elderly Surgical Patients

172 Background: Under the NCI ASCO Teams Project, we proposed a 4R Model of teamwork and patient self-management (pSM) (Trosman JOP ’16). 4R (Right Info/Care/Patient/Time) enables patient (pt) and care team to manage complex care continuum with an innovative multimodality 4R Care Project Plan. 4R includes a novel “project” feature – a graphical description of care interdependencies. 4R was previously piloted at 3 Chicago centers (Trosman ASCO ‘18). Methods: In this new study, we improved and tested 4R for impact on pSM at 4 safety net and 3 non safety net centers across the US. 4R Plans were provided to stage 0-III breast cancer pts Jan - Nov’18 (4R cohort). We surveyed the 4R cohort and a historical control cohort of pts who received care at same centers pre-4R, Jan - Dec ’17. Results: Survey response rates: 65%, 105/162 (4R cohort); 44%, 190/432 (control). 4R markedly improved 4 of 5 pSM metrics vs control (Table). Additional analyses showed that safety net pts had a significant increase in 4R vs control cohort in “seldom overwhelmed” (84%, 49/58 vs 64%, 67/104 respectively, p = .007), while non safety net pts had nonsignificant increase. Other metrics improved to a similar extent for safety net vs non safety net pts. Within the 4R cohort, 85% found 4R useful in organizing their care and 73% found 4R’s novel “project” feature useful in understanding care interdependencies. Safety net pts reported similar usefulness of 4R in organizing their care as non safety net pts (88%, 51/58 vs 81%, 38/47, NS) and similar usefulness of the “project’ feature in understanding care interdependencies as non safety net pts (74% vs. 72%, NS). Conclusions: 4R significantly improved patient self-management, but further efforts are needed to expand the benefit to as close to a 100% of pts as feasible. Safety net pts benefited from 4R at similar or higher rates than non safety net pts, indicating that 4R may reduce care disparities. An expansion of 4R across the US continues this work. [Table: see text]

297 Background: Investments in infrastructure to enhance care delivery are often partnered with practice participation in alternative payment model contracts and innovative care delivery models. Oncology nurses routinely are physically located in a cancer practice. We sought to understand the impact of centralizing resources to work remotely building upon triage pathways already in place on staffing and symptom call resolution with the goal of optimizing outpatient symptom management and patient satisfaction. Due to a national RN shortage and a historical high number of RN vacancies in oncology, we thought this this innovative staffing solution may attract, retain, and elevate the role of RNs. Methods: A needs assessment was conducted to evaluate call volumes, staff levels and duties. A gap analysis was performed to determine which duties would be assigned to remote triage versus in person staffing. Some sites had triage; all sites upgraded to new optimization of assessment and management. Standardized evidence based care and communication pathways were implemented. RNs were trained to follow structured workflows for call ticket resolution. A regional pool supported primary triage RNs who were assigned to each site. The model allowed for flexible staffing while building and maintaining relationships with local providers. Additionally, remote triage RNs were given the opportunity to augment their assessment with audio/visual telehealth as needed. Results: In the first 4 months, 9 pilot sites decreased symptom management time by 50%; 1 site decreased by 70% (over 120 minutes down to 27 minutes). Since remote triage began, average resolution times reduced from 2.52 hours to 1.31 hours. One pilot site had an in-person triage position posted and attracted 4 applicants over 4 weeks. When the position was converted to a remote role, 38 applications were received in 1 week. Offering remote triage positions allowed RN recruitment from other states and gave tenured RNs within the organization an attractive new work model. Conclusions: Remote RN work is an attractive opportunity for RNs allowing for broader recruitment of candidates. Removing triage RNs from the clinic site allows them to focus on triage resolution and as a result call resolution times decreased substantially. Standardized communication pathways were developed, rolled out, and optimized in both virtual and in-person Triage RN roles statewide. Adherence to these communication pathways is critical to ensuring timely symptom management resolution and a sustainable workforce.

Liver transplant recipients continue to have high perioperative resource utilization and prolonged length of stay despite improvements in perioperative care. Enhanced recovery pathways have been shown in other surgical populations to produce reductions in hospital resource utilization. A prospective, observational study was performed to examine the effect of an enhanced recovery pathway for postoperative care after liver transplantation. Outcomes from patients undergoing liver transplantation from November 1, 2013, to October 31, 2014, managed by the pathway were compared to transplant recipients from the year before pathway implementation. Multivariable regression analysis was used to assess the association of the clinical pathway on clinical outcomes. The intervention and control groups included 141 and 106 patients, respectively. There were no demographic differences between the control and intervention group including no differences between the length of surgery and cold ischemic time. Median intensive care unit length of stay was reduced from 4.4 to 2.6 days (P < .001). The intervention group had a higher likelihood of earlier discharge (hazard ratio [95% CI], 2.01 [1.55-2.62]; P < .001), and a 69% and 65% lower odds of receiving a plasma (P < .001) or packed red blood cell (P < .001) transfusion. There was no significant effect on hospital mortality (P = .40), intensive care unit readmission rates (P = .75), or postoperative infections (urinary traction infections: P = .09; pneumonia: P = .27). An enhanced recovery pathway focused on milestone-based elements of intensive care unit management and predetermined management triggers including hemodynamic goals, fluid therapy, perioperative antibiotics, glycemic control, and standardized transfusion triggers led to reductions in intensive care unit length of stay without an increase in perioperative complications.

Innovative dental care delivery and coverage models

6527 Background: Under the “NCI ASCO Teams” Project, we proposed a 4R Model of teamwork and patient self-management (pSM) (Trosman JOP ’16). 4R is Right Info / Care / Patient / Time. It enables patient (pt) and care team to manage interdependent care along the care continuum with an innovative multimodality personalized 4R Care Project Plan. We piloted 4R at 3 centers (academic, community, safety net) and assessed its impact on pSM. Methods: 4R Plans were administered to breast cancer pts stage 0-III Sep ’16 – Aug ’17 (4R cohort). We surveyed the 4R cohort and a comparable historical cohort of pts who received care pre-4R, Jun ’15 – May ’16 (control). We used simple frequencies and Fisher’s exact test in analyses. Results: Survey response rates: 68%, 185/271 (4R cohort); 47%, 241/410 (control). 75% of 4R respondents reported 4R Plans very useful / useful in overall understanding and organizing their care; 68% found 4R’s novel “project” component, very useful / useful in managing timing & sequencing of interdependent care. Care complexity impacted 4R usefulness: 67% of pts who received > 6 care services found 4R very useful / useful vs. 47% of pts who received < = 6 services, p = .01. Pts with lower care complexity suggested how to make 4R more useful to them, eg focus on endocrine therapy. Table compares pSM metrics in the 4R and control cohort. Care complexity was a significant factor of feeling overwhelmed for pts in the control cohort (51% of pts receiving > 6 care services felt overwhelmed vs. 31% of pts receiving < = 6 services, p = .02), but not a significant factor for pts in the 4R cohort (30% vs. 28%, p = .9). Conclusions: The 4R model significantly improved pt self-management in early breast cancer and reduced the impact of care complexity on pts, but provider factors of pSM need improvement. A 4R pilot at additional 12 cancer centers across the U.S. is in progress. Aspect of pSM %, 4R cohort, N = 185 %, Historical control cohort, N = 241 P value Know stage of your cancer 93 80 .0001 Care plan clear / very clear 84 67 .0001 Able to manage own care well / very well 78 69 .05 During care, seldom / never overwhelmed, not in control of your care 71 58 .008 Care coordination by providers to support the patient 72% 69% .5 Having a “go to” clinician to support the patient 76% 78% .7

224 Background: Under the “NCI ASCO Teams” Project, we proposed a 4R Model of teamwork and patient self-management (pSM) (Trosman JOP ’16). 4R is Right Info / Care / Patient / Time. It enables patient (pt) and care team to manage interdependent care along the care continuum with an innovative multimodality personalized 4R Care Project Plan. We piloted 4R at 3 centers (academic, community, safety net) and assessed its impact on pSM. Methods: 4R Plans were administered to breast cancer pts stage 0-III Sep ’16 – Aug ’17 (4R cohort). We surveyed the 4R cohort and a comparable historical cohort of pts who received care pre-4R, Jun ’15 – May ’16 (control). We used simple frequencies and Fisher’s exact test in analyses. Results: Survey response rates: 68%, 185/271 (4R cohort); 47%, 241/410 (control). 75% of 4R respondents reported 4R Plans very useful / useful in overall understanding and organizing their care; 68% found 4R’s novel “project” component, very useful / useful in managing timing &amp; sequencing of interdependent care. Care complexity impacted 4R usefulness: 67% of pts who received &gt; 6 care services found 4R very useful / useful vs. 47% of pts who received &lt; = 6 services, p = .01. Pts with lower care complexity suggested how to make 4R more useful to them, eg focus on endocrine therapy. Table compares pSM metrics in the 4R and control cohort. Care complexity was a significant factor of feeling overwhelmed for pts in the control cohort (51% of pts receiving &gt; 6 care services felt overwhelmed vs. 31% of pts receiving &lt; = 6 services, p = .02), but not a significant factor for pts in the 4R cohort (30% vs. 28%, p = .9). Conclusions: The 4R model significantly improved pt self-management in early breast cancer and reduced the impact of care complexity on pts, but provider factors of pSM need improvement. A 4R pilot at additional 12 cancer centers across the U.S. is in progress.[Table: see text]

Summary Today, persons living with HIV (PLWH) are living longer because of antiretroviral therapy and other factors, but they continue to face substantial comorbidities and high health-care costs. Recognizing the high cost and high utilization of care associated with these patients, Mount Sinai Health System in New York transitioned to value-based payment arrangements in 2014 with an innovative care delivery model at the Institute for Advanced Medicine (IAM). IAM is now one of the largest hubs for HIV care in New York state and has achieved both quality and cost outcomes at scale. In 2018, their viral load suppression rate (88%) exceeded New York City’s aggregate viral load suppression rate (77%). While total-cost-of-care analyses are ongoing, they also have generated shared savings and outperformed health plan partners’ risk-adjusted benchmarks. Here, they describe their 5-year experience implementing and scaling IAM’s value-based care delivery model. The model focuses on reducing new HIV infections, managing total cost, and building long-term care pathways for PLWH within their health system.

Enhanced recovery pathways in gynecologic oncology

Creating a Multidisciplinary Placenta Accreta Program

Guidelines for pre- and intra-operative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations — Part I

Objective To study perioperative comprehensive nursing methods during thyroid surgery with cavity mirrors. Methods 24 cases of thyroid surgery through laparoscopic breast in recent years in our institute were analyzed and the prognosis of patients before and after perioperative care were also compared. Results After perioperative comprehensive nursing practice, the average operation time and intraoperative bleeding had no significant differences, while complications rate, using rate of analgesics,utilization from the bed, the postoperative meal time, average hospital stay were all significantly higher than those before perioperative care. And the postoperative complications were mainly subcutaneous effusion,subcutaneous emphysema, headache and dizziness. Conclusion Effective and meticulous perioperative comprehensive care can prevent cavity mirrors thyroid surgery complications, alleviate postoperative unwell conditions and promote the patients' recover, which is an important factor for successful thyroid surgery. Key words: Laparoscopic; Resection of the thyroid gland; Perioperative nursing

Multimodal pain management is an integral part of enhanced recovery pathways. The most effective pain management strategies have not been determined. The purpose of this study was to compare liposomal bupivacaine transversus abdominis plane block with epidural analgesia in patients undergoing colorectal surgery. This is a single-institution, open-label randomized (1:1) trial. This study compared liposomal bupivacaine transversus abdominis plane block with epidural analgesia in patients undergoing elective open and minimally invasive colorectal surgery in an enhanced recovery pathway. Two hundred were enrolled. Following randomization, allocation, and follow-up, there were 92 patients with transversus abdominis plane block and 87 patients with epidural analgesia available for analysis. The interventions comprised liposomal bupivacaine transversus abdominis plane block versus epidural analgesia. The primary outcomes measured were numeric pain scores and the overall benefit of analgesia scores. There were no significant differences in the Numeric Pain Scale and Overall Benefit of Analgesia Score between groups. Time trend analysis revealed that patients with transversus abdominis plane block had higher numeric pain scores on the day of surgery, but that the relationship was reversed later in the postoperative period. Opioid use was significantly less in the transversus abdominis plane block group (206.84 mg vs 98.29 mg, p < 0.001). There were no significant differences in time to GI recovery, hospital length of stay, and postoperative complications. Cost was considerably more for the epidural analgesia group. This study was conducted at a single institution. This randomized trial shows that perioperative pain management with liposomal bupivacaine transversus abdominis plane block is as effective as epidural analgesia and is associated with less opioid use and less cost. These data and the more favorable risk profile suggest that liposomal bupivacaine transversus abdominis plane block is a viable multimodal perioperative pain management option for this patient population in an established enhanced recovery pathway. http://www.clinicaltrials.gov (NCT02591407). See Video Abstract at http://links.lww.com/DCR/A737.

University Hospitals Case Medical Center, in Cleveland, Ohio, has been at the forefront of the development of enhanced recovery pathways (ERP) for over a decade. The Division of Colorectal Surgery has helped to carefully develop and investigate many elements that are now standard in ERPs at many institutions around the world. Utilizing a multidisciplinary approach to perioperative care, many patients can now be discharged home safely following colectomy in 24–48 h. The team, consisting of the attending surgeons, nurse practitioners, colorectal fellow, general surgical residents, enterostomal therapy nurses, and registered nurses, coordinate care within the guidelines of a well-established ERP to ensure the safest and most comfortable experience for patients. Through our work on enhanced recovery in the colorectal patient population, we have developed protocols that incorporate these principles to all abdominal surgery specialties including surgical oncology, gynecology oncology, general surgery, hepatobiliary, and urology. In this chapter, we provide an overview of our institute’s ERP for colorectal surgery, beginning in the preoperative period and continuing through discharge and follow-up.