Under new management

Under new management

April 2013
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Published in the April 2013 issue of Today’s Hospitalist

SEVERAL YEARS AGO, the chief of surgery at the Veterans Affairs hospital in Los Angeles grew concerned about the number of elective surgeries being cancelled at the last minute.

His solution? Ask the hospitalists to take over the preoperative clinic there, a management role previously held by anesthesiologists. (An anesthesiologist still sees each patient the morning of surgery.)

The result, as described in a study published in the November/December 2012 issue of the Journal of Hospital Medicine, was not only fewer last-minute cancellations, but a significant reduction in length of stay for some of the sickest inpatients.

“We see everybody, but the people who benefited the most were the sicker patients,” explains hospitalist Sondra Vazirani, MD, MPH, director of the preoperative clinic at the VA Greater Los Angeles Healthcare System and the study’s lead author.

Having hospitalists head up the clinic has produced another big plus: reducing the number of elective operations that arguably shouldn’t happen at all because patient risk is too high.

“We haven’t collected data,” says Dr. Vazirani, “but there is a significant number of cases that we delay or cancel.” That gives clinic personnel and patients’ primary care physicians time to treat a patient’s high blood pressure, high blood sugar or other medical conditions that could make a surgery too risky.

“Hospitalists’ knowledge of chronic disease states and perioperative stressors,” she notes, “make them ideal practitioners to identify, quantify and attempt to reduce perioperative risk.”

The study also found that inpatient mortality rates fell after hospitalists took over the clinic (0.36% vs. 1.27%). According to the study, that may be due to hospitalists doing a better job identifying patients at higher perioperative risk, then intervening or deferring a procedure. As the study concluded, “This could have resulted in better surgical candidate selection with fewer postoperative complications, especially among patients with significant medical comorbidities.”

Reduced LOS
One population in which Dr. Vazirani says the hospitalist-run clinic has reduced same-day cancellations for medically avoidable reasons is diabetic patients.

Surgeons “are asked not to schedule patients for preoperative clinic for elective cases if patients’ hemoglobin A1C is greater than 9%,” she explains. “Patients are supposed to go back to their primary care physician instead for diabetic optimization.”

Delaying surgery for such patients creates an opportunity to both treat them and reduce their risk of postop complications. And those patients are much less likely to become a same-day surgical cancellation.

Since the hospitalists took over clinic management, mean length of stay for evaluated patients dropped from 9.87 days to 5.28, while median length of stay fell from three days to two. By comparison, Dr. Vazirani notes, a subset of the VA’s surgical patients who historically have never been and still are not seen by the hospitalists “those having cardiothoracic surgery “did not see a similar decrease in postop length of stay over the same time period.

That’s an indication, she notes, that perioperative care at the hospital didn’t improve across the board over time so that “we would have seen an improvement whether the hospitalists were there or not.” National VA data also bear out that theory.

Retraining midlevels
Much of the care at the LA VA’s preop clinic is delivered by midlevel practitioners, which included two nurse practitioners and one physician assistant (PA) during the study time periods. Working with protocols and templates, they operate under the supervision of a hospitalist assigned to the clinic.

Using midlevels is a holdover from the days that anesthesiology managed the clinic. When Dr. Vazirani took over operations in July 2004, she retrained the existing midlevels to “make sure they had an internal medicine viewpoint and could perform a detailed medical preoperative assessment.”

That included giving them weekly lectures on medical disease management and preoperative assessment. Dr. Vazirani also compiled a syllabus of key articles about perioperative issues “so they had a packet of evidence-based medicine” to refer to. “Implementing evidence-based medicine,” she notes, “is one way we improved the quality of care.”

She also wrote protocols that the midlevels use, which helped standardize evaluation and management. Those include guidelines for what lab tests and imaging to order. Protocols also cover perioperative beta-blockade (who should be on it and who shouldn’t), pulmonary function tests, and how to “bridge” appropriate warfarin patients with low-molecular weight heparin or unfractionated heparin. While the hospitalists exercise close oversight, Dr. Vazirani says, the midlevels “have knowledge behind what they are doing” as a result of the added education.

For the first several years, she and her assistant director staffed the clinic the majority of the time. Since then, the hospitalist division and its responsibilities have grown, and many more hospitalists now rotate through. “We have also added a second PA,” she says, “increasing our capacity by 33%.”

Dr. Vazirani notes that consistency is the result of the preop evaluation note being largely templated. “There are questions we want to make sure are asked such as: Have patients used steroids in the past year? That triggers the provider to think about stress-dose steroids.” There is also a question about whether patients take herbal medications. “People forget to ask about that, and it can be important. Standardization and reducing variability are key to quality improvement.”

Periop recommendations
What also helps, Dr. Vazirani says, is having a section at the end of the template where the hospitalists and midlevels list perioperative recommendations based on the history and physical.

Those might include the need for endocarditis prophylaxis or perioperative beta-blockers. Or they’ll note that the patient is a brittle diabetic and that providers should consider a medicine or endocrine consult in the hospital. It is a one-time visit, and the decision to follow the clinic’s perioperative recommendations is “voluntary on the part of the surgical team,” according to the study.

Every patient scheduled for any type of surgery except cardiothoracic at the VA Greater Los Angeles is referred to the preop clinic. Ideally, patients come two to three weeks before their scheduled operation. The clinic expedites evaluations to honor surgical dates for urgent procedures.

The clinic also has a social worker assigned to it who makes sure that patients have advance directives completed before surgery. There is also an “exit nurse” whose job it is to go over preoperative instructions, verbally and in writing. Dr. Vazirani notes that this staffing was already in place when leadership changed hands.

According to the study, the patients who seemed to benefit the most from the hospitalist-run clinic were those whose American Society of Anesthesia score was three or higher, regardless of age, gender or type of surgery. (The score indicates that patients have at least severe systemic disease, not mild.) More patients also received perioperative beta-blockers (33.2% vs. 26.2%) when seen in the hospitalist-run clinic than under the reign of the anesthesiologists.

“We have found it is useful to send everyone,” Dr. Vazirani explains. “But if there were limited resources, our paper suggests that the people who benefit the most from a clinic like this are the sicker ones.”

Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.

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