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Surgical redesign delivers earlier discharges

A health system rethinks its approach to nutrition and mobility

January 2019
ambitiouredesigning the care and recovery of surgical patients

Published in the January 2019 issue of Today’s Hospitalist

2019 MAY BRING some big changes for the hospitalists with the Geisinger Health System, the powerhouse health network and health plan with 13 hospitals throughout northeastern and central Pennsylvania and New Jersey.

That’s because the new year should see an even bigger roll-out of an ambitious program already in place to redesign the care and recovery of surgical patients. Started in 2017 as a pilot project among colorectal and neurosurgical patients, the program—called ProvenRecovery—has been expanded, as of November 2018, to more than 40 different types of surgeries system-wide. With that expansion, 15,000 surgical patients a year will be taking part in the initiative.

The goal for 2019, however, is to extend participation to 100 surgical specialties in the Geisinger system. That roll-out will include the service lines for which the hospitalists provide surgical comanagement and act as attendings, explains associate hospital medicine director Malachi Courtney, MD. He also points out that because ProvenRecovery has slashed lengths of stay—by 39% for participating neurosurgery patients and 44% for patients undergoing colon surgery—the hospitalists’ overall census could be reduced.

“I foresee a natural progression of thinking about NPO status and mobilization in a different manner.”

Malachi Courtney, MD
Geisinger Health System

For a system in which the larger facilities are at capacity much of the time, Dr. Courtney adds, that’s great news. It’s also a huge benefit for patient safety and experience.

Proper nutrition
The ProvenRecovery program first grew out of an inpatient flow committee on which Dr. Courtney serves. “We wanted to focus on different strategies to improve patient flow,” Dr. Courtney recalls.

Colorectal surgeon Thomas Erchinger, MD, a colleague who’s also on that committee, suggested one idea that quickly gained momentum: the enhanced recovery after surgery (ERAS) protocol. Literature in both the U.S. and Europe backs the use of that protocol not only for accelerating surgical recovery, but as a way to reduce mortality, hospital complications and readmissions among surgical patients.

The ERAS protocol formed the basis of ProvenRecovery, which has three components. First, the program completely upends the approach to nutrition in surgical patients. Instead of being told not to eat anything after midnight the day before their operation, patients are instructed to drink three protein-rich shakes a day for the five days leading up to the surgery. The Geisinger clinics performing patients’ preop evaluations give them kits with those drinks. (Geisinger’s outpatient physicians do the preop evaluations, not the hospitalists.)

Patients now also eat a light meal up to six hours before surgery and drink clear fluids until two hours preop. At that point, they receive a clear carbohydrate-enriched drink that they’re able to absorb before their surgery begins. Dr. Courtney notes that nutrition is also now a big focus immediately postop, with patients receiving early nutrition.

Early mobility and pain management
Also immediately postop, another component of the ProvenRecovery program kicks in: early mobility, with patients being roused and, if possible, walked around their beds in the recovery room. Responsibility for early mobility, says Dr. Courtney, is being divided between the physical therapists and the nurses, depending on patient complexity.

The third program component—appropriate pain management—aims to minimize the use of opioids as much as possible during surgery and after (including at discharge), and sometimes avoids them altogether. With this multimodal pain management strategy, clinicians rely instead on non-opioid medications and local anesthesia.

While lower length of stay for surgical patients participating in the program translated to more than $4,500 in savings per colorectal case, the ProvenRecovery program achieved another result: an 18% reduction in the use of opioids.

“That not only lowers the risk of addiction but of complications as well: aspiration pneumonia, altered mental status and hypotension,” Dr. Courtney points out. He adds that Geisinger, like many other health plans, now limits the amount of opioids that doctors can prescribe at discharge. In addition, hospitalists on the floors have cut back on using IV opioids and are transitioning patients to PO opioids or other oral agents more quickly.

Accelerated discharge planning?
Most of the patients covered so far by ProvenRecovery—those undergoing colorectal surgery, craniotomies, ob/gyn procedures and bariatric surgery—have been managed by their surgeons. But Dr. Courtney and his hospitalist colleagues rotate through surgical comanagement for orthopedics, including all elective joint replacements, as well as for many ear, nose, and throat, and urology patients.

It remains to be seen, he says, how surgical comanagement for those patients will change once ProvenRecovery is expanded to include those service lines. Lower lengths of stay for those patients should speed up discharge planning. Already, he points out, hospitalists take part in daily, multidisciplinary BOOST rounds, which grew out of a Society of Hospital Medicine initiative (Project BOOST) to introduce discharge planning earlier in a patient’s hospitalization to minimize readmissions.

Dr. Courtney also believes that taking such a different approach to patient nutrition and mobility may inform other areas of patient care.

“I foresee a natural progression of thinking about NPO status and mobilization in a different manner” as a result of the program, Dr. Courtney says. “One of the biggest complaints that hospitalists’ patients have is that they’re not able to eat, and the culture of hospital medicine is that if patients need to be NPO, they need to be NPO. But ProvenRecovery looks at nutrition in a fundamentally different manner.”

The same is true for early mobilization. “You realize that these different approaches are vitally important for hospitalized patients.”

Phyllis Maguire is Executive Editor of Today’s Hospitalist.

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Kurt P, Twitter
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In the not too distant future – enhanced recovery protocols like this will be the standard of care everywhere: Surgical redesign delivers earlier discharges.