An important tool in value-based orthopedic surgery: ERAS for ASCs

Enhanced Recovery After Surgery (ERAS) is a concept initially designed for multimodal pain management for patient care, addressing the psychosocial as well as physical challenges associated with pain management. However, as bundled episodes of care have become more common in orthopedic surgery, surgeons are beginning to apply patient optimization to the entire care continuum.

Daniel Hoeffel, MD, a private practice orthopedic surgeon based in St. Paul, Minn., extends the ERAS concept to include physician well-being.

"When you take care of patients, there is an emotional toll and unless we are looking back at ourselves and trying to refill that tank, we're not going to make it," he said on Oct. 19, 2018 at the Becker's ASC 25th Annual Meeting: The Business and Operations of ASCs in Chicago, where he gave a presentation titled "Optimizing the Orthopedic Patient for ERAS (Enhanced Recovery After Surgery): Importance of Pathway & Partnership," which was sponsored by Johnson & Johnson Medical Devices Companies.

"If you took the medical schools in Chicago and combined each medical school class, we would need that many providers every year just to replace the number of physicians that commit suicide," Dr. Hoeffel said. "I want to use that as a rallying call to say the [quality improvement efforts] we are trying to pursue for our patients, the things we are trying to pursue from a business perspective, are meaningful for all of us."

During the discussion, Dr. Hoeffel discussed how ERAS support the goals of the quadruple aim and value-based care, as well as offered best practices for delivering better patient care.

What is ERAS?
Traditionally, healthcare providers sought solutions to problems with technology: a new implant, device or smart watch. Now, surgeons and allied health professionals are examining care delivery processes and making changes. "Process is not low hanging fruit. Process is dirty and grimy. But when we combine our thinking around both product and process, I argue we get to a place where we really want to be," he said. "We end up with patients and providers who are satisfied."

Healthcare providers are familiar with lean and Six Sigma process improvement methods, and ERAS is another tool to optimize patient care. ERAS goes beyond the orthopedic specialty and surgical episode to address the patient pharmacologically and from a psychosocial aspect, as well as their home situation.

"When we are entering the world of [Bundled Payments for Care Improvement-Advanced] and continuing [Comprehensive Care for Joint Replacement model], we have to be thinking not just about the perioperative period — the minute you hit preop to when you are discharged from the hospital — but also the month you are waiting before and after surgery occurs. Now in the world of bundles and outcomes, we are thinking larger and larger scale, and I think we are going to eventually end up thinking panoperatively," Dr. Hoeffel said. "That means considering, for the surgery that is done, how you are addressing the comorbidities and chronic issues one and two years out from surgery."

Some healthcare organizations have deployed ERAS teams to obtain training in protocol development and implemented lessons learned with the broader care team. Dr. Hoeffel recommends these organizations continue to audit process updates to examine outcomes for perpetual improvement.

"We have to approach care sequentially, so we are not missing the outliers," he said. "We should standardize to make easy work easy, so we have more time to focus on the outliers and avoid complications in those outliers. Once we get through the first or second round of bundling, there won't be any more fruit in standardization. Then, you still need to save costs and achieve better outcomes, and that's when you'll have to focus on the outliers."

Why implement ERAS?
The goal of ERAS, as well as other process improvement methods, is to align, standardize and look for outliers. In practice, providers follow the patient and the data; if without data, providers aren't competitive because they don't have the information
to communicate with the payers, the government and patients.

Healthcare organizations can engage industry partners to collaborate on data gathering and reporting, which allows them to communicate patient outcomes. "You can go to your partners and figure out if there is anyone else nationally doing the same thing you are trying to do, and leverage those partnerships," Dr. Hoeffel said.

During his presentation, Dr. Hoeffel outlined five key thoughts on ERAS implementation:

1. Define a pre-admission state, an admission state and post-discharge state. The pre-admission state depends on the overall health of the patient. Diabetes management assistance could take three months to control, while untreated hypertension could take two to three weeks. Post-discharge for bundled payments should roll out for 90 days or more.

2. Provide educational experiences pre-admission, during admission and post-discharge. The surgical care team can design pathways that alert patients with text messages, emails, voice messages and linked videos for pre-operative patient education with a thoughtful process design.

3. Put pain management in its own category of delivery care, especially in the wake of the opioid crisis. Patients with a history of alcoholism, addiction or already taking opioids, will require a customized approach to care.

4. Tackle the psychological issues as well as cognitive impairment, including mild dementia. The care team can mobilize around the patients to ensure they understand individualized care plans. Social and psychosocial issues can be huge barriers to optimizing patient outcomes.

5. In the ASC setting, providers must make sure the patient is a good candidate for outpatient surgery and identify whether they'll have the necessary support to successfully recover at home. "When you can navigate care digitally, you can tell the patient we want them walking to the mailbox. Then, next week, if you made it to your mailbox without being short of breath, then we want you walking to the mail box twice. It sounds crazy, but these things engage patients, involve them in care and bring them benefit," Dr. Hoeffel said.

Based on data Dr. Hoeffel and his team gathered, 15 percent of patients who had total knee replacements in an ASC sought care post-operatively before their regular check up, but just one in five of the patients had medical necessity for additional care.

The benefit of strategic partnerships
Healthcare providers can assemble one or two big footprint partners who handle most of the pre-operative, intra-operative and post-operative issues, and then focus on smaller partnerships that will add value and benefit to what they do.

"You create alignment when you pursue an ERAS strategy of physicians, nursing staff and the ancillary and midlevel providers. In addition, it positions you for growth. If you have protocols that are standardized, written down, that people can look at, audit and improve, you can have a scalable solution that is reproducible," he said. "Getting the business side involved in ERAS gives them a clinical perspective, and clinicians can learn about the business side. That is very important when you are trying to scale."

As an extension of the quadruple aim, ERAS is one of the simpler tools to deploy. Clinicians and administrators don't need to be the smartest or most experienced individual in the room to begin the process improvement; they just need to be a leader.

Companies for Consideration

Some of the tools are subtle and some are obvious. If we want to automate a care pathway, we need digital care navigation. CareSense® by MedTrak, Inc.™ is my partner of choice. We are seeing digital care navigation start to gain momentum in the orthopedic world.

Part of the appeal is that they provide patient information and guidance along the way instead of a single booklet where the patients get all the information at once. We are able to [reach] them electronically with a text, email or phone call or through another application alert to help guide them during the pre-operative and post-operative period. We have also gone through the subtle change of reducing the number of instruments utilized for surgery. We are no longer just consumers of the products from companies, but we are also consumers of the process. To me, it's important to think about the footprint of a partner, which means can the partner help us with data collection, wound management and dressings? For example, I choose to use DERMABOND® PRINEO® Skin Closure System because it offers ease of application and ease of post-operative care due to no surgical dressings. The philosophy behind ERAS, new technology and industry partners, such as the Johnson & Johnson Medical Devices Companies, can help orthopedic surgeons meet their patients’ recovery and outcome goals.

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