creating a conflict of interest, or the appearance of a conflict of interest that might bias the content of the presentation. Nor is there any significant financial interest in any product instrument, device, service or material discussed in the presentation including the source of any third party compensation related to the presentation. WHO WE ARE Carolinas HealthCare System has a unique story to share. Operating as a fully integrated system and connecting and transforming care delivery throughout

the Carolinas, our overarching goal is to provide seamless access to coordinated, high quality healthcare and provide that care closer to where our patients live. WHO WE ARE With 42 hospitals and 900+ care locations, the depth and breadth of services results in a full continuum of integrated care including: Prevention and general wellness Primary care at more than 180 locations Specialty care via several nationally recognized service

lines Critical care with one of the largest virtual (e-ICU) programs in the nation Continuing care including home health, skilled nursing, hospice, palliative care centers, inpatient/outpatient rehab, and long-term acute care hospital AT- A - G L A N C E 42 hospitals and 900+ care locations in North Carolina, South Carolina and Georgia More than 7,800 licensed beds

More than 11 million patient encounters in 2013 3,000+ system-employed physicians, 14,000+ nurses and more than 60,000 employees $1.5 billion in community benefit in 2013 More than $8 billion in annual revenue The regions only Level I trauma center One of five academic medical centers in North Carolina One of the largest HIT and EMR systems in the country WHERE WE ARE

SHVI Presence at CHS Hospitals CMC - Main CMC - Pineville CMC - Northeast CMC - Union 7

SHVI Presence at CHS Hospitals CMC - University CMC - Mercy Cleveland Regional Medical Center 8

Adult Vascular Surgery 7 Surgeons Main (6) Northeast (.5) Pineville (1.5) Union (.5) Vasc Surgery Endovascular

Vasc Medicine 3 Interventional Cardiologists Advanced Care Practitioners Main (4) Pineville (.2) Office Responsibilities - Union (.2) Office

Responsibilities - Trainees 4 Fellows (2 per year) 9 COURSE DESCRIPTION

Review the benefits of establishing a clinical pathway in the acute care setting. Identify key players who are essential in providing a holistic approach to patient care. Gain support from key stakeholders within that specific medical division. Review methods on how to develop and implement a

new, innovative process. Potential barriers surrounding implementation. Carolinas Medical Center Vascular Lower Extremity Amputation Pathway. COURSE OBJECTIVES Participants will be able to identify: The benefits and understand the process for creating a clinical pathway. Key stakeholders. Strategies and potential barriers for successful

implementation of a clinical pathway. Creation clinical pathway (Group break-out). COURSE OUTLINE

Definition of a clinical pathway and potential benefits Current State Goals Phases of Care Future State Group creation of clinical pathway Questions and Remarks DEFINITION OF CLINICAL PATHWAY AND ITS BENEFITS

Clinical pathways are standardized, evidence-based interdisciplinary care management plans, which identify an appropriate sequence of clinical interventions, timeframes, milestones and expected outcomes for a comparable patient group; i.e. by diagnosis or surgical procedure. The aim of a clinical pathway is to enhance the quality of care across the continuum by improving risk-adjusted patient outcomes, promoting patient safety, increasing patient satisfaction, and optimizing the use of resources.

CURRENT STATE The arithmetic average length of stay at Carolinas Medical Center for non-traumatic below knee and above knee amputation from September 2012 August 2013 were 17.78 and 7.46 respectively. There was a decrease in coordination for the amputee population. Discharge plans for rehabilitation GOALS To supersede the recent data released in 2013, the goal

was to decrease the average length of stay from day of surgery to discharge to 3 days Collaborate with leadership team for buy in Create an multidisciplinary team task force Improve quality of care Minimize cost to the patient and institution PHASES OF CARE Phase One: Pre operative/Day of Surgery PEOPLE PACU, ICU, and unit nursing education

Preoperative pain management education Collaborate case management and social work Endocrinology consult PROCESS Pain management Antibiotic skin prep Smoking Cessation Questionnaire A1C assessment PHASES OF CARE Phase One: Pre operative/Day of Surgery

TECHNOLOGY Cerner IDX Premier PHASES OF CARE Phase Two Post Operative Day 1 PEOPLE Patients PT/OT/Rehab Consultations Amputee Empowerment Partners

Nursing staff PROCESS Foley removal Out of bed as tolerated Contracture prevention Patient education-Continued through all phases PHASES OF CARE Phase Two Post Operative Day 2 PEOPLE Patients

PT/OT/Rehab Amputee Empowerment Partners Nursing staff PROCESS Combination IV/PO pain management Assess and monitor I/Os PHASES OF CARE Phase Three Post Operative Day 3 PEOPLE Patients

PT/OT/Rehab liaison Vascular surgeon Nursing staff PROCESS First dressing change of residual limb Continue assessment of pain with oral medication Continue mobilization Discharge to acute or subacute rehab preferred. Home with home health/outpatient therapy VASCULAR AMPUTATION PATHWAY

PATIENTS 71 y/o male admitted 1/22, s/p R BKA on 1/23/14 PT/OT/CCM/Rehab/Social Support Services consulted POD 1 (1/24). Patient listed for rehab on day of consultation for POD 3. Awaiting insurance approval for rehab POD 3. Patient discharged to acute rehab POD 4 (1/27). Total LOS 6 days. VASCULAR AMPUTATION PATHWAY

PATIENTS 78 y/o female admitted 1/28, s/p L BKA on 1/29/14 PT/OT/CCM/Rehab/social support services consulted POD1 (1/30). Patient discharged to sub-acute rehab, (patients preference), on 2/3/14. Patient on IV pain meds 1/31/14. Total LOS 6 days. VASCULAR AMPUTATION PATHWAY PATIENTS

82 y/o female admitted 2/3, s/p R BKA revision (2/3/14) - PT/OT/CCM/Rehab POD1 (2/4). - Patient returned to sub acute rehab, (patient preference) on 2/6/14. - Total LOS 3 days. KEY ACCOMPLISHMENTS After the implementation of the vascular lower extremity amputation clinical pathway pilot: Below knee amputation length of stay was reduced to 9 days.

Above knee amputation length of stay was reduced to 5.66 days. Financial impact by providing a savings or $2,247.00 per day in room cost alone. 30 KEY ACCOMPLISHMENTS Below knee amputation average cost reduction $19,128.66 in room cost (8.78 days). Above knee amputation average cost reduction

$4,044.60 in room cost (1.8 days). Provided the appropriate continuity of services to increase patient satisfaction and outcomes. PILOT DATA Pilot LOS 17.78 18 16 14

DAYS 12 10 9 7.46 8

5.66 6 4 2 0 LOS BKA LOS AKA Before

After F A V O R A b L

E 9/2012 to 8/31/2013 FUTURE STATE As of September 2014, there were a total of 39 above knee and below knee amputation cases. The LOS O/E ratio for 2013 was 1.27 and currently in 2014 the ratio is 1.16. Incidentally, the Readmissions O/E for 2013 was 2.16, as of September 2014 the ratio is 1.27.

The data displays a rapid rate towards the goal in a short duration of time. FUTURE STATE DATA FUTURE STATE DATA LESSONS LEARNED / FUTURE RECOMMENDATIONS Collaboration with multidisciplinary team to clearly define a holistic approach to wellness.

Utilized PAGER format in order to adhere to regularly scheduled meetings to maximize efficiency. Benchmark data to assist the team in providing effective and efficient care to the vascular amputee population. Bridge the gap between internal and external stakeholders. 36

LESSONS LEARNED / FUTURE RECOMMENDATIONS Components For A Successful Initiative Develop and manage a task force for a unified purpose to produce positive results Timeliness of feedback with the self-audit results Tangible support by administration Setting up co-leadership 37

SPECIAL THANKS TO OUR TEAM MEMBERS Timothy Roush, MD, Medical Director, Vascular Surgery Debbie Denton, Clinical Director Tom Draper, AVP of SHVI Sandy Estep, RN Cassandra McLeod PT, DPT-Clinical coordinator

Jamie Hartz, PT, PT/OT Director Lynne Davis RN, NM 6 tower Diamond Station-Williams RN, CCM Manager Cheryl Fisher, Ultrasound Manager Janet Huffman, RN Rehab

Chris Jenkins, Amputee Empowerment Partners Kevin Lobdell, MD Director of Quality THANK YOU FOR YOUR ATTENTION!! REFERENCES 1. Cheah J. Clinical pathwaysan evaluation of its impact on the quality of care in an acute care general hospital in Singapore. Singapore Med J. 2000 Jul;41 (7):335-46 2. Choudhury,S PhD, Reiber,G, PhD; et al. Postoperative management of transtibial

amputations in VA hospitals. Journal of Rehabilitation Research and Development. Vol 38 No.3, May/June 2001 3. Dean,R; et al. Diagnosis and Treatment in Vascular Surgery. Copyright 1995 Appleton & Lange. A Simon and Schuster Company. 4. Gailey, R. et al. The Amputee Mobility Predictor: An Instrument to Assess Determinants of the Lower Limb Amputees Ability to Ambulate. Arch Phys Med Rehabil. Vol 83. May 2002 5. Guus Schrijvers, PhD, Professor, Arjan van Hoorn, and Nicolette Huiskes. The care pathway: concepts and theories: an introduction. Int J Integr Care. 2012 Jan-Dec; 12(Special Edition Integrated Care Pathways): e192. 6. Kinsman et al., What is a clinical pathway? Development of a definition to inform the

debate BMC Medicine 2010, 8:31 7. Kurtin P, Stucky E. Standardize to excellence: improving the quality and safety of care with clinical pathways. Pediatri Clin North Am. 2009 Aug; 56(4):893-904 REFERENCES 8. Rotter T, Kinsman L, James EL, Machotta A, Gothe H, Willis J, et al. Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs. Cochrane Database of Systematic Reviews 2010;Issue 3. Art. No.: CD006632; DOI: 10.1002/14651858.CD006632.pub2 9. Schrijvers, G,PhD. The care pathway: concepts and theories: an introduction. International Journal of Integrated Care. Volume 12. 18 September 2012. 10. Sumpio B, Shine S, et al. A Comparison of Immediate Postoperative Rigid and Soft Dressings for Below Knee Amputations. Ann Vas Surgery 2013. 27: 774-780 11. Unger, J; et al. Reduction in Hospital Length of Stay for Patients Requiring Lower Extremity Amputation. Journal of Vascular Surgery September 2012(Vol. 56, Issue 3,Page 890) CONTACT INFORMATION Phalan Bolden, MSN, FNP [email protected] Latasha Ruffin, PT, DPT

[email protected]

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