Becker's Hospital Review

September 2016, Hospital Review

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19 Executive Briefing patients and families," Ms. Duran said during the webinar. "This call is the Guided Patient Services call. In this call, the care coordinator or nurses set the expectations for the hospital stay to the patient and their family." Patients also fill out questionnaires and meet with the surgeon in advance to identify possi- ble comorbidities, undergo additional tests if needed and discuss risk management strate- gies. If patients are flagged as high risk, coor- dinators make home visits and more frequent phone calls to ensure the patient is prepared for surgery and recovery. Care coordinators also work with the pa- tient and the clinical team to plan the pa- tient's discharge prior to admission to facili- tate a smooth transition to the next phase of care, whether in the home or a post-acute care facility. 4. Design a hip fracture workflow. Given the latest changes CMS has proposed mak- ing to the CJR model, it is especially per- tinent for hospitals to design a robust hip fracture workflow, as these cases are not preplanned but incur equally high costs to elective hip and knee replacements. "The hip fracture patients that fall into BPCI are trauma-induced diagnoses," said Ms. Du- ran. "These patients do not have the benefit of having a planned surgery or planned dis- charge disposition." Often, hospitals are not sure if such patients — who are typically older with more serious comorbidities — will enter the bundle until after the surgery takes place. With CJR, they will no longer have a choice. NYU Langone's Hospital for Joint Diseas- es identifies hip fracture patients prior to admission if they come in through the emergency department or from an out- side hospital. The clinical care coordinator meets with them at the bedside, reviews an informational brochure on the bundle, completes a risk-assessment survey and identifies the appropriate disposition. 5. Optimize care management during the hospital stay. An essential element of optimizing care during the inpatient stay is continuous quality improvement, a the- ory-based, data-driven management sys- tem that looks at processes and outcomes and tries to determine common causes for variation. The key elements of CQI include teamwork and continuous review of prog- ress. In terms of the CJR model, enhanced recovery protocols are also integral to CQI. ERPs, which aim to manage patients' pain and get them ambulating as soon as pos- sible, are critical to optimizing the inpatient period of the episode of care. "Surgeons must work closely with nurses, so- cial workers and care managers to monitor the patient's progress and readiness for dis- charge and ensure the post-discharge ser- vices are in place," said Ms. Duran. The team must also work together to stay on track for the expected discharge date and address any barriers as needed. While patients who are able to discharge to the home after surgery typically experi- ence faster recoveries with lower rates of post-operative injuries or infections, not all patients are ideal candidates for home. Some may need a skilled nursing facility or another post-acute care provider. In other situations, it may be necessary to move a patient from the home to a SNF to address issues that arise. 6. Minimize narcotics in pain manage- ment. The anesthesiology team's primary goals under a joint replacement bundle in- clude adequate pain relief, faster mobiliza- tion and decreased length of stay, according to Milad Nazemzadeh, MD, clinical assistant professor and associate director of anesthe- siology at the Department of Anesthesiolo- gy, Perioperative Care and Pain Medicine at NYU Langone Medical Center. It is integral to provide a multimodal ap- proach to pain management during and after surgery and minimize use of narcotics, Dr. Nazemzadeh explained during the webi- nar. Patient-controlled analgesia, peripheral nerve blocks, indwelling epidurals and fem- oral nerve catheters have been eliminated at NYU Langone Hospital for Joint Diseases. In a multimodal approach to preoperative oral preemptive analgesia, which reduces pain and enables faster ambulation after surgery, Dr. Nazemzadeh said the anesthesiologists use oxycodone controlled release (10 mg), acetaminophen (1,000 mg), celecoxib (200 mg) and pregabalin (50 mg). They minimize narcotic use by using intraoperative periar- ticular injections, such as EXPAREL® (bupi- vacaine liposome injectable suspension), administered by the surgeon. "There are important benefits of using re- gional anesthesia over general anesthe- sia," said Dr. Nazemzadeh. These benefits include lower incidence of venous throm- boembolism and decreased need for intra- operative narcotic use. 7. Optimize fluid management. Optimiz- ing hemodynamics — fluid management — during surgery allows for more stable blood pressure and heart rate, as well as faster recovery room times, according to Dr. Nazemzadeh. It also enables early am- bulation and rapid rehabilitation. NYU Lan- gone Hospital for Joint Diseases' goal is to give patients about three liters of IV fluid from the time surgery starts until the patient leaves the recovery room. However, the to- tal IV volume is determined by patient his- tory, length of surgery and estimated blood loss during surgery. Conclusion The CJR model imposes high demands on the entire care team, making coordination of care and communication all the more critical to success. The post-discharge period is an especially critical time for the care team to maintain communication with one another and the patient, as it comprises the vast ma- jority of the episode of care under CJR bun- dle. Although the patient is either in another medical facility or at home, the hospital is still on the hook for his or her outcomes. If administrators and staff work together to empower physicians and design new clinical care pathways, each can share in the bene- fits while improving the health of the patients who trust them with their care. Full Prescribing Information is available at www. EXPAREL.com Important safety information: • EXPAREL is contraindicated in obstetrical paracervical block anesthesia • EXPAREL has not been studied for use in pa- tients younger than 18 years of age • Non-bupivacaine-based local anesthetics, including lidocaine, may cause an immedi- ate release of bupivacaine from EXPAREL if administered together locally. The adminis- tration of EXPAREL may follow the adminis- tration of lidocaine after a delay of 20 min- utes or more. Formulations of bupivacaine other than EXPAREL should not be adminis- tered within 96 hours following administra- tion of EXPAREL • Monitoring of cardiovascular and neuro- logical status as well as vital signs should be performed during and after injection of EXPAREL as with other local anesthetic products • Because amide-type local anesthetics, such as bupivacaine, are metabolized by the liv- er, EXPAREL should be used cautiously in patients with hepatic disease. Patients with severe hepatic disease, because of their inability to metabolize local anesthetics nor- mally, are at a greater risk of developing tox- ic plasma concentrations • In clinical trials, the most common adverse reactions (incidence ≥10%) following EX- PAREL administration were nausea, consti- pation, and vomiting n Pacira Pharmaceuticals, Inc. (NASDAQ: PCRX) is a specialty pharmaceutical company focused on the clinical and commercial development of new products that meet the needs of acute care practitioners and their patients. The company's flagship product, EXPAREL® (bupivacaine liposome injectable suspension), indicated for single-dose infiltration into the surgical site to produce postsurgical analgesia, was commercially launched in the United States in April 2012. EXPAREL and two other products have successfully utilized DepoFoam®, a unique and proprietary product delivery technology that encapsulates drugs with- out altering their molecular structure, and releases them over a desired period of time. Additional information about Pacira is available at www.pacira.com.

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