In the latest of a long-running series of relocations and remodelings at University of Colorado Hospital, the Pre-Procedure Services Clinic moved from the sixth floor of the Anschutz Outpatient Pavilion (AOP) to the second floor of Anschutz Inpatient Pavilion 1 on Dec. 8. The clinic, which is responsible for preparing patients for surgeries, now occupies a space that formerly housed a 10-bed section of the Medical Intensive Care Unit (MICU).
Pre-Procedure Services, which had shared its space with several others in the AOP, is now a self-contained clinic. It has its own waiting area; seven exam rooms (up from five); a consultation room; work areas for staff, case managers, and nurse practitioners; and a call center for staff who contact and answer questions for patients prior to surgery. There is also a room for EKG testing.
The project made use of the old space by retaining many of the former inpatient rooms. But the remodeled exam rooms now have comforting natural scenes affixed to the doors. Movable walls created the work rooms and call center, and visitors are welcomed at the front door by a waiting room and a new front desk.
Work on the project began last summer, said the clinic’s charge nurse, Karla Fauria, RN, who was the point of contact for staff and other services. The move began Friday, Dec. 4, and the clinic was closed for just one day, Dec. 7, to finish supply restocking, furniture moving, and so on, before reopening in the new space the following day.
The move made geographic sense, as it places Pre-Procedure Services a short distance from the hospital’s ORs and anesthesiologists, who play an important role in the clinic’s work. Surgery Check-in and the Pre-op and Post-Anesthesia Care units are also close by. But the relocation also involves redefining the services the clinic will offer, said Christine Woodman, RN, MSA, nurse manager of Pre-Procedure Services and Outpatient Surgery.
Already in the works is expansion of the pre-operative phone calls to patients, Woodman said. The process prior to the move was for Call Center staff to contact patients four days ahead of their procedures to go over instructions, obtain medication lists, and confirm schedules. It all typically took about 10 minutes.
The Call Center vastly improved patient satisfaction in 2009 by giving patients their time of surgery four days in advance of the surgery date. But the relatively short calls, coupled with tight pre-surgery time frames, Woodman said, sometimes didn’t catch problems that cropped up the day of the procedure. That meant costly delays or cancellations that were also dissatisfiers for both patients and providers.
“The short calls allowed no time to obtain a patient’s medical history,” Fauria said. “There were sometimes cardiac abnormalities or histories of high blood pressure that we were not aware of.”
The new process aims to head off those problems. Nurse practitioners will still see high-acuity patients, who make up about one-quarter of the surgical volume, in advance. But nurses in the Call Center will contact the others two weeks ahead of time, Woodman said, and complete a detailed review of their medical history, medication list, and instructions for surgery. They will also help to schedule patients for lab tests and EKGs, to catch problems ahead of time that would snarl schedules on the day of surgery. Patients can also walk in to the clinic for these tests, Woodman said.
The new “pre-anesthesia testing” process has been rolled out to the Surgical Oncology, Urology, and Orthopedics clinics, Fauria said. All surgical clinics are slated to come on board next spring, she added.
Home, sweet home
These changes are only one part of a broader effort to create a “perioperative surgical home” designed to prepare patients even more thoroughly for surgery and ensure a good recovery after it, Woodman said.
The idea aims to improve patient care across the board and to support the hospital’s participation in the Centers for Medicare and Medicaid Service’s “Comprehensive Care for Joint Replacement Model,” or CJR. That program, which is scheduled to begin in April, will give hospitals a flat “bundled” payment for knee- and hip-replacement procedures. Hospitals will be responsible – and financially at risk – for managing the patient through a 90-day “episode of care,” including care provided at other facilities. The cost of hospital readmissions will come out of the bundled payment.
An important component of the perioperative surgical home is “pre-habilitation” to “prepare the patient ahead of the surgery more thoroughly,” Woodman said. That might include bolstering nutrition, monitoring fluids, testing exercise tolerance, encouraging weight loss, identifying potential airway problems, providing smoking cessation, managing pain, and many other factors.
Tom Gronow, the hospital’s chief operating officer, said the Pre-Procedure Services Clinic move is an integral part of the strategy for pre-habilitation and participation in the CJR.
“The goal is to more effectively prepare patients for surgery,” he said.
The move to comprehensive care also demands that hospitals continue to assist patients after their procedures, which is key to limiting their lengths of stay and reducing their risk of readmission. Post-surgical services might include calls to check on incisions, pain levels, medications, and other needs, Woodman said.
“The idea of the perioperative services home is to optimize treatment for patients ahead of time and during the surgery, and follow up with them after they leave the hospital,” she said. “The current model leaves the patients with minimal multi-disciplinary follow-up once they go home from surgery. We are creating a smoother continuum of care with better outcomes and follow-up care post-surgery.”