Proof That Post-Op Co-Management of Vascular Patients Improves Outcomes

Challenge

Hospitalized vascular patients typically display a high incidence of severe comorbidities. These high-risk surgical patients can present huge challenges to the success of a hospital’s post-operative care program, not just from the patient safety angle, but with repercussions on extended lengths of hospital stay, number of readmissions, and unforeseen associated costs.

Four major New York City hospital systems sought to create improvements in surgical outcomes by collaborating with Healthcare Risk Advisors (HRA), part of TDC Group. The task was to develop a program of post-operative care that, when applied to this patient population, represented a safer surgical care model.

Response

The HRA team developed a surgery-hospitalist co-management program, designed to improve the quality of care of these high-risk surgical patients. They assigned a full-time perioperative hospitalist to a service of 8 to 12 postoperative vascular surgery patients in each of the four academic medical centers. The patients selected to participate in this Vascular Surgery Co-Management Service were those identified as most at risk for perioperative deterioration, defined as patients rated ASA 3 or higher in the American Society of Anesthesiologists Physical Status Classification System.

Within this co-management relationship, the surgeons and hospitalists each shared responsibility for the care of their hospitalized surgical patients. The hospitalist managed the patients’ medical conditions, and the surgeon managed their surgical issues.

After performing their preoperative evaluation, the co-managing hospitalists actively participated in patients’ postoperative care. They addressed chronic medical issues like diabetes, cardiac conditions, and kidney disease. They communicated with surgeons, nurses, other doctors, and team members, and then facilitated the transition of care to community caregivers, skilled nursing facilities, and rehabilitation facilities. 

Resolution

The results of the co-management exercise were studied for periods ranging from 14 months to two years, with all studies recording positive outcomes following the Vascular Surgery Co-Management Service. Quantitative measures of the success of this intervention included auditing patient charts to confirm that notes from both co-managing physicians were present. Patient outcomes were calculated using a risk-adjusted calculator from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Surgical Risk Calculator.

The HRA team and their hospital system collaborators found that, at one institution under the Vascular Surgery Co-Management Service, patient mortality declined by half, corresponding to a decrease in the risk-adjusted, observed-to-expected mortality rate ratio. Patient-reported pain scores were significantly improved. In addition, nurses reported improvements in their perceptions of team communication and patient safety.

Atul Gawande, MP, MPH, surgeon, writer, and public health researcher, has said that what differentiates great hospitals from good hospitals is that the great hospitals see a complication and rescue the patient more often. The goal of HRA’s co-management program is to go a step further and see potential complications before they happen, mitigating the need to rescue patients by preemptive attention to comorbidities and clinical deterioration.


The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.