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To raise the quality of orthopedic care for all patients, we conduct patient safety and outcomes research, with a particular emphasis on the increasing burden of medical costs. Here, we highlight some of our recent efforts to improve the quality, cost, and outcomes of .

Evidence-based Blood Management Intervention Decreases Transfusion Rates

Nearly 13.5 million units of red blood cells (RBCs) are transfused each year in the United States, making transfusion one of the most common hospital procedures. The annual cost of these transfusions is more than $3 billion. Some portion of this spending likely represents waste, since randomized trials show that restrictive transfusion rates do not adversely affect outcomes. Prior studies show that clinical decision support (CDS), including education and technology changes, can improve institutional transfusion habits. Our goal was to determine whether CDS interventions could reduce transfusion use and costs at �ٺ���Ƶ Orthopedic Hospital.

We tracked blood transfusions for all inpatients over two consecutive periods totaling 24 months: the pre-intervention period from January 2014 to February 2015 and the post-intervention period from March 2015 to December 2015. A total of 69,159 discharges were included. The intervention had two components: (1) embedding new institutional transfusion guidelines in the computerized provider order entry (CPOE) system and (2) providing targeted education to physicians in high-utilizing service lines, including medicine, cardiothoracic surgery, orthopedic surgery, and general surgery. According to the institutional guidelines, transfusion for hemoglobin values > 7 g/dL was considered potentially inappropriate (PI-RBC). The primary outcome was PI-RBC use per 100 patient discharges for the entire institution. We also analyzed PI-RBC use for physicians in medicine service lines who received targeted education (M+e), physicians in surgical service lines who received targeted education (S+e), and physicians in surgical service lines who did not receive targeted education (S).

Overall, our institution decreased PI-RBC transfusions from 13.4 units to 10.0 units per 100 discharges, with nine consecutive months below the baseline mean (p = .002). PI-RBC transfusions in the M+e group decreased from 15.7 units to 11.0 units per 100 discharges, with nine consecutive months below the baseline mean (p = .002). PI-RBC transfusions in the S+e group decreased from 19.6 units to 15.1 units per 100 discharges, with seven consecutive months below the baseline mean (p = .008). In contrast, the S group decreased PI-RBC transfusions from 12.9 units to 11.5 units per 100 discharges, without consistent months below the baseline mean.

We calculated savings using the estimated cost of $522 per unit of RBCs. The overall cost decrease was $17,748 per 1,000 discharges. By intervention group, the cost reduction per 1,000 discharges was $24,534 for group M+e, $23,490 for group S+e, and $7,308 for group S. There was no significant post-intervention change in quality metrics, length of stay, death index, or case mix index.

Physicians may be unaware of the disadvantages of aggressive RBC transfusion strategies and may transfuse inappropriately, causing potential harm and financial cost. Our study showed that targeted education combined with CPOE-embedded guidelines is an effective means of influencing physician behavior, and that the combined education-technology intervention is more effective than the CPOE intervention alone.

Remote Video Auditing (RVA)

RVA is a process by which surgical cases are captured live on video cameras. Each of our operating rooms is equipped with video cameras. Operative cases are then chosen at random to be remotely observed on a live basis. Videos are viewed in a remote secure location on a real-time basis. They are not recorded. Our residents review the cases with an attending to look for potential breaks in sterile technique. We use an electronic-based grading tool on which to record observations.

RVA is a powerful tool, which we will leverage to improve general OR discipline in order to increase patient safety and reduce SSIs. This program aligns with �ٺ���Ƶ Health’s commitment to transform itself into a High Reliability Organization (HRO). This is especially important, as in the future, SSIs following hip and knee replacement surgeries will be included in the Centers for Medicare & Medicaid Services (CMS) hospital-acquired conditions (HACs) penalty program. We have partnered with our nurse educators to develop a document that defines proper OR sterile techniques and practices.

Our goals for RVA are:

• OR quality improvement and SSI reduction through increasing awareness of sterile technique and promoting OR discipline
• to provide our residents and trainees with education on sterile technique and experience in participating in quality and safety improvement programs
• to promote teamwork and camaraderie with OR staff; both of these satisfy ACGME and CLER requirements for trainee participation in continuous quality improvement (CQI) programs. We feel that involving first- or second-year residents is the most effective way of achieving our goals.

We created a document that accompanies the RVA cloud-based observation instrument, which details proper sterile technique according to AORN and APIC standards. This includes a primer on proper OR attire, safe handling of sharps, maintaining a sterile field, proper OR personal movement, and correct skin prepping and patient draping technique. These are essential components of a safe OR. Traditionally, formal resident education in these areas has been inconsistent. This is an opportunity to raise the educational standard in OR sterile technique for our residents. Additionally, this document will have content stressing mindfulness and proper teamwork between staff and residents.

To date, , clinical professor of orthopedic surgery, and her team have viewed 22 surgeries performed by 18 different attendings. Her team’s findings have been extremely informative. Trends observed include:

• sleeves contaminated when gown put on for surgeon—usually with shaking out gown
• surgeons and assistants have hands out of sterile field
• brushing against drapes by non-scrubbed staff
• beards not covered consistently; beard covers not always adequate
• masks not consistently used properly

These findings have been communicated with our entire department and we are convinced that this increased awareness will result in higher quality care and increased patient safety.

How Common Is Wrong-site Surgery in Orthopedics?

Wrong-site orthopedic surgery is a rare but preventable catastrophic event that harms patients, surgeons, and surgical teams. Most hospitals have adopted the World Health Organization Surgical Safety Checklist and the Joint Commission’s Universal Protocol for Preventing Wrong-Site, Wrong-Procedure, and Wrong-Person Surgery. Nonetheless, these adverse events continue to occur in orthopedic practices in the United States.

Every orthopedic surgeon is at risk for performing a wrong-site surgery during his or her career. Although the true incidence of wrong-site surgery is not known, it appears to vary depending on subspecialty.

• As many as 1 in 4 orthopedic surgeons will be involved in a wrong-site surgery during an active 25-year surgical career.
• Orthopedic spine surgeons appear to be at highest risk for wrong-site surgery, with errors occurring as frequently as 1 in 3,000 cases.
• Orthopedic hand and arthroscopic knee surgeons may experience wrong-site surgery as frequently as 1 in 27,000 cases.

Pennsylvania is one of the few states that mandate reporting of wrong-site surgery; since 2004, the state has collected data on more than 500 wrong-patient, wrong-body part, wrong-side, and wrong-level events. When broken down by specialty (knee, hand, spine, and non-orthopedic) orthopedic surgery accounts for nearly a quarter of wrong-site procedures.

Strategies for Preventing Wrong-site Surgery

Surgical leadership, commitment, and vigilance are critical to preventing wrong-site surgery and ensuring that validated safety processes are used in all orthopedic settings. Orthopedic leaders at �ٺ���Ƶ Health recently used two closely linked interventions to increase patient safety:

Our institution maintains an electronic database of patient safety information. Project leaders used this database to identify surgical bookings that specified the wrong side for a procedure (regarded as a “near-miss” event). They then provided education to appropriate surgeons and staff on the safety implications of inaccurate scheduling.

Project leaders also began observing time-out procedures in the OR and reviewing time-outs for deficiencies. They then provided targeted feedback to surgeons and OR staff who performed time-outs improperly, and counseled them on correct processes.

Within six months, the incorrect booking rate decreased from 0.75 percent to 0.41 percent (p = 0.0139). In addition, the improper time-out rate was reduced from 18.7 percent to 5.9 percent (p < 0.0001).

Surgical Site Infection Report

Preventing deep surgical site infection (SSI) is a major priority for the . Over the last several years, our SSI rates have fluctuated as department leaders implemented improved care processes and clinical protocols—and responded to new clinical and operational challenges.

The overall rate of deep SSI at �ٺ���Ƶ Health is low, and SSI rates in all categories have declined steadily over the last two years. The SSI rate for primary knee arthroplasty now stands at 0.24 percent, the lowest ever at our institution.

Tracking and Understanding Procedure-specific OR Case Times

Surgeons naturally work at different speeds. Nevertheless, longer case times represent higher costs—a major obstacle to improving OR performance under bundled payment. While more complex cases often require extended operating time, longer case time does not necessarily mean higher quality. Research using the New Zealand National Joint Registry shows that operating too quickly and too slowly both lead to poor outcomes. Outcomes begin to worsen as operative time (incision to closure) falls below 45 minutes and when operative time surpasses 90 minutes.

At �ٺ���Ƶ Orthopedic Hospital, we track department case times and report them on a quarterly basis. Breaking out the data by surgical area helps department leaders understand the issues that may be driving long median case times. We also examine outlier cases, drilling down on the specific causes of long operating time. Addressing these factors systematically—with process improvement and education—helps us keep operating times within an acceptable range.

Optimizing Length of Stay

One goal of the Department of Orthopedic Surgery is to ensure that joint replacement patients are discharged as expediently and safely as possible. Yet in the new environment of value-based payment, orthopedic leaders are taking a deeper look at practices surrounding hospital discharge.

Bundled payment programs make providers responsible for costs and outcomes across the entire episode of care, from surgery through the 90-day post-acute period. This expansion of the care episode calls for a nuanced approach to discharge planning. Specifically, providers now need to weigh the outcome and cost implications of multiple post-surgery pathways, including inpatient hospitalization, sub-acute rehabilitation, and home recovery.

At �ٺ���Ƶ Health, we continue to strive for a balanced approach focused on what is best for patients. Building on our efforts to reduce length of stay overall, we are leading efforts to fine-tune discharge decisions to ensure the best patient outcomes in the most cost-efficient manner.

Length of Stay Reduction

Minimizing inpatient days following joint replacement surgery remains a sound clinical goal. Reducing length of stay helps patients recover faster; decreases the likelihood of many complications, including infections; and helps control inpatient costs. To this end, the Department of Orthopedic Surgery has developed two innovative programs for knee and hip replacement patients:

• The Guided Patient Services (GPS) Program facilitates efficient discharge with upfront planning and communication. A social worker works with the patient before hospitalization, to set the patient’s expectations about the hospital experience and his or her discharge plan. Any issues are addressed prior to admission, leading to a smoother discharge process.
• The Rapid Rehab Program allows eligible patients to begin rehabilitation immediately after surgery, while they are still in the post-acute care unit (PACU). The program has significantly reduced average length of stay for joint replacement patients, and participants report higher levels of patient satisfaction.

Maximizing Value of Post-discharge Care

Prompted by bundled payment programs, orthopedic providers are examining the cost and outcome implications of discharge from the inpatient facility to a subacute rehabilitation facility versus discharge home.

There is no clear evidence that rehabilitation facilities, which add to the cost of care, improve patient outcomes following joint replacement. In contrast, home discharge with home-based rehabilitation and physical therapy is lower cost and provides excellent clinical outcomes. In light of this, orthopedic leaders should consider whether it is cost-efficient to keep patients in the hospital longer if it enables home discharge.

To answer this question, we examined the total episode costs of two post-acute care strategies: discharge to a rehabilitation center and extended inpatient stay followed by discharge home with services.

Many patients discharged to a post-acute inpatient rehabilitation facility will be there for an extended stay before being discharged home. In a typical scenario, the patient remains in the facility for 21 days, for a total cost of approximately $16,000. In contrast, an extended inpatient stay costs approximately $3,000 per day.

Because the cost of additional acute care hospital days is relatively low and the cost of an extended stay at an inpatient rehabilitation facility is relatively high, it can be cost-effective to extend the patient’s inpatient stay—if it allows therapy and recovery to progress, enabling a safe home discharge.

Our decision analysis data demonstrate that keeping patients in the acute facility for up to 5.2 additional days results in overall lower costs than discharge to a post-acute facility—which supports the importance of a balanced approach to discharge decisions. We do not suggest that all joint replacement patients should be discharged home, but rather, that a discharge that is both safe and cost-efficient—not a shorter inpatient length of stay—should be the primary focus of discharge planning. Extending the inpatient stay is a strategic option that merits careful consideration.