integration of care: ‘patients first’ - wrosc · 2013. 9. 19. · •msp funding unresolved ....
TRANSCRIPT
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Integration of care: ‘Patients First’
Dr. Arno Smit – WROSC
Physician seminar / open house
June 6, 2013
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Integration / streamlining
Hospital based services
• historically: effective model
• adequate funding
• timely programming adjustments
• stakeholders involvement
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Integration / streamlining
Over last decade Peace Arch Hospital
• Population growth +++
• Hospital capacity basically unchanged
• Critical clinical areas identified
• Loss of clinical ability (e.g. pediatric care)
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Elgin Park School, June 5, ‘13
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Integration / streamlining
Orthopaedics at PAH
• Priority review directed care
• Acute vs. non-acute
• THR / TKR vs. other ortho
• Other FHA surgical resources
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Elgin Park School, June 5, ‘13
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Integration / streamlining
Acute ortho care at PAH
• Ambulatory vs non-ambulatory
• PAH level 2 trauma center
• Hip / long bone ## etc timely care
• Ankle/wrist ## etc variable
• Pediatric ortho referred out
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Integration / streamlining
Non-acute ortho care
• PAH to be primarily used for THR / TKR
• UBC THR / TKR
• Delta Hospital
• Other: Jim Pattison Outpatient Centre
• PAH non-arthroplasty ortho OR expansion delayed
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Elgin Park School, June 5, ‘13
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Integration / streamlining
Access to PAH as of spring 2013
• THR / TKR < 6 months
• Shoulder / knee arthroscopy etc
> 2 years (consent signed 2010)
• Foot surgery / hardware removal etc essentially no or minimal access
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Integration / streamlining
• It always gets worse before it gets better
• MD / RN guardians of care systems
drivers of change
• Building of capacity ‘just doing it’
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White Rock Orthopaedic Surgery Centre
Non-hospital surgical facility
November 2007
Fully accredited
Class-1 facility
Over 700 cases (spring 2013)
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White Rock Orthopaedic Surgery Centre -Fully accredited
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White Rock Orthopaedic Surgery Centre
General orthopaedic perspective
Timely assessment
Completion of diagnostic process
Refer/treat as appropriate
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White Rock Orthopaedic Surgery Centre
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White Rock Orthopaedic Surgery Centre
Safety first
• crash cart, defibrillator
• MH cart, lipid rescue
• difficult airway equipment
• emergency exit / transfer to ambulance
• patient eligibility 2-step
• ACLS
• etc….
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White Rock Orthopaedic Surgery Centre
Climate control
• Laminar airflow
• Positive pressure, 20 air changes/h
• HEPA filtered
• Two air ‘curtains’
• OR lights no boom/arm
• avoids eddy formation
• Minimal intra-op disruption (doors)
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White Rock Orthopaedic Surgery Centre
Sterile processing
• Robust
• Decontamination separate
• Certified staff
• Ongoing external review
• Minimal ‘same-day’ turn-over needed
• Equipment in OR traffic minimized
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White Rock Orthopaedic Surgery Centre
Patient experience
• Familiar staff (reception, surgeon, anaesthesiologist, nursing)
• Private (carrousel concept)
• No pain, no sounds, no distress
• Tight follow-up
• Questionnaire
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White Rock Orthopaedic Surgery Centre
In-house x-ray and ultra-sound
Full anaesthesia capability
Emphasis on pain management
Continuity of care through entire
process
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White Rock Orthopaedic Surgery Centre
In-house ‘point-of-care’ X-ray
• Recent addition (2013)
• Streamlining of acute care (?)
• Intra-op x-ray no need for C-arm
• Diagnostic exposure minimized
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White Rock Orthopaedic Surgery Centre -X-ray
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White Rock Orthopaedic Surgery Centre
In-house ‘point-of-care’ ultrasound
• Recent addition (December 2012)
• Enhanced accuracy of injection therapy
• Diagnostic / surveillance
• Intra-op imaging
• Dynamic assessment by treating clinician
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White Rock Orthopaedic Surgery Centre -Ultra-sound
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White Rock Orthopaedic Surgery Centre
Ultrasound assisted injection
• Overall patient experience improved
• Attention to details
• RN assurance
• Local skin preparation
• Needle placement under direct vision
• MSP funding unresolved
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White Rock Orthopaedic Surgery Centre -Full anesthesia capability
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White Rock Orthopaedic Surgery Centre
• Consistent anaesthesia support
• Pre-emptive local anaesthesia
• IV sedation – GA – spinal
• Chronic pain : LES, trigger point injection
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White Rock Orthopaedic Surgery Centre
Pre-emptive local anaesthesia
• Refined over the years (RMF)
• Knee / hip COA 2007
• Consistently low pain scores in PACU
ACL, shoulder scope, RC…
• Effective for approx 16 h
• NSAIDs as adjunct
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WROSC non-surgical care
• Assessment / diagnosis
• Counselling, physio etc
• Osteoporosis assessment and treatment
• Bracing (OA, ACL, AT tear, etc)
• Casting
• Injection therapy
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WROSC non-surgical care
Injection therapy - supportive / bridging
• Corticosteroid
• Visco-supplement
• Platelet rich plasma
• Intra-articular Botox
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WROSC non-surgical care
Injection therapy
-approx 30-40 injections /week
Most common
• Acutely painful shoulder
• OA knee/ankle
• Tendinopathy hip
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WROSC non-surgical care
Injection therapy
Less common
• OA hip
• Piriformis
• Tennis elbow
• Trigger finger
• deQuervain’s
• etc
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WROSC surgical care
• Knee: arthroscopy, ACL …
• Shoulder: arthroscopy, rotator cuff, stabilization, biceps, AC joint …
• Foot/ankle: arthroscopy, hallux valgus/rigidus …
• Hand/wrist: carpal tunnel, tendon sx …
• Hardware removal: plates, IM nails
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WROSC surgical care
Knee Arthroscopy
Assessment (MRI 90% accurate)
Meniscal tear
Osteochondral injury
Ligament reconstruction (ACL)
Removal loose bodies
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WROSC surgical care
Knee OA and arthroscopy
• Degenerative changes irreversible
• OA and meniscal tear more pain
• Optimizing mechanics
• Methodical progression of intervention
• Injection / bracing as required
• Postpone or avoid replacement
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WROSC surgical care
Knee OA and arthroscopy
• Long wait progression
• Inevitable?
• Early intervention?
• Time is precious
• No cure, still high satisfaction rate
• Appropriate management of progressive condition
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WROSC surgical care
Knee – ACL reconstruction
• Brace bridging vs definitive tx
• Must avoid repeat giving way
• Reconstruction often most practical
• Wide age range: mid-teens into 70’s
• Allograft: revision / middle age and up
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WROSC surgical care
Other knee procedures
• Osteochondral bone graft (OATS)
• Soon (?): living allogeneic chondrocyte transplantation (Health Canada approval 2013)
Of note: replacement surgery can be done in hospital in timely fashion
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WROSC surgical care
Shoulder Arthroscopy
Assessment: aMRI 85-90% accurate
Rotator cuff repair
Labral repair (Bankart / SLAP)
Debridement damaged /Degenerative tissue
Decompression / Acromioplasty
Distal clavicle resection
Removal loose bodies
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WROSC surgical care
Shoulder arthroscopy
• Assessment remains important
• Maturity: knee>>shoulder>hip
• ‘MRI arthrogram of hip and shoulder 85-90% accurate’ against what?
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WROSC surgical care
Shoulder: MRI vs Arthroscopy - gold standard?
• Video clips of antero-superior shoulder anatomy poor consensus between orthopaedic surgeons
• Clinical implications of finding a disruption
numerator vs denominator approach
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WROSC surgical care
Pathology vs normal variant
• Anatomy did not arise from text book
• Text books arose from anatomy observations
• Concepts are re-evaluated from time to time
- MRI / Ultrasound etc
- arthroscopy
- anatomy labs
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WROSC surgical care
Pathology vs normal variant
• Wave of enthusiasm retreat
• Early knee arthroscopy medial plica
• Many unnecessary excisions
• Live and learn!
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WROSC surgical care
Pathology vs normal variant
Early shoulder arthroscopy
- labral non-adherence
- mainly anterosuperiorly
- over-diagnosed as pathologic
- wide variety of normal variants
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WROSC surgical care: shoulder arthroscopy-SLAP tear
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WROSC surgical care:
shoulder arthroscopy-SLAP tear
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WROSC surgical care:
shoulder arthroscopy-SLAP tear
• Sudden force through shoulder can disrupt biceps anchor
• Pain may fluctuate in severity
• Role of biceps tendon as pain generator
remains under debate
• Opinion leaders: Dr. S. Snyder
Dr. S. Burkhart
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WROSC surgical care:
shoulder arthroscopy-SLAP tear
• Treatment:
Once conservative treatment failed
debridement, repair or tenotomy and
tenodesis
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WROSC surgical care: shoulder arthroscopy – rotator cuff
Rotator cuff repair
• Conservative tx: approx 70% success
• Balanced strengthening
• Injection(s) to facilitate rehab
• Acute massive tears best early repair
• Chronic tears approx 90% success after repair
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WROSC surgical care
• General:
Removal of Hardware (plate/IM nail etc)
Carpal tunnel release
Ulnar nerve transposition
Foot and ankle surgery
Hand and wrist surgery
Selected bone grafting
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WROSC surgical care
• Hip Arthroscopy - being developed
Intra-operative X-ray capability
Specialized traction equipment
Overnight stay capability
Specialized arthroscopy equipment
Additional training
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WROSC surgical care
• Hip Arthroscopy – being developed
Assessment: aMRI 85-90% accurate
Labral tear
Osteochondral injury
Loose body
Impingement
Expected roll-out : towards end of 2013
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WROSC and funding
• Once surgical treatment proposed:
Excessive delay may jeopardize outcome (initial pain generator vs established pain patterns)
PAH wait times: 18-24 months or longer
‘Partially insured services’
WROSC wait times: 4-8 weeks
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WROSC / Pt / FHA / ICBC / Lawyer
• Physician funding: through Teleplan
• Facility funding:
Not recoverable through Teleplan
Not recoverable through extended health
Can be provided by FHA / MoH
Can be provided by patient
Can be provided by ICBC
Can be provided by law firm
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WROSC / ICBC / Lawyer
• 2011 – Present:
Funding approval rate increasing
Satisfaction rate high
Patient/plaintiff’s interests well-served
Wide variety of cases
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WROSC/ICBC: Typical Scenario
1) Initial Request
Work-up complete Surgery proposed
Funding requested
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WROSC/ICBC: Typical Scenario
2) Reply from Law Office:
Letter re: Rationale for surgery
- Causation
- Implications of delay, etc
Possibly formal report (less common)
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WROSC/ICBC: Typical Scenario
3) Funding authorized
Surgery performed
Recovery and rehab
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WROSC/ICBC: Typical Scenario
4) Completion
Final report
Court hearing (rare)
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WROSC/FHA
• Trial of FHA/MoH funded arthroscopy
50 knee arthroscopies, 2011
funding not extended
• Could help with back log in daycare surgery
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WROSC/FHA
• Role in provision of acute care:
Assessment of ‘walking wounded’
Pediatric trauma?
Adult trauma?
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Discussion
Streamlining of surgical MSK care is feasible
This is beneficial to patients
What is next?
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Discussion – What is next?
Acute ortho care?
• Pediatrics majority could be dealt with at WROSC
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Discussion - what is next?
Acute ortho care ?
• Walking wounded reduce pressure on PAH ER?
-From family physician’s office or walk-in
clinic WROSC
-Assessment / X-rays / treatment plan
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Conclusion
The concept and process of integrated care were introduced
Local resources were identified
Expanded access to care options were presented
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Thank you…
Looking forward to further working with you.