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St. Luke's Perioperative Clinic Focuses on Best Possible Outcomes

By Dr. David C. Pate, News and Community
March 26, 2013

The reason that I am so optimistic that St. Luke's can transform health care is that our physicians and our employees are leading the transformation. I have the chance here to feature the work of our physician leaders, and I will continue to share stories of improvements they are leading.  

In today's post, I’m showcasing the great work being led by Dr. Betsy Olberding that is already helping to achieve the Triple Aim. By identifying high-risk patients and making changes, she is making care safer and outcomes better.

Better care leads to lower cost for these patients when preventable complications, longer stays, and the associated increases in costs are avoided. Better care also involves improved coordination of care and management of care transitions, which helps us reduce the risk of unplanned emergency room visits and readmissions and the associated increase in costs. And all of this results in better care at a lower cost.  

Dr. Elizabeth “Betsy” Olberding saw the potential for better surgical outcomes as a hospitalist, and is leading the charge from a new pilot clinic in our Meridian hospital.

Dr. Olberding joined St. Luke’s in 1999, coming from the Veterans Affairs in Montana. The VA was an “early adopter” of the hospitalist approach, and Dr. Olberding saw firsthand the benefits that the close collaboration between physicians, hospital staff, and patients brought when it came to results.

Her new perioperative medicine pilot program outreach has grown out of the work of St. Luke’s hospitalists. 

Dr. Olberding meets with John Noble at the clinic as he prepares for knee surgery.

Dr. Roger Stagg first developed St. Luke’s hospitalist program about eight years ago. In the early years, the focus was on the hospital component of the program and the complexities of hospital care and the surgical needs of inpatient adults.

Over time, the program has evolved, with an increasing emphasis on process improvements that culminate in improved quality and patient safety. Among those are adjustments and refinements of all aspects of surgical care.

Perioperative medicine refers to the medical evaluation and management of surgical patients before, during, and after surgery. In the United States, more than 44 million patients undergo non-cardiac surgery each year.  

About 30 percent of surgical patients in the U.S., roughly 35 million people, are over age 65, and that population is growing. For the most part, surgery is more complicated the older the patient is, and there can be more complications. And of course, these factors mean longer recovery times, more discomfort, higher costs, and a whole host of additional considerations that drive St. Luke’s and other health care organizations to want to improve how these procedures occur.

And the situation becomes even more challenging when patients come in for surgery without a primary physician, which happens often. Historically, primary care physicians have attended to pre-operative clearance for surgical patients, but there has been opportunity to design a more structured approach.

In the past, pre-operative clearance has focused on cardiac fitness for all surgery. Over time, evidence-based processes have been developed for cardiac risk stratification, pulmonary risk stratification, and pre-op medication management, but these advances have not necessarily been consolidated for the benefit of all patients.

Dr. Olberding, working with a team of physicians, clinicians, and others from across many of our departments, has determined that we can attend to and coordinate many of these needs in the same location and through the same office, rather than through various physicians in stages before surgery. This is a model of preoperative surgical care used at many large hospitals, reducing the number of last-minute cancellations, the lengths of stay, and the rate of post-operative infections.

A few years ago, Dr. Olberding became interested in St. Luke’s “Project Zero,” an effort led by Dr. Kevin Shea and Dr. Howard King to reduce surgical site infections. Project Zero encompassed the idea of an improved preoperative evaluation process.

That was the catalyst for her. She connected with our ortho/neuro physicians and anesthesia team. All saw the need, the potential, and the evidence-based grounds for starting a dedicated pre-op clinic. The Cleveland Clinic and others had shown impressive results with this approach, and everyone from our orthopedic surgeons to our pre-admission testing nurses to the staff in anesthesia could see the opportunity.

 “We just kind of took it and ran with it,” Dr. Olberding recalls.

The concept was presented to St. Luke’s Treasure Valley leadership a year ago. The anticipated savings, in the form of cost avoidance, is estimated at $1 million annually because it is expected to improve outcomes for patients, reduce length of stay, decrease re-admissions and complication rates, and better optimize staff and physician time and resources. Dr. Olberding was realistic about the investment in the idea, telling our decision-makers, “You’re going to see the value of this downstream.”

The clinic, which is co-located with St. Luke’s pre-op testing department in the Meridian Medical Office Building and open Monday through Thursday, started up last fall. Dr. Olberding has been leading the project as the site director, working with Dr. Kellen Ronnau to provide medical coverage.  

Dr. Olberding prepares information for a patient before surgery. The clinic is being well-received.

Dr. Olberding and the pre-op clinic team work with patients scheduled for total joint replacements, back and general surgeries such as bowel and colon surgeries, bariatric surgeries, urology, and some gynecologic procedures at our Boise and Meridian hospitals.

Dr. Olberding, who is juggling work at the clinic and her other responsibilities as a hospitalist, and the clinic staff are building data, so results are mostly anecdotal at this point. Surgeons have reported satisfaction with the clinic’s work, and the anesthesia group has appreciated the staff’s workups.

Very tangible impacts, however, become apparent in conversation with Dr. Olberding.

In one instance, an elderly man from outside the area was scheduled for a total knee replacement. His cardiac risk assessment indicated questions about his pulmonary and cardiac status. His oxygen saturation was at the edge of the safe range, which indicated the possibility of unevaluated mild heart failure.

Further evaluation and treatment were clearly called for, but the man was physically and financially unable to return for some of the outpatient evaluation. Dr. Olberding collaborated with hospital colleagues to conduct an observation day of evaluation the day before surgery to prepare him for the operation.

Based on his condition, “If he had not come to us and showed up the day of surgery, anesthesia would have canceled his surgery, no question,” she said.

In other instances, younger people scheduled for back surgery have shown uncontrolled blood pressure and diabetes. In these cases, Dr. Olberding and the team have prescribed appropriate medications and connected the patients with primary care physicians.

“I think we have averted some disasters and last-minute cancellations,” she said. “We have an expectation that we have to show that what we’re doing actually matters. I think we’re adding a lot of value and we’re doing a good job.”  

Word is filtering out about Dr. Olberding’s work as she makes the rounds to educate other physicians and clinics, and clinic use has grown slowly but steadily.

“We’re still early days and we definitely need to be busier,” she said, adding that the clinic schedule is 60 percent full and she’s aiming for 80 percent this spring. The team sees about 15 to 20 patients a week and as many as 22, but would like to see closer to 30 patients a week.

Dr. Olberding’s work is notable in that it hits the mark when it comes to all three of St. Luke’s Triple Aim goals: better health, better care, and lower costs.

 “We have made a decision,” she said. “We assume that evaluating these patients and doing whatever we can do to make sure they are in the best medical shape they can be in, will lead to the best medical outcome possible.

“And we’re trying to make it as seamless as possible,” Dr. Olberding said. “We want to make this a good, safe process for the patient. That’s the goal, to get them through this stressful period with a really good outcome.”

I am proud of the great work being led by St. Luke's physicians and undertaken by St. Luke's employees, such as that of our outpatient pharmacy that I recently featured.

About The Author

David C. Pate, M.D., J.D., is president and CEO of St. Luke's Health System, based in Boise, Idaho. Dr. Pate joined the System in 2009. He received his medical degree from Baylor College of Medicine in Houston and his law degree from the University of Houston Law Center.