By David Cooke, MD
“Mr. Jones’ chest x-ray looks normal.” the intern said to me on morning rounds. Mr. Jones just had a transhiatal esophagectomy or THE. The esophagus is the muscular tube that connects the back of one’s throat to their stomach. It can develop cancer or become completely dysfunctional because of benign processes, and therefore need to be removed. A THE involves cutting out the patient’s esophagus, in Mr. Jones’ case for cancer, bringing the stomach up behind the heart, and sewing it to what’s left of the esophagus in the neck so the patient can eat again. It is varsity level surgery, with an up to nine percent hospital death rate and 50% complication rate (Connors, et al. Journal of American College of Surgeons, 2007). “What chest x-ray?” I asked. “The one this morning.” the intern replied. “There shouldn’t be an order for a chest x-ray, since I discontinued that order three days ago.” I said. “He has been getting x-rays every day, Sir.” I take a deep breath. As a surgeon, it is no longer acceptable to lose your cool. M*A*S*H, ER, Gray’s Anatomy, that’s for TV. A stereotypical Hulk like outburst gets you a ticket to the Ombudsman. “Let me guess, the three previous x-rays look normal also?” the resident nods. “And why is Mr. Jones getting x-rays every day when I myself discontinued the order three days ago?” At this point his nurse points out: “I think what happened since all the other patients on the cardiothoracic surgical service get chest x-rays every day, except yours, the x-ray technician assumed that you must have forgotten to place the order, and does the x-ray on your patients anyway.”
Morning rounds are a daily and traditional routine in academic medicine. I’m sure Hippocrates did morning rounds. Our general thoracic surgery morning rounds consist of the surgical attending, resident and/or fellow, medical student, physician assistant, nurse-in-charge and in succession, the individual nurse for the patient. The goals of morning rounds are to: 1) develop a care plan for the patient, 2) teach, and 3) make sure all care givers including the patient and their family, are on the same page. That’s how it goes, in theory. That day I realized we were caring for our thoracic surgery patients in an inefficient manner. I didn’t know how much a chest x-ray costs, but it couldn’t be cheap. We were accomplishing the first two goals, but goal three was a non-starter. We were not on the same page. We were earnestly throwing the kitchen sink at our patients to care for them, but we were not providing them value.
The cost of healthcare is like the Energy Monster in my daughter’s favorite TV show WordGirl. It gets bigger with waste, but it can get smaller too if we become more efficient. How do we increase the value of care for our patients? The answer, as it often is, is a grass roots approach. I adapted a postoperative clinical pathway (POP) for the care nuances of esophagectomy. The POP provides daily guidelines for nine patient-care categories, including radiographic tests. All care providers can look at the pathway, and if the patient’s case is uncomplicated understand what tests should or should not be performed that day. The POP reduced hospital length of stay, readmission rate, and dropped total hospital costs by 37% and hospital radiographic costs by 69% (Cooke et al, Society of Thoracic Surgeons 49th Annual Meeting, 2013). How did these results happen? We think the standardized use of radiographic tests diminished radiographic costs. Structured communication between the health care provider teams and the patient and their family limited confusion and minimized hospital length of stay and readmission rates.
We expanded our POP to guide patient care for our other thoracic surgical procedures, and additional efforts will reengineer the standard POP to be patient-centered, where the patient is actively involved in their care. “Why am I getting a chest x-ray? According to my pathway, the x-ray is not mandatory. Did the doctor say I need one?” In essence, to maintain and improve patient value, and make the Healthcare Monster smaller, we get everyone on the same page.
David Tom Cooke, MD, FCCP, FACS is Associate Professor and Head, Section of General Thoracic Surgery at UC Davis. Dr. Cooke is engaged in patient-centered outcomes research and public medical communication.