Improving Post-Surgical Outcomes With Proactive, Multidisciplinary Care

Announcer:
This is Clinician’s Roundtable on ReachMD. On this episode, we’ll hear from Dr. Karen Bauer, who’s a certified nurse practitioner wound specialist at Emory Heart and Vascular in Atlanta. She’ll be discussing best practices for implementing multidisciplinary care models in surgical wound management. Here’s Dr. Bauer now.

Dr. Bauer:
Communication breakdown happens everywhere in post-surgical management, and I think that's just a testament to our system as a whole. And I would emphasize that that communication and care pathway needs to start happening prior to the surgery. So getting the people involved that need to be involved prior to surgery helps us manage the patient post-surgically.

I think that oftentimes the biggest breakdown is when the patient is discharging from the PACU, or they're discharging from the hospital to post-acute centers, or they're discharging from the hospital to home health. To minimize breakdown in communication post-surgically, it starts pre-surgically. I think the biggest breakdown is when the patient is transitioning from care setting to care setting because within that transition, we have different clinicians that are differently trained. The information that we're receiving is oftentimes really extensive, and it's hard to filter out what's really important.

So I think ways to mitigate that are one, to have care navigators involved with our surgical processes—nurses, medical assistants, or somebody who can help that patient traverse the system—and two, using our standardized systems. We rely heavily on our electronic medical records for situations like this, but oftentimes, if we have our order sets or our smart phrases and we think we're all good and standardized, the people receiving that might not be able to find it. So again, having somebody who can take that role on and make it their own with some of the care pathways that are unique to the institution fills a really big gap.

Key takeaways for integrating multidisciplinary care in post-surgical wound or skin management are one, starting to look at all of this prior to surgery and making sure that we're optimizing the patient to the point possible prior to surgery with regard to physical functioning, nutrition, and skin care as a whole. And two, making sure that we're prepared for the detailed nature of these care transitions and care coordination and making sure that we are leveraging every resource at our disposal, be it digital, the human element to that with care navigators, or simply using some of the tools that our EMRs provide for us to help standardize the care of the patient as they transition from setting to setting.

Announcer: 
That was Dr. Karen Bauer discussing the importance of collaborative care planning in wound management. To access this and other episodes in our series, visit Clinician’s Roundtable on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!