From left: Margaret “Maggie” Erdman, MMS, PA-C, Katlin “Katie” Dlugosz, MMS, PA-C, and Lisa George, MS, presented the Cedar surgical access project at a Hospital and Healthsystem Association of Pennsylvania conference this spring.
In early 2021, as Mercy Philadelphia Hospital prepared to transition to the PHMC Public Health Campus on Cedar, making sure patients still had access to all the care they would need was a crucial concern. Penn Medicine took on the role of staffing the emergency, inpatient, and behavioral health services at what’s now known as the Hospital of the University of Pennsylvania–Cedar Avenue (HUP–Cedar). However, patients needing surgeries and other resource-intensive procedures would get that care at the main HUP campus at 34th and Spruce streets (HUP–Spruce).
Identifying which patients need surgery, and how urgently, would be a challenge without surgeons on-site. There was also the matter of making sure the patients, many of whom receive Medicaid and may lack access to primary care, received the appropriate surgical follow-up care. “For them, the 2.3 miles’ distance to the main HUP campus is not inconsequential,” said Lisa J. George, MS, a master improvement advisor for HUP Quality and Patient Safety based at Cedar. “So it is important that we design solutions to support them.”
The HUP Cedar Surgery Quality Improvement Workgroup
The answer: an innovative model in which two physician assistants, Margaret “Maggie” Erdman, MMS, PA-C, and Katlin “Katie” Dlugosz, MMS, PA-C, along with senior surgical resident physicians, provide full-time, in-person surgical consults at HUP–Cedar and collaborate remotely with Penn surgical faculty. This on-site surgical access team began in early 2022 and manages an average of over 20 surgical consults per week, in addition to coordinating follow-up care. The HUP–Cedar Surgery Quality Improvement Workgroup—founded by George and HUP surgical resident Sara Ginzberg, MD, MS, to monitor patient outcomes under this new care model and drive process improvement – was recognized in April with an achievement award at the Hospital and Healthsystem Association of Pennsylvania Leadership Summit in Harrisburg.
Helping Patients on Their Way to Surgical and Non-Surgical Treatments
Evaluating patients at HUP–Cedar means it’s possible to assess whether their condition requires surgery, to support them through their follow-up care needs either way, and to speed up access to emergency surgery when needed.
Dlugosz treated one patient who was experiencing abdominal pain; it wasn’t clear if the source was appendicitis requiring surgery – or gastroenteritis. She worked with an attending physician at HUP–Spruce to develop a plan for the patient to visit the outpatient clinic for further evaluation. She then reached out to the clinic to make sure the patient, who did not speak English and lacked insurance, could get in for an appointment.
The experience working on this team “has really taught me as a provider to stop and take a minute and make sure that the plan I’m giving the patient is actually attainable for them,” Dlugosz said. “When you give the plan to the patient and they’re like, ‘No, I can’t do that,’ and ‘I can’t do that either,’ you really start to think about it more.”
One of the workgroup’s main goals is to support the on-site team in providing the right care at the right time for each patient’s needs. Many patients have conditions that do not require immediate surgical intervention, and by identifying these patients up front, the on-site team has significantly reduced the number of unnecessary patient transfers to HUP–Spruce, which in turns helps patients return home faster. As an example, the on-site team saw over 200 consults at HUP–Cedar for urology conditions in their first year, but only 10% of those required transfer for surgical urologic care at HUP–Spruce, Erdman said.
“A driving factor in safely managing the other 90% of urology consults at HUP–Cedar's campus is our team's comfort with bedside procedures and urologic management, without which a larger number of patients would require transfer,” Erdman said.
For patients facing significant barriers to follow-up care, such as lack of health insurance or transportation challenges, the team collaborates with Penn’s Center for Surgical Health, which provides one-on-one surgical patient navigation for uninsured and underinsured patients. Helping these patients at every step of the way means they won’t need to return to the Emergency Department the next month with the same problem, Ginzberg said.
Faster Emergency Access to the Operating Room
Another major focus of the workgroup, which meets monthly, is to ensure that patients who need emergency surgery are transferred to HUP–Spruce without delays in their treatment. Through months of collaboration with the transfer center, the PennSTAR ground medical transportation program, and Perioperative Services, the group built a process for patients with surgical emergencies to be taken directly from HUP–Cedar to a HUP–Spruce operating room (OR). Previously, patients had to be transferred to an inpatient bed first.
“You can imagine that adds a bunch of time; first there has to be an empty bed, which often there isn’t, and then there’s the physical time it takes to wheel the patient to the bed first; and then pick them up again, and wheel them to the operating room,” Ginzberg said. “And if it’s truly an emergency, you can’t afford that.”
As part of this new process, the OR can start staffing the room, pulling supplies, and getting everything set up to receive the patient prior to their arrival. Dozens of patients from Cedar as well as other hospitals in the region have utilized this direct-to-OR pathway, as of March 2023.
“We’ve seen it benefit patients coming from all over, both from our other Penn Medicine hospitals and beyond,” Ginzberg said. “I can’t prove it, but I have to believe that [the changes] have saved lives and complications.”