File - AACD Perioperative Leadership Summit
Transcription
File - AACD Perioperative Leadership Summit
4/16/2015 Agenda Challenges at Advocate Lutheran General Hospital in implementing the PSH and… what happens to the PSH when CMS unbundles surgical care in 2017? • How to get started in a private practice group with limited resources • Discussion on steps to implement • LEAN- where are we in the process • Challenges • Early results • Making it work even in less than optimal situations • Next Steps Challenges at Advocate Lutheran General Hospital in 2 Advocate Lutheran General Hospital Anesthesia Group (PRAA) Structure • ALGH • Pure private practice group staffing: 700 beds NW Chicago Part of 12 soon to be 15 hospital system (largest in ILL) 30K cases Truven’s top 100 16 times Truvens top 5 academic systems 6 times Cerner IP, Allscrips OP,eClinical Works OP, Compass, Crimson, NSQIP, Midas, OR business mgr spreadsheets USNWR recognized 1000 MDs on staff 250 surgeons Profit 60M/System endowment 3.5B soon to be 5.5B under management 36% MC/MC 26 OR rooms, 8gi rooms, OB, OOR, plus 5 surgery centers and 12 bed SICU managing 46K anesthetics 36 full time docs and 9 part time docs and soon to be 8 CRNAs, 38MDs, 10part time docs No support staff, outsourced billing and management Zero stipend 7 x14 “library” and 1 office shared by medical director and non-MD coordinator Chairman’s office outside of OR FES pay per case and no pay for “extra work” Cardiac, SICU, OB, PAT, PEDS coordinator provide service with no comp. 3 1 4/16/2015 Getting started…Our Process • Applied for ASA Surgical Home study group • Support from Competent management and C level support is essential • Hired our savior “Flo” • Set goals • Divided process into various parts • PAT, pre-intra, post, case management and post D/C snif, LTAC all “lead” by different docs OR Directors scope covers all except post D/C Metrics • LOS • Unplanned 30 day readmission • Financial– Total inpatient stay cost – Total intra-op cost – Total direct supply cost per case • Clinical – NSQIP Chose Colorectal Service because • Single group of 3 surgeons doing 750 cases and almost no co-other surgeons doing these cases • Very difficult players..but as compared to others, maybe not No clinical staff in their office Lots of issues with their preop processes • Yet, they appeared to want to improve…. • Several outcomes drove us to choose this service line LOS and Readmission METRICS 2013 2014 Surgeons Top Decile Surgeons Top Decile % of Readmission within 30 Days 8.43% 12.19% 10.33% 11.99% ALOS 6.80 7.07 6.03 6.70 Source: Crimson • Data-Enhance Recovery Colectomy • SSI – On time 1st case starts – Surgery time- ERAS < 3 hour anesthesia time • Patient Satisfaction Scores 7 8 2 4/16/2015 Average LOS- 2013 to 2014 Trend % 30 Readmission- 2013 to 2014 Trend Source: Crimson Source: Crimson 9 10 Top 5 Reasons for Readmission within 30 days Early challenge: not all data matches chosen procedures Direct Supply Cost per Case by ICD-9 FY2014 Advocate Lutheran Performance ICD-9 Primary Px Top 5 Reasons for Readmission Jan 2012-June 2014 Cohort Performance Case Volume variance to Direct Supply Cost per Case 75th Opportunity percentile $2,159 $791 $26,103 1733-LAP RIGHT HEMICOLECTOMY 33 4593-SMALL-TO-LARGE BOWEL NEC 10 $2,069 4594-LG-TO-LG BOWEL ANASTOM 5 $2,397 N/A N/A $37,777 $1,110 $11,097 4863-ANTERIOR RECT RESECT NEC 72 $2,434 $525 4869-RECTAL RESECTION NEC 9 $3,043 $2,013 $18,118 129 $2,376 XXX $93,096 TOTAL Jan 2012 to June 2014 (DRG) Value % Total # cases 90th 75th 50th 25th # of facilities 389-G. I. Obstruction W Complication 6.9% 8 $1,070 $648 N/A $1,190 $483 $1,368 $959 N/A $1,909 $1,030 $1,830 $1,557 N/A $2,445 $2,315 $2,389 $2,086 N/A $3,105 $2,850 82 43 392-Esophagitis, Gastroent & Misc. Digest Disorders W/O Major complication 5.17% 6 862-Postoperative & Post-traumatic infections W Major complication 5.17% 6 393-Other digestive system diagnosis W Major complication 5.17% 6 394-Other digestive system diagnosis W Complication 4.31% 5 74 49 Source: Advisory Board Notes: Benchmark values calculateion cases fro Nov 2013-Oct 2014 TOTAL # of CASES= 111 in Crimson 31 Source: Crimson Clinical Advantage 11 12 3 4/16/2015 A Big Challenge-no single source Surgeon challenges and Ulterior Motives • All the data lives in different data bases with different structures and personnel • NSQIP • Cerner registry • Compass • Crimson and Midas for quality • HCAHPS for patient satisfaction • Compass for some surgery financial data • Business manager spread sheets for some financial data not always matching our designated PSH group • Initially we found the surgeons were willing to participate BUT…. They really wanted to improve turn over time Epidurals done out of the OR More consistent service from Anesthesia • Then they would play 13 Advocate Lutheran General PSH/ERAS Mission • Promote coordinated care • Reduce – – – – Setting Goals Cost of care LOS Complication rates Re-admissions • • • • Promote optimal patient safety Standardize practice using evidence based practices and research Improve the patient experience and satisfaction Improve overall satisfaction of Patients, Surgeons, Anesthesia, Nursing and other clinical staff • Provide quality & improvement measures demonstrating success, outcomes based on research (NSQIP, SCIP) 15 16 4 4/16/2015 SharePoint Site What is the Goal? • The goal of the PSH is to enhance value and help achieve the Triple Aim: a better patient experience, better health care, and lower costs. 17 18 Lean Methodology Act STUDY Study DO Step 8 Step 7 Step 6 Plan + Step 5 Step 4 Step 3 Step 2 Step 1 Interview Staff 19 Assemble steering teamSelected a physician leader for each phase and its members Gathered literature. Collected quality baseline data Collected list of protocols for each phase Observed current state. Value – stream Mapping. Develop protocols and clinical pathways Trial protocols And Clinical Pathways Step 10 PSH/ERAS Steering Team Step 9 Analyze the pathways and protocols and new Workflows and handoffs. Monitor Data Implement finalized processes Finalize protocols, and clinical pathways. processes Finalize and clinical physician pathways. scorecards Develop and Physician dashboard Ad HOCAdvocate Home health Nutrition Geriatric MD Nursing Education Scorecards and Colorectal dashboard. Anesthesia Pre-op-Dr. Young Intra-op-Dr. Nishant Shah/ Pain- Dr. Adanin and Dr. Hennes Post-op-Dr. Bissing Post Discharge-Dr. Bissing Surgeons: Dr. Park Dr. Prasad Dr. Marecik Lead Anesthesiologist Dr. Bissing Surgeon in Chief Dr. White Administrator Cindy van Brenk Post Discharge Care Coordinators IT Suzzie Kwon Marketing Evonne W Post-Op Tammy Burrows PSH Project Team Pharmacist Noreen Kelly, Amish Doshi Quality Mary Fleming Intra-op RN Marta Tobolski Service Erin Pangallo POCU Lynn Nolan & Steve Jermeay Hospitalists Dr. Kushner Dr. Affinitti Finance Stephanie Xanthopoulos 20 Physical Therapist Doug Reed Researcher Suela Sulo PST Steve Jermeay & Lynn Nolan Project Manager Flo Ostomy RN Marina Makovetskaia Kiokemeister 5 4/16/2015 Perioperative Surgical Home Protocols PERIOPERATIVE SURGICAL HOME PROVIDES A ROBUST INTEGRATION OF THE ENTIRE PATIENT CARE CONTINUUM Each phase of care has a well-defined series of care elements and protocols Preoperative Phase(Scheduling from office & PST) Intraoperative Phase Postoperative Phase Post Discharge Phase (POCU/MOR) (Phase 1 PACU, 7 Tele) (Home/Facility) Education & Expectation Management Pain Management Diabetes Optimization Preoperative Phase (Scheduling from the office and PST) Skin Prep (SSI Bundle) Wound Care Intraoperative Phase Postoperative Phase Post Discharge Identify Risk Factors Co- Morbidities Screening Intraop Analgesia- Epidurals Early feedings /diet Phase Anesthesia clinical pathways Early Ambulation (POCU/MOR) (Phase I PACU, 7 Tele) (Home/facility) Lab orders Goal Directed Fluid Therapy Physical/OT Therapy Consult Use of Pre-op Meds Nausea and vomiting control Primary Care Follow-up Bowel Prep Early removal of NG tubes/catheters Arrangements made for SNF/LTC if needed What are the metrics in each phase that will be measured? Each phase of care has a well-defined series of care elements and protocols- each with an emphasis on patient centered care and shared decision making 21 Stoma Care Prescriptions Standardize nursing care Transition Phone Call Center Risk for Readmission Interview Transfusion Therapy PIC Line Placement Anemia evaluation/management DVT preventive Therapy Post-op Analgesia Home visit by Home Health Normothermia Stoma Education Follow-up phone calls from RN Nutrition Optimization Alcohol consumption Smoking Cessation Strength and Conditioning Inclusion of Hospitalist D/C of Antibiotics Chemical Prophylaxis 22 Colorectal Procedures for PSH Why these procedures? • Laparoscopic Right Hemi colectomy • Laparoscopic Left Hemi colectomy • Low Anterior Resection • Current research focuses on these procedures and there is a lot ERAS protocols that are in the literature • Research has shown that patients that are under anesthesia 3 hours or less have a faster recovery and shorter LOS 23 24 6 4/16/2015 Top 5 Procedures (Jan 2014- Dec 2014) SOURCE:SURGINETStephanie Xanthopoulos 25 Abdominal Perineal Resection Abdominal Perineal Resection Laparoscopic Anoplasty Anoscopy Anus Botox Injection Bowel Resection Bowel Resection Left Hemicolectomy Bowel Resection Left Hemicolectomy Laparoscopic Bowel Resection Right Hemicolectomy Laparoscopic Coloanal Pull-Through Coloanal Pull-Through Laparoscopic Colon Resection Low Anterior Laparoscopic Colonoscopy Laparoscopic Assisted Colonoscopy OR Colostomy Closure Colostomy Revision da Vinci Abdominal Perineal Resection Laparoscopic da Vinci Bowel Resection Left Hemicolectomy Laparoscopic da Vinci Bowel Resection Right Hemicolectomy Laparoscopic da vinci Bowel Resection Ultra Low Laparoscopic da Vinci Coloanal Pull-Through Laparoscopic Exam Under Anesthesia Fistulectomy Gastrostomy Tube Insertion Hemorrhoidectomy Hernia Repair Inguinal Hernia Repair Umbilical Hernia Repair Ventral Hernia Repair Ventral Laparoscopic Ileoanal Pull - Through Ileoanal Pull - Through Laparoscopic Ileostomy Closure Ileostomy Revision Lesion Excision Rectal Lesion Excision Torso Mini Procedure - GEN Neuro Stimulator Insertion Stage II Neuro Stimulator Lead Insertion Stage I Pilonidal Cyst Excision Rectal Prolapse Repair Rectal Vaginal Fistula Repair Rectocele Repair Sphincterotomy Transanal Excision of Rectal Tumor Grand Total Total of Top 5 Bowel Resection Procedures 2 1 10 10 19 23 13 100 58 2 6 1 1 25 3 1 5 9 8 10 7 19 153 1 34 1 1 4 16 2 6 26 4 46 2 1 12 12 9 17 3 4 10 3 700 204 Office Changes Pre-operative Phase Office and Pre-Surgical Testing 26 Surgery-Colonoscopy Check list • Surgery-Colonoscopy Checklist Form • Scheduling- to identify the ERAS Patients with and without Epidural placementPENDING • Introduction to the New Pre-Surgical Clinic 27 28 7 4/16/2015 Pre-Surgical Clinic • Meet 2 afternoon sessions per week (Tuesday and Thursdays 12pm-4pm) in current PST space • Multidisciplinary clinic- “one stop shopping” concept • Serves as the home base for the patient and a point of contact before and after surgery • Allows for proactive planning for post-discharge transitional care, and active follow-up with high-risk patients. • Patients will be prepared for discharge before their admission • Patients will be educated on postop expectations and their healing process 29 Serves all five of the major goals of the PSH: • Provides a portal of entry to perioperative care and ensures continuity. • Stratifies and manages patient populations according to acuity, comorbidities, and risk factors. • Delivers evidence-informed clinical care. • Manages and coordinates the follow up of the perioperative care across specialty lines. • Measures and improves performance and costefficiencies. 30 Providers and Clinicians in Clinic- Plan- DRAFT • • • • • • Goals of Pre-Surgical Clinic Hospitalist PST Nurse Ostomy RN- AD HOC basis Lab Discharge Planner- TBD Nutritionist- TBD Risk Assessment-Reduction Tools (used in Clinic) • • • • • • • • NSQIP Cardiac Risk Calculator POP-Pulmonary risk calculator PONV screening tool Delirium tool- Mini Cog Assessment Nutritional status tool- in Cerner Anemia/blood count protocol OSA - STOP Bang screening tool Risk of readmission tool- currently used only by the Case Manager 31 8 4/16/2015 Other screenings Education Booklet • • • • • • The booklet is a guide to help patients and their families understand what to expect during the entire surgical and hospital experience. • The goals of the booklet are: Diabetes –HbA1c test Albumin and Creatinine levels Alcohol use Smoking cessation Preconditioning/exercise – To help the patient understand and prepare for surgery – Explain how the patient can be an active participant in their care and decision making – Provide daily goals to recover faster 33 34 Pre op steps Intra-operative Phase POCU and OR • • • • • • • • • • • • Home NPO after midnight for solids and nonclear liquids Clear liquids until 4 hrs. preop Carbohydrate drinks 4 hrs. prior to surgery POCU Celecoxib 400mg po Pregabalin 75mg po Tylenol 1000 mg po (All to be part of preop order set initiated by colorectal service) Epidural placement T7-10 (to be placed by Anesthesiology) 35 9 4/16/2015 Intra-op steps Intra-op steps • • • • • • • • • • • • • • • Operating Room Epidural specifics: Lidocaine 2% bolus 20 min prior to incision in increments of 3-4 cc to test correct placement and to cover incisional pain Bolus epidural at the end of the case with 4-5 cc 0.25% bupivacaine to cover incision as patient awakens Epidural to be activated after bolus at the end of the case at 4-10 cc/hr and run with 0.125% bupivacaine with 2 mcg fentanyl at the end of the case Rate to be determined by anesthesiologist General notes on epidural usage. Keep in mind epidural activation can and usually results in a decrease in venous capacitance and sometimes a drop in SVR. These changes also result in changes on a device such as the Flo Trac that may direct the clinician to administer more fluid because preload has decreased. As a result, we would like to only use the epidural at the beginning to test and simultaneously cover the pain associated with incision and later when the patient is awakening. Narcotics Discretion of Anesthesiologist. Minimal use preferred so as to decrease the amount of time it takes for bowel function to return. Discretion of Surgeon. Please ask PPM if Toradol 15 mg can be administered. If yes, then administer approximately 30 minutes before the end of the case. Do not administer Toradol if the patient has significant renal impairment. • • • • • • • • • • • • • • • Fluids Use PIV started in preop to infuse 1 liter crystalloid prior to incision Start basal rate and connect to pump. Fluid rate based on lean body weight; max 80kg 1cc/kg/hr for laparoscopic cases 3cc/kg/hr for open cases Decrease rate to 1cc/kg/hr when transferring to PACU 2nd PIV to be placed in the OR Flo-Trac mediated fluids will be administered through this IV Flo-Trac Arterial Line to be placed after patient is induced and intubated No arterial lines for short cases such as right hemicolectomies. Use best judgment and place if needed for patient safety We may have other noninvasive monitoring that functions similar to the Flo-Trac to assist with fluid administration in those cases SVV better than SV because of increased compliance of heart in most patients under 65 years of age and without any signs of heart failure Must wait 5-10 minutes to make sure the values are not an aberration. Use clinical judgment when deciding to infuse fluids based on values. Correlate decision making with position changes such as T-burg and other changes such as insufflation Intra-op steps Intra-op steps • • • Follow SVV protocol – SVV values should be consistent for 5-10 minutes before following protocol treatment options. • Also one must always keep in mind the other factors that can cause a change in stroke volume variation that does not relate to fluid responsiveness. This includes cardiac arrhythmias (more than 4 times a minute), non-controlled ventilation, and fluctuations in intra-abdominal pressure or thoracic pressure. • If there are frequent cardiac arrhythmias than one will not be able to use stroke volume variation and should not follow this protocol • – SVV Guided Fluid Intervention • If the stroke volume variation is greater than 12 % for an appropriate amount of time and everything else has been deemed appropriate than one should give a 250ml bolus. • This bolus SHOULD NOT affect blood product administrations in either transfusion thresholds or for amount of products. After the bolus has been administered one should go back to reassess the SVV again looking for the percent change. • If the value is now less than 12%, then this is showing that one is making an improvement in the patients stroke volume optimization • – – • • • • • • • • • • • • • • • . Ventilate at about 8cc/kg IBW Decrease tidal volumes as needed for patient safety If BMI >30, then decrease actual body weight by approximately 30%. If you use other methods to calculate approximate IBW, that will be appropriate as well PONV prophylaxis Dexamethasone 4mg at start of case Ondansetron 4mg at end of case Add scopolamine patch for high risk cases preoperatively Post Operative Delirium Give little to no versed if patients are slightly altered or cannot answer simple questions such as why they are getting their procedure Give muscle relaxant at beginning of case and small to no dose of reversal. Try to avoid reversal as much as possible. Miscellaneous Place OG tube at the beginning of case and remove it at the end of the case Epidurals will not be placed for right hemicolectomies Dr. Prasad will label which cases need epidurals and they will be listed as such on the schedule An attempt will be made to have the CRNAs staff these cases to help facilitate epidural placement in the preop area • 10 4/16/2015 Epidural Placement Workflow Intra-op Status • Implementation of: – Epidural placement in the POCU – SSI Colorectal Bundle • Utilize CHG Sage wipes in the POCU the day of surgery • Closing Mayo Tray • Changing gloves and gowns – Consistent Colorectal Team in the OR 41 42 POCU Time Audit Analysis with Epidural INTRAOP Time Audit Analysis with Epidurals 2:52 6:00 2:36 2:24 2:13 2:06 2:04 30% decrease in total me in POCU from 1/7 to 2/4 1:55 4:48 2:09 4:35 1:48 Average Times 3:45 1:26 0:59 3:36 4:04 3:53 3:313:30 3:22 3:05 2:49 2:32 2:20 2:24 2:20 0:57 0:37 1:23 0:30 0:28 0:230:22 0:070:09 0:00 43 0:150:13 0:09 0:04 0:18 0:10 0:03 0:08 0:05 0:05 0:17 0:29 0:16 0:10 1:12 0:58 0:04 0:03 0:13 0:10 0:030:05 0:03 0:06 1/7/15 1/14/15 1/21/15 1/28/15 2/4/15 Total Avg. Hand off me 0:07 0:04 0:03 0:05 0:03 0:04 Epidural Placement 0:09 0:09 0:37 0:08 0:17 0:16 Anesthesia me in POCU 0:23 0:15 0:59 0:18 0:30 0:29 End of epidural to pt to OR 0:22 0:13 0:10 0:05 0:10 0:12 Total me in POCU 2:36 2:13 2:06 2:04 1:48 2:09 0:31 0:26 0:18 0:17 0:20 0:11 0:080:080:110:050:100:08 0:090:07 0:02 1:13 1:06 0:59 0:42 0:12 0:56 0:48 0:46 0:40 0:06 0:040:05 0:00 Total me for line and foley placement Total me for prep and posi oning 1/7/15 Total drape me 1/14/15 Time from end of drape me to surgeon arrival 1/21/15 Time from pt in OR to surgeon arrives 1/28/15 Total anesthesia me 2/4/15 Total room me Turnover me (1st to 2nd pt) Total Avg. 44 11 4/16/2015 Summary- Results and Opportunities Wins • • • • All staff showed up on time for epidural placements in the POCU Average total time for patients in the POCU decreased by 30% from Jan 7th to Feb 4th Right hemi-colectomy patients on the average under anesthesia for < 3 hours. Left hemi-colectomy and LAR patients are under anesthesia on the average >3.5 hours. Turnover decreased by 40% on average from first and 2nd weeks. (3 people are now available for turnover) Need to work on • Decreasing total anesthesia time. • Resident delays • OR staff not sure which resident is assigned to their room • Residents are not consistently present during positioning. • Delay between end of epidural placement to transfer to OR Post-Op Phase Phase 1 PACU 7 Telemetry 46 Post-op status • In PACU-Monitor epidural fails • On 7 Tele – No PICC lines delays- patients are getting screened 24-48 hours after surgery if they need a PICC line – PT- need to develop an algorithm for patients that need PT. Needs to be based on age and pre-surgical clinic assessment – Ostomy education on the weekends 47 48 12 4/16/2015 Revised Post–op Protocols Daily goals are developed for patients regarding: • Activity and early mobilization • Early feeding and diet • Early removal of Foley catheter • Post-op analgesia Post-Discharge Phase Home or Facility 50 49 Post Discharge • Transition care- currently 24 hour phone calls done only once • Looking at software system to help with postop discharge calls- vendor meeting with surgeons in March • Follow-up to find out top 5 SNIF’s the colorectal patients go to after discharge • Meet with Advocate Home Health 51 Next Steps • Pilot Pre-Surgical Clinic- tentative start date March 1st • Build risk assessment tools and place on SharePoint Site for all to access. • All protocols to be placed on the SharePoint Site – Icon to be placed on PC’s • • • • Complete education booklet for patients Office staff to utilize revised surgery checklist Anesthesia intra-op protocols Anesthesia analgesia protocols – Work with pharmacy to trial Exparel and IV Tylenol on select group of patients-need algorithms – Build order sets 52 13 4/16/2015 Project Timeline Next Steps (cont.) T arget Date Deliverables ST AT US PERFORM INTERVIEWS IN A LL A REA S Aug-Sept.2014 DEVELOP A SHA REPOINT SITE • Begin development and implementation of post-op protocols – Educate staff and build order sets • Clinician 3 RN’s to assist with Ostomy education for patients on weekends and off-shifts- education and training being developed • Work with Case Management on how changes in their role will effect the ERAS patients OVERVIEW OF PROJECT MEETING WITH SURGEONS KICK-OFF MEETING WITH STEERING COMMITTEE Oct. 14 VA LUE STREA M MA PPING-CURRENT STA TE PERFORM WA STE A SSESSMENT EVIDENCED BA SED A SSESSMENT GA THER PROTOCOLS FROM A LL A REA S Nov./ Dec. Jan.- Feb 2015 DEVELOP CLINICA L PA THWA YS BEGIN IMPLEMENTA TION OF NEW PROCESSES A ND PROTOCOLS IDENTIFY METRICS REPORT OUT TO LEA DERSHIP- UPDA TE BRA INSTORM A ND IDENTIFY SOLUTIONS WITH TEA MS BUILD RISK A SSESSMENT TOOL UPDA TE A ND REVISE PROTOCOLS DEVELOP EDUCA TIONA L MA TERIA LS FOR PA TIENTS PILOT PRE-SURGICA L CLINIC- DEVELOP PROCESS DEVELOP A ND PLA N OUT SOLUTIONS- need leadership approval MARCH/APRIL 15 PLA CE PROTOCOLS A ND A LGORITHMS ON SHA REPOINT SITE ROLL OUT PROTOCOLS IN EA CH PHA SE May/ June 2015 Jul-14 DEVELOP EDUCA TIONA L MA TERIA LS FOR STA FF DEVELOP A ND PILOT NURSE NA VIGA TOR ROLE/ TRA NSITION NURSE IMPLEMENT/EXECUTE SOLUTIONS (develop Future State Map) FINA LIZE CLINICA L PA THWA YS PSH SHOWCA SE- WA LK-THRU'S IMPLEMENT/EXECUTE SOLUTIONS (develop Future State Map) FINA LIZE REVISIONS TO FUTURE STA TE FINA LIZE CLINICA L PA THWA YS COSTS FUTURE PROCESSES REPORT OUT FINA LIZE EDUCA TION MA TERIA LS Jul-14 TEA M CELEBRA TION NEEDS ATTENTION COMPLETE PENDING 53 Barriers Summary • Anesthesia has no paid time to develop program • Limited hospital support with high threshold for ROI • Clinical and quality systems are a mess • Surgeons still paid on volume (anesthesia too) • Disparate primary care and surgeon referral • Every department is overburdened and over measured for productivity • Burn out by same providers doing all the projects • Show me the money/ROI, (NSQIP) 55 What happens in 2017? UNBUNDLED SURGICAL CARE 56 14 4/16/2015 Questions?? 57 15