Hello, and welcome to the Critical Care Crosstalk. My name is Dr. Saras Chandra Vallabha Josula. I'm an interventional cardiology fellow at the Emory University. I'm previously trained in cardiovascular medicine and critical care medicine, and it is my distinct pleasure today to host the anesthesiology section Crosstalk. We have two esteemed professors, senior teachers, and mentors to many students and residents along training. And I would love for them to introduce themselves, tell us where they're from, and what was the single most thing that attracted them to the field of anesthesia critical care. Michael? Thank you. Yes. Hello, everyone. My name is Mike Scott. I'm a professor in anesthesiology and critical care medicine at the University of Pennsylvania. A lot of people know me really for enhanced recovery after surgery, or ERAS. I had an unusual training. I was triple boarded. I started in medicine and then liked the excitement of critical care, so moved into anesthesiology because in the UK that's the way you go into critical care, and that really set my destiny. And then I did some fellowships in pediatrics, and then ended up doing critical care as well. So that's how I ended up where I am. Thank you, and welcome, Michael. We have Lisa with us. Hi, I'm Lisa Weave, and I also kind of had a circuitous route to critical care. I thought I was going to be a trauma surgeon, and while I did love the surgery part, I truly loved the critical care aspect and understood that the skill set that I needed to do critical care was actually the pharmacology and the procedural skill set of anesthesia, so that's how I got into the anesthesia game, and then went over and did the fellowship in critical care. And so that's really where I ended up with my true love. Well, clearly both of you feel very strongly and passionately about the field, so again, it's an honor to have you here with your experience and wisdom. So maybe we'll have Michael open the floor with a few thoughts of his, and then switch over to Lisa, and then we'll go back and forth. Michael, please go ahead. Yeah, thank you. So what we thought we'd discuss today is the role of the perioperative intensivist and clinical pathways to enhanced recovery after major surgery. So I'm going to start by painting a picture of enhanced recovery and talk about where the best value as perioperative intensivists we can offer, and then open up for discussion with Lisa. So I think everyone is now well aware that enhanced recovery after surgery is well embedded into most surgical pathways around the world. It's a multimodal, multidisciplinary approach to the care of the surgical patient, and really actually doesn't change the surgery, it changes the process of what happens to the patient around the time of surgery. We know it reduces length of stay, variability, costs, it's being used pathway-wise across many different surgical specialties, and in emergency general surgery even. And the great thing about it is it's simple, straightforward, and it basically offers improved quality of care for less cost and reduced complications. So really it's a bit of a no-brainer. But I think everyone knows that when we move into major surgery for high-risk patients, that things can actually get very challenging. And the way I look at an enhanced recovery pathway is it's just a pathway, but there are many different macros where you keep the patient on the path. Some of these are just simple evidence-based protocols, like giving antibiotics and anti-nausea drugs. But other things are much more individualized for the care of the patient, like fluids, hemodynamics, and analgesia, and it depends on the patient, depends on the surgery, depends on the surgical approach and how well it goes. And to me, the elephant in the room has always been the fact that we do need a time at the end of surgery where we try and get that patient's physiology back to normal as quickly as possible. Because I think at the end of surgery, that's when you've got all these physiological changes. You're going from positive pressure ventilation to spontaneous ventilation. You've got breakthrough pain. And then you've got fluid shifts and increased oxygen consumption. And you've often got a SERS response, and you're mildly vasodilated. And you've got acute incident resistance because of the stress response. So we've got really a perfect storm in our patients at the end of surgery, and they go to the PACU often only for a few hours, or they go to ICU. But there's a large proportion of patients that sort of fall in between that, where they're not well after two hours, but they're not going to ICU. And this is an area which I think that we can actually address. And from where I was in the UK, in Guilford, we had a post-operative unit by our ICU where all major surgical patients went, and they had a period where they were hemodynamically optimized with non-invasive cardiac out monitoring, so fill flow pressure. So we made sure they were resuscitated properly by using echo, bedside ultrasound, and non-invasive flow devices, troubleshot their analgesia without giving them lots of opiates, and insulin for the metabolic response. So that's what I want to paint, is where are we going in the next 10 years of perioperative medicine in order to address what is the high-risk surgical patient where we still know 80% of our complications are? Thank you, Michael. That was phenomenal. And I agree with you. I think that's a very under-addressed question, either from a disposition standpoint or just from the overall outcome standpoint. And I think we'll have Lisa share her thoughts both on the enhanced recovery pathway, but also her vision of telemedicine and rapid response before we go back and forth between each other. Lisa, please go ahead. And I fully agree that we've done a tremendous—we've actually standardized a huge amount of that perioperative response with the ERAS pathways, which I think have done a tremendous amount to actually identify when patients are going off pathway, because before that we'd never had pathways, so we didn't know if they were off them. And then they really got into trouble. But just to take it even a step prior to the OR, I think that's truly when postoperative enhancement begins, is actually in the preoperative arena, because when I started surgery, one of the first things that someone told me was surgery is a very long training program not to decide how to—not to learn how to operate, but who to decide not to operate on. And it seems that in the academic world, we've forgotten some of those lessons, and we tend to operate on everybody, and that's just the world that we live in. So I think surgical choice is a huge component of that postoperative recovery, and then preoperative optimization is something that I don't think we stress enough, either because it's not covered by insurance or there's so much pressure to get patients through the operating room that we don't actually take that pause to say, how can I get this patient in a better condition before this major surgery so that their postoperative recovery is already enhanced as it is? The things that like truly matter, the nutrition, the optimization, smoking cessation, exercise tolerance, those are the kinds of things—correcting anemia is really the stuff that we don't actually have the time to do anymore, but truly do impact what that postoperative recovery looks like. So we at Vanderbilt have actually—we've got a high-rise clinic, which is called the High Risk Evaluation for Surgery, and these patients, when they're identified, mostly by their surgeons, and we've taught people criteria of what makes you a high-risk patient, they come in and they get evaluated by intensivists and anesthesiologists that are either doing the liver room or the cardiac room, so there's a lot of big stress on the big organ physiology, and that high-rise group actually designates these high-risk patients. So we try, and in the limited time that we have preoperatively, we try and optimize that patient group. Now, when they get through surgery, we do have ERS protocols for just about every kind of surgery that you can think of. One of my concerns with ERS protocols is that the guidelines become these rules, and then people don't adjust the ERS protocol to the patient. They just kind of do the ERS protocol for that surgery, and I think sometimes we lose capture of our patients there because we're not thinking about it as a guideline, we're thinking about it as a set of rules, but that being said, I do think it's a great thing to standardize the approach because then we do know when patients are coming off of those protocols. Our postoperative period is our highest risk period because what we tend to do at Vanderbilt, and I'm sure that this happens in a lot of hospitals, is that we tend to co-locate patients not by their acuity or their physiology, but by the type of surgery they had because the orthopedic nurses know how to take care of the orthopedic drains, and that's where the OT and PT is for that team, and so we really have designed hospital systems to best manage to the nursing and the physician benefit where we co-locate these patients, and so the way I think about it is sometimes we have triathletes who are coming in for their hip replacement, and they're put on the same floor as the 88-year-old who has an albumin of two who's also broken her hip, and she's on that same floor, but these are two very physiologically different patients going through the same operation, and so one of the approaches that we took was we're not going to ever break the co-location culture, well, not very easily at least, I wouldn't say never, and we don't have the benefit of a postoperative recovery, a period 24-hour recovery space where we could optimize these patients, so what we've ended up doing is developing a dedicated critical care outreach team that can then move to the patients as well as we're now in the process of putting together a deterioration index where we can actually monitor these patients in real time and then put this critical care outreach team to really go out and help support and manage these patients to maintain them on pathway before they get into trouble and need a rapid response and an escalation to the ICU, and this team is actually made up of dedicated nurse practitioners, critical care nurse practitioners who are pretty much the bedside managers, and then on the back end of that we have a tele-intensivist, so an intensive care physician in the perioperative space, so it's not a pulmonologist, it's actually an anesthesia intensivist who works in all the perioperative surgical units, who basically manages the patient, evaluates the electromedical record, and then uses the bedside MP team as their hands, eyes, and ears at the bedside while they drive some of the care plan, educate the primary teams, and perhaps change the trajectory of some of these acutely deteriorating high-risk patients, and our goal is really to make sure that patients who need to escalate up to ICUs get there very quickly so we can manage them before all hell breaks loose, and then the patients who just need to have pathway corrections, maybe a little more pain meds, less delirogenic meds, maybe they need a little more fluid, maybe they need some diuresis, that's really what this team is out there to do to try and prevent that acute deterioration. Thank you. That's very remarkable, and I'm impressed by the ability to synchronize bedside MPs with telemedicine physicians, and that's a very unique description that I've heard. I have one question for both of you. Can you describe the system, I know Lisa talked to that end briefly, but the logistical challenges that your systems faced when you came up with when you came up with these concepts, and how much of a strain was it on resources, did it need additional resources, or how was the reshuffling of resources done to accommodate for this patient-centric model that both of you highlighted? Yeah, well I think what Lisa was describing is we're going to proactive medicine rather than reactive medicine, and that's the key, so everything from getting the patient ready for surgery, as she described, and we did something similar at the Commonwealth University where our last was with a very big pre-optive clinic, and not just clearing people for surgery, but actually interventions that will affect outcomes, so nutritional therapy, correction of anemia, diabetic control, and all those things. It's very hard to show value in these things, that's one of the biggest problems, and that was even back in the UK when we first proposed to do post-operative hemodynamic therapy in this high-level care unit, which really addressed what you were discussing, it was about the fact that we had all the different specialty patients all in the same place, and they're all immediate post-op, and I like your concept because that's exactly what we did, is we took the sub-specialty away, and we just looked at the acuity of the patient and the acuity of the surgery, and said who actually needs higher level of care, but to actually produce a business case and show that you can affect change is very hard, and I mean even with enhanced recovery it's hard, you can show reduced length of stay, you can show signals of SSI and AKI, but it's very hard in perioperative medicine to show true cause and effect because the numbers are high, it's easier when you've got your high-risk patients because there's more bang for the buck there, but I think that's fundamentally the thing that I've always faced the biggest hurdle, is getting executive buy-in and saying that this is a good thing, I think to most of us it's a no-brainer, but the first thing they say is okay, well you want to do one to two nursing for a few hours post-op, that's going to cost money, and where are you going to put them, so that it brings up all these logistics, so I like the, I think the other thing, this idea of an outreach team is interesting because that's what we did in the UK across the whole of the UK, and you're then bringing the care to the patient if you can't take the patient to the care, so I think that's a good thing as well, and then just generally it's like any performance improvement and quality improvement, you've got to convince everyone, get buy-in and decide in your team and who's going to actually deliver that, and you've got to have people that understand the physiology, so I like the fact that you've got anesthesiologists involved, because obviously we are just physiologists, that's our role, so I think that sounds very powerful. Yeah, we faced exactly the same hurdles where people were like that sounds lovely, but it's going to cost money, and I don't see that, and obviously cost avoidance is not something that ever buys you any great love or respect from anybody, particularly in your CFO suite, but what actually happened with us is that by, which this was a pure serendipitous event, I had four or five critical care nurse practitioners that had, they closed down a service line, and these nurse practitioners, all very seasoned, very experienced, amazing critical care nurse practitioners who didn't have a job, and I've been pushing this whole concept of this critical care outreach for a while, and they called me up one day, and they said, hey, the five of us don't have a job, should we do this thing that you've been talking about, and I said absolutely, so we didn't really even ask permission, we just did a pilot, we just naturally started to do this, and we took over rapid responses, all the surgical rapid responses across the hospital, and what we showed when we compared our response with a back tele-intensivist behind this dedicated team, where we weren't pulling resources from any ICU, is that we decreased inappropriate ICU utilization, which was a huge deal, because our ICUs are running at capacity or beyond capacity all the time, so the minute that we were freeing up ICU beds, our first pilot, we freed up 365, 364 ICU days, which is basically the equivalent of building another ICU bed, and I think that got people's attention, and then when we showed how much it really helped and supported the nurses on the floor, it was a nurse retention opportunity, that really got people's attention, so we came at it from, once we had the ability, we just did it, and once we had the ability to show people the true, real effect that people were truly feeling, we had ICU days opening up, we had nurse satisfaction, we had patient and family satisfaction, they were so happy when they saw the team coming around, they used to send us cookies and stuff, and I did, I branded them in orange, so we were called Team Orange, and it has really been a fantastic experience. We still had to fight tooth and nail for someone to actually fund it as a formal project once the pilot had finished, but people are certainly realizing the value now, and particularly with COVID and all the impact on the hospital and throughput, this team has been an absolute godsend and a bonus, because it is not pulling overworked nurses and rapid response people off of their units that they're working on, and this team can then deal with a lot of what's going on across the hospital, as well as the focus on proactively trying to keep patients safe, so it's been a tremendous boon, and obviously I'm not one to waste a good pandemic if I have to, and we've shown that we've really been able to come into our own, and so I'm hoping that this is enough to prove our worth and grow the team and get to 24-7 coverage. That's what we're working towards. Right now, we've got a 12-, 14-hour window, but we're trying to work to 24-7. Fantastic. I have, again, a question for the both of you. Both of you established this a couple years ago now, a few years ago now, and now you're working your way towards sustaining the model. How do we continue to show the value addition of this to our current practice, A, and B, are there any formal measures? Do you do quality improvement studies? Do you do survey-based questionnaires? What do you do to show the continued value, the sustainability, and the efficacy of the models that you've created? I think data is key, and that can cost a lot of money to actually get the data out. At VCU, we built a data warehouse and to have people program and do that and there's a lot of time of people to commit to say you know what data do we need so basically you know the EMR is just a load of shelves with a load of values on and you've got to say I want these values and make and pick them off the shelf make sure they're the right values and then actually analyze it correctly and then using the quality markers are key so vision markers just like SSI AKI they're all good signals of quality so I think it's important to map those and then if you can do a cost episode that's even better and I think the thing that's really driving this now with CMS and increased bundle care that you only need one complication now which can cost an average thirty to forty thousand dollars that's coming off your bottom line so you've then got to do another ten surgeries to make that money back so I think bundle payment actually is a way it's really driving people to focus on not getting complications and making sure that patients you know don't do badly and that is really I think the leverage to pre-optimization to the standardized pathways but also the early identification of when patients are getting complications because failure to treat is the other thing so as Liza was saying the sooner you get on this and be proactive and just and patients do follow patterns you know Whipple's procedures different from a hepatic resection different from a thoracotomy so if you've got the right experience team around you I think that's the way that it's pattern recognition and as you say keep this pathway it's guidelines but not tram lines so you know certain things are good but there are certain patients and if it's different things and that's why I describe it as a pathway of macros and not everyone gets all the macros because if you don't lose blood then you don't need the blood macro but it's that sort of thing so it really is changing the way we're looking at surgery though I think and it's particularly in the high-risk population so I to summarize data and outcomes and costs are key to map as well as patient satisfaction I forgot that patient reported outcomes of course are the big thing at the moment and I fully agree if it's we don't have data you're kind of dead in the water so same same version we have a very very robust IT data Mart system at Van Bulten obviously we're on EPIC so we do get that that whole infrastructure that EPIC brings but I've had a huge amount of help with from the IT department building a data Mart with but it's really a data lake so you can slice and dice the data where you're looking for different meaningful outcomes depending on which patient population you're looking at but you've certainly got to understand to obviously get programs financed and to get them to be able to grow you've got to beat your your institution's financial goals so you've got to understand what their metrics are what's meaningful to them because I've struggled for a long time to understand that what's meaningful to a clinician is not meaningful to a CFO you think that they should be but it's just a different way of looking at data and looking at numbers and so a lot of the things we do is really around understanding what it is that the the hospital needs to see from data and financial perspective and an OTE and then what we need to be doing from a clinical perspective to change that to improve patient outcome and then we do a lot of subjective surveys with our nursing staff to better understand how we support their needs because nurse retention particularly right now where nurses are so scarce is a huge driver of a lot of quality programs at in hospitals and so that's one of the big things we also concentrate on is that level of support that we supply and we we add to our nurses particularly at night when we have young nurses inexperienced nurses at the bedside with high acuity very high risk patients. Thank you Lisa. A follow-up question to both of you I mean both of you are very experienced and have worked with many young trainees at different levels of training. If somebody who's in training wants to pick up some of these unique pathways and make it their own take ownership and bring to their hospitals what advice do you have for them how should they go about creating this model or how should they collaborate with institutes such as yours and creating such efficacious models? Yeah I mean there's two ways you can introduce things you can do horizontal by specialty or you can go vertically and just say right we're going to standardize pre-optive care and optimization what happens in the pre-surgical unit pacu and things and then go horizontally per specialty. I think if it's your first pathway you want to find a surgical champion and an anesthesia champion and just do that one pathway but having done this a lot and a lot of different organizations we did it Virginia Commonwealth because they we had executive buy-in we did five pathways immediately horizontally things like bariatrics, gynonc, colorectal and orthopedics and then we dropped in vertically everyone going to the pre-optive clinic standardized pre-surgical unit instructions and the same for the pacu and then the two key things that that you get need to get right for each surgery is the opioid sparing analgesia pathway depending on surgery and approach and then hemodynamic therapy. So we did separate things for both of those so currently there's a hemodynamic profile for each of the types of surgery and using non-invasive monitors optimizing the patient prior to the incision going through the surgery optimize at the end and then ideally a pickup in the 6 to 12 hours the pacu you can use ultrasound or if they go to a higher level care unit you've got all these other non-invasive clinic output options there. I think for a program I think a little it is an interesting program because it is unique but really as long as you have intensivists that are interested in the perioperative space and really my interest in the perioperative space began when I was just got irritated with people who were coming into my surgical intensive care unit that either weren't going to benefit from being in the ICU or who just needed a quick resolution of a problem and that was really how I moved out of the ICU into that perioperative area but when people are interested in the process and the workflow I think we and particularly in anesthesia critical care we are seeing that that whole idea that critical care only happens inside of an ICU and nothing happens outside we're now just expanding the fact that critical care can happen wherever the patient is and preferably we'd like to keep them there because we don't have space in our ICU so it doesn't take much except to have an intensivist and to have some nurse practitioners available and face time is really what you we could we started with but it's really understanding the culture of what it is your hospital needs and then you morph the program to really meet the needs of the institution and that and your patients because that's really how you're going to be successful and then the program will mature and grow as you get some wins under your belt people see the value and then you start adding adding stuff onto it like we now have added sepsis early detection of sepsis onto the critical care outreach team so not only are we dealing with surgical patients now we're even moving over to medical patients so we're just expanding the reach of the ICU outside of the ICU right right no great points great points follow-up question to the both of you in these trying times how has the pandemic impacted both the execution or importantly how has it impacted you know the innovation in the fields that you guys are working in yeah well you're talking to someone who's just spent week after week in COVID ICU so it's innovation it's it's not really been around I must say on my side we we actually basically used that well as the pandemic sucked up more resources and more people to focus on COVID patients we expanded our focus to really go across anyone who was non-COVID to really support care and maintain quality and maintain throughput because the worst thing we could have happen was patients spending longer in the hospital than they needed to be because we needed every hospital we need every hospital bed that we can get so the the goal is we've now expanded to doing rapid response on our medical patients because all of the medical people are kind of tied up in their units and so while it's not an area that I'm super comfortable with because we don't really have like a ground zero where the surgery happened it's just kind of this amorphous ongoing deterioration so we are working to get pathways around some of the medical patients so we can help their teams kind of standardize some of the stuff that they do so we can help them get them their patients like ready for milestones ready to get out of the hospital quicker. Thank you. Did you guys have questions for each other? Just curious. No I think we we use a lot of ERS protocols and they definitely do have helped us tremendously and as I say what I really like about ERS is that we now have a standardized pathway for a lot of these patients and so it's very easy to know when they're coming off pathway and to correct that so with my team when we're looking at patients who are showing some physiologic derangement it's very easy to say well this is where they should be and this is what should be happening and so why isn't it and then we help guide the primary teams to get them back on pathway so I think ERS has been a wonderful kind of level setter for a lot of these patients. It's interesting you say that because you almost it's an early indicator of complications isn't it when they're when they're just not following the pathway and you often see that way before even scans show anything going on especially you know with intra-abdominal leaks and things or anastomosis that aren't quite right. The patient's just slow and just doesn't quite ever get going. Fascinating. I know we're in the anesthesiology crosstalk section so I had a question for the average non-anesthesiologist. So what role do you think non-critical care, non-anesthesiologist or somebody who's not like either of you how can they incorporate themselves into your care paradigms and what role do you envision for them? I think if you're thinking you know peri-optive care and post-operative optimization and things we don't really do a lot if you're not ventilated really if you think of critical and high-level care it's getting it is fluid and vasopressors it's insulin and antibiotics and oxygen and there's not you know there's other things that are peculiar to that patient and surgery but those are the core things if you don't go wrong on those then the patients get a better outcome so I think there's the skill set of being able to do bedside echo look at the IVC the heart and the lungs and understand non-invasive hemodynamic monitoring so you know and I think we now are seeing a general acceptance that low-dose pressures are useful because we used to keep throwing fluid, fluid, fluid and then you get the arterial pressures low, venous pressure high, back up, reduction, transcapillary gradient then you get all those downstream problems so an early fix an early identification of vasodilation tends to you know stop all the bad things downstream and I think that's the other problem with all of this it's very hard to show the outcomes and people think well you're not doing much you've increased the blood pressure by 10 points but if you look at the IMPRESS study that was published a couple of years ago where they basically had major surgical patients and they optimized flow and then they just ran very low dose norepinephrine and put about 10 points on the blood pressure they had an enormous reduction in all cause complications, better less delirium and AKI because you're perfusing organs better and less pulmonary problems because you're not fluid overloading them and also less sepsis because you're probably ensuring the gut's perfused better because a lot of the downstream sepsis is probably coming from the gut so yeah it goes back to what Lisa was saying with her whole approach and what what she's done and also enhanced recovery it's all about being proactive and making sure things don't go wrong in the first place and if you do pick them up early and fix it early and then the patient will always do better so the skill set to do that is the key. I think what we're trying to do is as we learn what our deterioration indices mean and how it is we need to approach those patients our goal is to try and educate our trainees and our nurse practitioners and our primary teams attendings at the bedside that when you recognize this pattern and the deterioration index is telling you this is what's going on this is our expectation of what you do because our goal is to truly make this a proactive sustainable approach and it's not going to be sustainable if it's just a small team that has to manage it all the time we really have to have everyone understand when you get this data this is what it means and this is the expectation of what you do with it so that we can get everyone on board to try and be proactive because unfortunately the way we've broken up care where we have limited duty hours and we have people rolling off and rolling onto teams and it's almost shift work you've lost that kind of old-fashioned continuity of care where it was one internal one resident that looked after a patient from the beginning to the end and that's where we lose that pattern recognition so quickly so it's having the right data that is actually that something actionable and that we have the expectation that the person who has that data is going to action on it and that's our goal is ultimately to educate across the spectrum around this but we don't have enough experience under our belt yet to best understand how to approach educating around this data I think what's interesting at the moment is the opportunity as well with waveform analysis we've already seen you know hypotension prediction and we're also going to more and more non-invasive types of physiological data and waveforms and that could be really key because then as you say we can put this on every patient and if we can then send it up in the cloud the waveforms and analyze them it could be an early signal with physiological derangement and then go and find what's going on and fix it earlier yeah no these are great great thoughts I think we are coming close to our scheduled time so maybe a couple of closing comments from both of you on your views about where this is going the future of your fields and what advice you have for people listening in yeah well I think we're going into the realm of individualized medicine I think we will be able to identify more and more the risk factors for different patients having different procedures will and with big data and regression analysis if we can collect all this data then we'll know what pathway patients should be doing and what the optimal care is for them because we'll be able to do that so I think the days of the RCT are actually more limited these days we've had all these big RCTs with thousands of patients and very low return of signal so I think we're getting to the point in the future really we want all our patients on one big database somewhere and so that we can look at that and then we can use the technology to do a deeper dive and determine what really matters and affects outcome and I think better understanding the use of technology and wearables because I do think that we're going to get into a space where a patient who is designated as high risk will probably have a wearable that they would start before they come into the hospital so you can look at their movement and their heart rate variability and a lot of the other things so then when they're in that perioperative window we're able to customize their physiology to their baseline as opposed to the standardized baselines that we put on alerts right now and that I think is going to change the dynamic of first of all recognizing when patients are getting into trouble as well as the fact that not overreacting because sometimes we do more harm by over treating than we do by just actually saying well that is the baseline that that patient has and letting them be so I think that using technology and and then also being able to extend that care into the home environment or rehab where you have the continuity going across that to prevent patients having to be readmitted to prevent worsening outcomes and complications in the post hospital period is also going to be very important in these high risk patients. Yeah absolutely I totally agree there because also the bundled payment is very aggressive in the 90 day out in the UK we have a sort of 30 to or 60 day window but to do 90 days it's very hard to land someone without complications at 90 days and of course then all the cost comes back on the on the hospital system so yeah I think that's a really really good thoughts there yeah. Thank you again on behalf of the in training section which was the critical care cross talks on behalf of the SACM congress and specifically the anesthesiology section thank you Lisa thank you Michael for sharing your time your wisdom you have excellent excellent thoughts on these very very interesting subjects and hopefully once this goes live we'll have excellent participation we'll have many questions coming in and I look forward to meeting with you again thank you both. Thank you. Thank you.

perioperative intensivist

clinical pathways

enhanced recovery

proactive medicine

individualized patient care

data analysis

continuous monitoring