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Improving Outcomes through Pre-hospital Checklists

Improving Outcomes through Pre-hospital Checklists. Thomas Varghese Jr. MD, MS. Presented at Washington State Hospital Association Safe Table, July 31, 2013. Healthcare System in Washington State. QI Performance Surveillance. Research and Development.

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Improving Outcomes through Pre-hospital Checklists

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  1. Improving Outcomes through Pre-hospital Checklists Thomas Varghese Jr. MD, MS Presented at Washington State Hospital Association Safe Table, July 31, 2013

  2. Healthcare System in Washington State QI Performance Surveillance Research and Development Translation of Research into Practice Presented at Washington State Hospital Association Safe Table, July 31, 2013

  3. Clinician-led QI using clinical data • Focus on quality and cost-effectiveness • Data • Impacts behavior through: • Benchmarking • Education • Standard orders • Checklists Presented at Washington State Hospital Association Safe Table, July 31, 2013

  4. BeforeElective Colorectal Resection, CHARS 2000-2003 Presented at Washington State Hospital Association Safe Table, July 31, 2013

  5. After Elective Colorectal Resection CHARS 2006-2009 Presented at Washington State Hospital Association Safe Table, July 31, 2013

  6. Patient Voices Leverage Healthcare Data Stakeholder Input Clinician Offices Evidence generation CER/PCOR Partners in QI and Research Hospitals Long-term Care Evidence into Practice Presented at Washington State Hospital Association Safe Table, July 31, 2013

  7. Focus on Decision Making PATIENT DOCTOR’S OFFICE OPERATING ROOM Presented at Washington State Hospital Association Safe Table, July 31, 2013

  8. PATIENT DOCTOR’S OFFICE OPERATING ROOM Presented at Washington State Hospital Association Safe Table, July 31, 2013

  9. Focus on Decision Making in Clinic PATIENT DOCTOR’S OFFICE OPERATING ROOM Presented at Washington State Hospital Association Safe Table, July 31, 2013

  10. Presented at Washington State Hospital Association Safe Table, July 31, 2013

  11. What is Strong for Surgery? • State-wide public health campaign • Evidence-based practices to optimize the health of patients prior to surgery   • 5 Pilot sites: • Virginia Mason • Swedish • Skagit Valley Medical Center • Harborview • UW Medical Center Presented at Washington State Hospital Association Safe Table, July 31, 2013

  12. Optimizing nutrition Smoking Cessation Medications Blood sugar control Presented at Washington State Hospital Association Safe Table, July 31, 2013

  13. Why Nutrition? • Malnutrition is prevalent in surgical patients. • Best determinant of surgical outcome. • Modifiable with appropriate intervention. • Immunonutrition may improve recovery. Presented at Washington State Hospital Association Safe Table, July 31, 2013

  14. Why Blood Sugar? • Link between high blood sugar levels and SSIs • Hyperglycemia - doubled risk of SSI • In some studies 47% of hyperglycemic episodes were in nondiabetics ! • 470 million people worldwide will have prediabetes by 2030 • 5%-10% per year will progress to diabetes • 35% of US adults older than 20 yrs of age and 50% greater than 65 years had prediabetes in 2005-2008 Latham. Inf Contr Hosp Epidemiol. 2001;22:607 Dellinger. Inf Contr Hosp Epidemiol. 2001;22:604 Lancet 2012; 2279-2290 2011 US Department of Health and Human Services Presented at Washington State Hospital Association Safe Table, July 31, 2013

  15. Why Blood Sugar? • > 65 years • 1 in 4 will have diabetes • 2 in 4 are prediabetic 2011 US Department of Health and Human Services Presented at Washington State Hospital Association Safe Table, July 31, 2013

  16. Why Medications? • Some medications and Herbal remedies ↑ risk of bleeding • Aspirin can be safely continued • Beta-blocker continuation associated with fewer cardiac events and mortality Chest 2012; 141:e326S-e350S; JAMA 2008; 300(24):2867-2878; Ann Surg 2012; 255(5):811-819; Arch of Surg 2012; 147(5):467-473 Presented at Washington State Hospital Association Safe Table, July 31, 2013

  17. Why Smoking? • Smoking is prevalent • 1/3 of all patients • Smokers have ↑ risk of complications • Pulmonary • Circulatory • Infectious • Impaired wound healing Presented at Washington State Hospital Association Safe Table, July 31, 2013

  18. Nutrition Screening • Any YES refer to RD • Is BMI less than 19? • Has patient had unintentional weight loss of >8 pounds in 3 months? • Has the patient had a poor appetite eating less than half of meals or fewer than two meals per day? • Is the patient unable to take food orally due to dysphagia or vomiting? Ana Isabel Almeida et al. Clinical Nutrition 31 (2012) 206-211. H.M. Reilly, et al. Clinical Nutrition (1995) 14 269-273.

  19. Risk Stratification • Hypoalbuminemia is an independent risk factor for SSI following surgery Hennessey DB, et al. Ann Surg. 2010;252:325–329. Presented at Washington State Hospital Association Safe Table, July 31, 2013

  20. SCOAP: Albumin & Complicationselective colon/rectal procedures Presented at Washington State Hospital Association Safe Table, July 31, 2013

  21. Presented at Washington State Hospital Association Safe Table, July 31, 2013

  22. Surgery and trauma patients are immune suppressed making them more susceptible to infection due to arginine deficiency. Arginine Deficiency Syndrome Risk of INFECTION T-Cell Dysfunction Immune- modulating formulas containing arginine, n-3 fatty acids, and nucleotides have been specifically designed to help meet the unique nutritional needs of the surgery and trauma population. Popovich 2006; McClave 2009; Zhu 2010 Presented at Washington State Hospital Association Safe Table, July 31, 2013

  23. Literature Review • Systematic Review • N=3,438 • 35 studies focused on elective surgery • Procedure types • 25 GI: 18 upper; 2 lower; 5 mixed • 10 non-GI • 23 – used arginine-based supplements • Pre-Op Use: ↓ Infectious complications 43% Drover JW, et al. JACS 2011; 212 (3):385-399 Presented at Washington State Hospital Association Safe Table, July 31, 2013

  24. Literature Review • Meta-analysis: 26 RCTs • N = 2496 • 1252 Immunonutrition vs 1244 Control (Isocaloric) • ↓ infection rates by 46% • ↓ length of stay ~ 2 days Marimuthu K, et al. Ann Surg 2012; 255:1060-1068 Presented at Washington State Hospital Association Safe Table, July 31, 2013

  25. Goals of Nutrition Target • Universal measurement of albumin • Pre-operative screening for malnutrition • Increase the use of appropriate, evidence-based nutritional support • Malnourished • Complex Surgery Presented at Washington State Hospital Association Safe Table, July 31, 2013

  26. Presented at Washington State Hospital Association Safe Table, July 31, 2013

  27. Checklists

  28. Public Health Campaign • Statewide awareness • Media events • Website • Mobilizing the community • Strategic partnerships • Surveillance and Feedback • Change in behavior Presented at Washington State Hospital Association Safe Table, July 31, 2013

  29. www.strongforsurgery.org Presented at Washington State Hospital Association Safe Table, July 31, 2013

  30. Building a Public Health Campaign:Developing a Social Media Presence • 85 “Likes” across 5 states (and South Africa!) • 115 Posts • Frequency 3/week • 7406 Total Hits • 5123 Unique Hits • 11% of Total Hitsin last month • Group shared with CERTAIN • Discussion post 1-2/month • 824 Tweets • 267 Followers • 246 Following • Frequency ~30/week • 139 Tweets • 226 Followers • 902 Following • Frequency 6/week Presented at Washington State Hospital Association Safe Table, July 31, 2013

  31. Initiating a Public Health CampaignPublications OR MANAGER Presented at Washington State Hospital Association Safe Table, July 31, 2013

  32. Presented at Washington State Hospital Association Safe Table, July 31, 2013

  33. Presented at Washington State Hospital Association Safe Table, July 31, 2013

  34. Data is linked to SCOAP for surgical outcomes evaluation and sent back to the clinicians’ office Patient completes S4S Checklists online prior to preoperative clinic visit, either at home or in the clinic A report of the patient’s answers is delivered to the clinician electronically The clinician reviews with the patient, and documents the preoperative optimization plan The patient is sent reminders about preoperative plan up until the day of surgery Presented at Washington State Hospital Association Safe Table, July 31, 2013

  35. ELECTRONIC CHECKLIST COMPONENTS - NUTRITION Patient Identifiers to Link to SCOAP Height: Feet, Inches Weight BMI Calculation BMI <19? Weight Loss No Poor appetite Yes PO Intolerance Dietitian Referral PATIENT INPUT CLINICIAN INPUT Inpatient operation? No Yes Check Albumin Complex surgery? No Yes Immunonutrition Presented at Washington State Hospital Association Safe Table, July 31, 2013

  36. ELECTRONIC CHECKLIST COMPONENTS - SMOKING Ever Smoked? Other tobacco? No Done Yes to either Time since quitting Smoked Within the Last 30 Days? No Discussion About Quitting Yes Total Years Smoked Set Quit Date Packs Per Day Consider: Quit Line Motivation to quit Consider: NRT High Med Low Consider: Rx No Quit >24h Yes How long ago? Longest time without smoking? Presented at Washington State Hospital Association Safe Table, July 31, 2013

  37. Change System/Individual Behavior • Education • Surveillance and Feedback • Administrative Changes • Peer to peer forces • Penalties • Rewards Presented at Washington State Hospital Association Safe Table, July 31, 2013

  38. Education • Surveillance and Feedback • Administrative Changes • Peer to peer forces • Penalties • Rewards Presented at Washington State Hospital Association Safe Table, July 31, 2013

  39. Get Involved • Attend Campaign Events • E-mail: tkv@uw.edu strongforsurgery@becertain.org • Inform Your Colleagues and Constituents • Visit the website: http://www.strongforsurgery.org Presented at Washington State Hospital Association Safe Table, July 31, 2013

  40. THANK YOU! Presented at Washington State Hospital Association Safe Table, July 31, 2013

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