Perspectives on Quality and Implementation of Best Practice

1. Perspectives on Quality and Implementation of Best Practice The CAEP Perspective Jim Ducharme MD CM FRCP Vice President IFEM Past President CAEP Editor-in-Chief CJEM

2. “Science is a noble endeavor, but it’s also a low-yield endeavor” “I’m not sure that more than a very small percentage of medical research is ever likely to lead to major improvements in clinical outcomes and quality of life. We should be very comfortable with that fact.” John Ioannidis November 2010

3. Can we expect research to ‘prove’ how to do it the right way? • “Ioannidis and his team have shown, again and again, and in many different ways, that much of what biomedical researchers conclude in published studies… is misleading, exaggerated, and often flat-out wrong. He charges that as much as 90 percent of the published medical information that doctors rely on is flawed.” The Atlantic, Nov 2010

4. Translating knowledge to best clinical practice • Changing process vs. changing outcomes • Unintended consequences • Implementation of a process to help one clinical presentation may negatively impact another presentation • E.G. :Trauma codes delay time to thrombolysis for STEMI if both present at the same time

5. A Canadian Example • A centralized cardiac cath centre receives patients directly from EMS if ST elevation on ECG • Circle of 100 km diameter around centre • Bypass all hospitals, even ED at cath centre • Lauded in papers, absolute decrease in mortality for those STEMI patients

6. However • Small communities were left without ambulance coverage for 3-4 hours at a time. • No one measured impact on mortality on patients with no access to EMS for extended periods • No one is following local MD ability to manage chest pain now that acute cases no longer seen • So how many people are really being saved?

7. Implementing best practice • A comprehensive, guideline-driven, evidence-based approach to clinical practice is feasible within the structure of a department of emergency medicine Ann Emerg Med 2008;51:80-86 • There is a need for physician buy-in, communication, planning for unintended consequences and management of expectations. Healthcare Quarterly. 2009;12:70-7

8. The Ian Stiell Influence in Canada • Best Practice as determined by clinical decision rules • Requires willingness of clinicians to apply these rules • Canada vs. USA • Limited to ‘simple’ decisions • Yes/No • X-ray or not

9. External factors limiting best practice • Overcrowding in Canada • M Schull, G. Innes and others • National guidelines not applicable to all sites • E.g. CAEP sepsis guideline recommends certain steps not practical or feasible in small community or rural sites • Are best practice standards transferable to all hospitals?

10. Pay for Performance? • Idea not in place in EM in Canada • Is present in Family Medicine • In many ways a misleading proposal • Fixed capital available for health care, most trying to decrease costs • Pay for performance: extra pay for some items must mean less funds for other areas • Negative impact elsewhere – unintended consequence • Who chooses which items deserve greater funding if done well?

11. CAEP’s (lack of) impact on Best Practice • Minimal guidelines current • Mandate to establish best practice patterns not entrenched as a key foundation in CAEP • Cost of effort without pharmaceutical influence prohibitive

12. Schull MJ, Hatcher CM, Guttmann A, Leaver CA, Vermeulen M, Rowe BH, Anderson GM, Zwarenstein M. Development of a Consensus on Evidence-Based Quality of Care Indicators for Canadian Emergency Departments. ICES Investigative Report. Toronto: Institute for Clinical Evaluative Sciences; 2010. Mandatory collection of consistent and comprehensive ED quality of care information is strongly recommended.

13. Highest Priority Indicators • ED Operations • ED length of stay (LOS) • BMJ 2011; 342 doi: 10.1136/bmj.d2983 (Published 1 June 2011) Guttman, Schull, Vermeulen et al • Patient Safety • Percentage of patients with an unplanned return visit to the ED • LWBS however does not seem to impact outcomes • Pain Management • Time to first dose of analgesic in all painful conditions requiring analgesia • Pediatrics • Septic work up and treatment less than 28 days, steroids for croup

14. Cardiac • % AMI receiving thrombolysis or PCI • Respiratory • % patients with asthma who received corticosteroids in the ED and at discharge • Stroke • Percentage of eligible patients with acute stroke who received tissue plasminogen activator (tPA); • Sepsis/Infection • Time to antibiotics in patients with bacterial meningitis; % patients with sepsis who received antibiotics within 4 hours

15. A. Drummond,Chair of CAEP Advocacy Committee • The CAEP message is one of political engagement and advocacy. • Managing the crisis (G. Innes, E. Grafstein) and researching the topic (M. Schull) are important but the overcrowding crisis has to be solved (political) • Politicians that control the dollars and the programs do not read research • Somebody has to translate this to politicians and policy gurus. • Emergency physicians have a lot of credibility in the halls of power.  Harness it.

16. Data Collection • What is Best Practice? It depends on who is reading data. • Accountant finds closed beds and crowded ED makes financial sense • Hospital administrator may consider elective surgery wait times greater priority than ED wait times • How do death rates in ED compare to death rates of patients waiting for surgery?

17. Cannot be studied in isolation • What we do costs money. • Fixed (and decreasing) hospital budgets in Canada • Establishing standards of care in ED • Has to be done in concert with rest of hospital • Will have impact elsewhere in hospital

18. More emergency physicians • Need to be involved in systems research • Need to be involved in discussions of cost effective care • We will have to not provide certain aspects of care • Cannot discuss best practice without including this aspect

19. Best Practice Conundrum • A patient with thrombocytopenia requires a medication (romiplostim) to stay alive – cost 100K per year • This is considered best practice in hematology • Is it best practice if looked at within the scope of all of health care? • How many more lives could be saved using that 100K elsewhere within the healthcare system?

20. In closing • Evidence based decision rules can provide best practice guidance • We have to be very cautious at applying research results blindly to patient care • We cannot practice within a vacuum: we need to consider how what we do impacts others within healthcare • Political lobbying is essential • Translating knowledge into practice is still laborious