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

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

Translation of Research into Practice

Research and Development


• Clinician-led QI using clinical data

• Focus on quality and cost-effectiveness• Data

• Impacts behavior through:• Benchmarking• Education• Standard orders• Checklists


BeforeElective Colorectal Resection, CHARS 2000-2003

17.7±38.2%


After Elective Colorectal Resection CHARS 2006-2009

9.6±29.4%


Evidence generationCER/PCOR

Partners in QI and

Research

Evidence into Practice

Clinician Offices

Long-term Care

Hospitals


Focus on Decision Making

PATIENTPATIENT

DOCTOR’S OFFICE

OPERATING ROOM

OPERATING ROOM


PATIENTPATIENT

DOCTOR’S OFFICE

OPERATING ROOM

OPERATING ROOM


PATIENTPATIENT

DOCTOR’S OFFICEDOCTOR’S OFFICE

OPERATING ROOM

OPERATING ROOM

Focus on Decision Making in Clinic



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


Optimizing nutrition

Smoking Cessation

Medications

Blood sugar control


Why Nutrition?

• Malnutrition is prevalent in surgical patients.• Best determinant of surgical outcome.

• Modifiable with appropriate intervention.• Immunonutrition may improve recovery.


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;22:607Dellinger. Inf Contr Hosp Epidemiol. 2001;22:604Lancet 2012; 2279-22902011 US Department of Health and Human Services


Why Blood Sugar?

• > 65 years• 1 in 4 will have diabetes

• 2 in 4 are prediabetic

2011 US Department of Health and Human Services


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


Why Smoking?

• Smoking is prevalent• 1/3 of all patients

• Smokers have ↑ risk of complicationsPulmonaryCirculatoryInfectiousImpaired wound healing


Nutrition Screening

• Any YES refer to RD

1. Is BMI less than 19?

2. Has patient had unintentional weight loss of >8 pounds in 3 months?

3. Has the patient had a poor appetite eating less than half of meals or fewer than two meals per day?

4. 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.

Risk Stratification

• Hypoalbuminemia is an independent risk factor for SSI following surgery

Hennessey DB, et al. Ann Surg. 2010;252:325–329.


SCOAP: Albumin & Complicationselective colon/rectal procedures



Arginine Deficiency Syndrome

T-Cell Dysfunction

Risk of INFECTION

Surgery and trauma patients are immune suppressed making them more susceptible to infection due to arginine deficiency.

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 2010Presented at Washington State Hospital Association Safe Table, July 31, 2013

• 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%

Literature Review

Drover JW, et al.JACS 2011; 212 (3):385-399


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


Goals of Nutrition Target

Universal measurement of albuminPre-operative screening for malnutrition Increase the use of appropriate, evidence-based

nutritional supportMalnourishedComplex Surgery



Checklists

Public Health Campaign

• Statewide awareness• Media events• Website

• Mobilizing the community• Strategic partnerships

• Surveillance and Feedback• Change in behavior


www.strongforsurgery.org


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 Hits

in last month

• Group shared with CERTAIN• Discussion post 1-2/month

• 139 Tweets• 226 Followers• 902 Following• Frequency 6/week

• 824 Tweets• 267 Followers• 246 Following• Frequency

~30/week


Initiating a Public Health CampaignPublications

OR MANAGEROR MANAGER




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

Data is linked to SCOAP for

surgical outcomes evaluation and

sent back to the clinicians’ office


Height: Feet, Inches Weight

Weight Loss

Poor appetite

PO Intolerance

Inpatient operation?

Complex surgery?

BMI CalculationBMI <19?

YesYesNoNo

YesYesNoNo

YesYesNoNo

Dietitian Referral

Check Albumin

Immunonutrition

ELECTRONIC CHECKLIST COMPONENTS - NUTRITIONELECTRONIC CHECKLIST COMPONENTS - NUTRITION

Patient Identifiers to Link to SCOAP

PATIENT INPUT

CLINICIAN INPUT


ELECTRONIC CHECKLIST COMPONENTS - SMOKINGELECTRONIC CHECKLIST COMPONENTS - SMOKING

Ever Smoked?

Smoked Within the Last 30 Days?

Total Years Smoked

Packs Per Day

Quit >24h

Yes to eitherYes to either

NoNo

YesYes

YesYes

NoNo

NoNo

Done

Discussion About Quitting

Consider: Quit Line

Consider: NRT

Consider: Rx

Set Quit Date

Motivation to quit

LowLowMedMedHighHigh

How long ago?

Longest time without smoking?

Time since quitting

Other tobacco?


Change System/Individual Behavior

• Education• Surveillance and Feedback• Administrative Changes• Peer to peer forces• Penalties• Rewards


• Education• Surveillance and Feedback• Administrative Changes• Peer to peer forces• Penalties• Rewards


Get Involved

• Attend Campaign Events• E-mail: [email protected] [email protected]• Inform Your Colleagues and Constituents

• Visit the website: http://www.strongforsurgery.org


mailto:[email protected]

mailto:[email protected]

http://www.becertain.org/strong_for_surgery

http://www.becertain.org/strong_for_surgery

THANK YOU!


Documents

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