Using the American College of Surgeons Strong for Surgery Toolkit to Optimize Patients for Surgery

Transcription

1 Using the American College of Surgeons Strong for Surgery Toolkit to Optimize Patients for Surgery April A partnership of the Healthcare Association of New York State and the Greater New York Hospital Association

2 NYS PARTNERSHIP FOR PATIENTS Agenda Topic Welcome and Introductions SSI Rates in New York Speaker NYSPFP Staff NYSPFP Staff Optimizing Peri-Operative Outcomes: Strong for Surgery Public Health Campaign Hospital Questions and Discussion Next Steps Thomas K. Varghese, Jr., MD, MS, Co-Director of the Thoracic Oncology Program and Associate Professor of Surgery, University of Utah, Hospital Participants Facilitated by NYSPFP Staff NYSPFP Staff 2

3 NYS PARTNERSHIP FOR PATIENTS Why Focus on Surgical Site Infections? 2.6% of 30 million operations per year are complicated by SSI (800,000 2 million SSI annually) SSI accounts for 38% of HAI in surgical patients SSIs are associated with: Increased length of stay Increased hospital costs (estimated increase of $1,300 $5,000 per case) Increased patient morbidity and mortality Increased readmission rates 3

4 NYS PARTNERSHIP FOR PATIENTS NYSPFP SSI SIR: Colon 4

5 NYS PARTNERSHIP FOR PATIENTS NYSPFP SSI SIR: Hip Replacement 5

6 NYS PARTNERSHIP FOR PATIENTS NYSPFP SSI SIR: CABG 6

7 NYS PARTNERSHIP FOR PATIENTS NYSPFP SSI SIR: Hysterectomy 7

8 NYS PARTNERSHIP FOR PATIENTS Surgery Bundle Elements Applicable Across Multiple Surgical Service Lines 8

9 NYS PARTNERSHIP FOR PATIENTS Implementation of Cross Applicable Bundle Elements Surgical subspecialties where implementation of bundle has begun % of hospitals that have started implementation in NYSPFP (n=108)* Hysterectomy 50% Cardiac Surgery 15% Orthopedics (Hip/Knee prosthesis) 57% Our hospital has not begun implementation of the colon bundle on any other surgical subspecialties 23% Other 15% 9

10 NYS PARTNERSHIP FOR PATIENTS NYSPFP Advanced Bundle Pre-operative Interventions 10

11 NYS PARTNERSHIP FOR PATIENTS NYSPFP Advanced Bundle Pre-operative Interventions 11

12 Optimizing Peri-Operative Outcomes: Strong for Surgery Public Health Campaign Thomas K. Varghese, Jr., MD, MS American College of Surgeons University of Utah 12

13 Optimizing Peri-Operative Outcomes Strong for Surgery Public Health Campaign Thomas K. Varghese Jr. MD, MS, April 9,

14 Initial Funding: 2012 to 2015 AHRQ Life Sciences Discovery Fund UW Dept of Surgery UW Patient Safety Innovation Program QI Programs Nutrition: Nestle HealthCare Opioid Minimization: Pacira Plan My Quit Pfizer 14

15 Quality Program of the AC 15

16 Problems Every year there are 210,000 Preventable Deaths ½ associated with an operation $30 billion per year J Patient Safety Sept 2013; 9(3): Wick EC, et al. 2011; 54(12): Eappen S JAMA. 2013;309(15):

17 Problems Every year there are 210,000 Preventable Deaths ½ associated with an operation $30 billion per year 1 in 4 colon resections readmitted within 90 days $300 million per year Soft Tissue Surgical Site Infections $3 billion in direct costs J Patient Safety Sept 2013; 9(3): Wick EC, et al. 2011; 54(12): Eappen S JAMA. 2013;309(15):

18 Generation of Evidence 18

19 Reality 15 to 17 years before findings from RCTs and cohort studies implemented into clinical practice. Healthcare is inefficient. JAMA 1999; 282: ; Health Professions Education 2003 J Am Med Inform 2001; 8(4): N Engl J Med 2003; 348:

20 Quality Practice Improvement (QPI) Science that defines tools and implements solutions to translate evidence-based knowledge into actionable items for effective incorporation into daily clinical practice. 20

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23 JAMA 2015; 313(5):

24 Surgical Outcomes 263 NSQIP hospitals 526 non-nsqip Mortality 4.9% 5.0% Serious Complications 11.3% 10.2% Reoperation 0.5% 0.5% Readmissions 13% 12.6% JAMA 2015; 313(5):

25 Feedback of outcomes alone may not be sufficient to improve surgical outcomes JAMA 2015; 313(5):

26 Focus on Decision Making 26

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28 Focus on Decision Making in Clinic 28

29 Raising Awareness Changing Practice 29

30 Pilot Year

31 Pilot Year

32 Behavior Change in the 21 st Century Public health campaign focused on surgeons, patients and other important stakeholders Implementation Bundles Interactive tools (checklists) to help optimize patients prior to surgery Integrated into workflow Surveillance and data feedback + 32

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34 Why Blood Sugar? Latham. Inf Contr Hosp Epidemiol. 2001;22:607 Dellinger. Inf Contr Hosp Epidemiol. 2001;22:604 Lancet 2012; US Department of Health and Human Services

35 Why Blood Sugar? Hypergycemia doubles the risk of SSI In some studies 47% of hyperglycemic episodes in nondiabetics Latham. Inf Contr Hosp Epidemiol. 2001;22:607 Dellinger. Inf Contr Hosp Epidemiol. 2001;22:604 Lancet 2012; US Department of Health and Human Services

36 Latham. Inf Contr Hosp Epidemiol. 2001;22:607 Dellinger. Inf Contr Hosp Epidemiol. 2001;22:604 Lancet 2012; US Department of Health and Human Services Why Blood Sugar? Hypergycemia doubles the risk of SSI In some studies 47% of hyperglycemic episodes in nondiabetics 470 million people worldwide Prediabetes by % of US adults 20 yrs Prediabetes 50% greater 65 years

37 Why Blood Sugar? > 65 years 1 in 4 will have Diabetes 2 in 4 are Prediabetic 2011 US Department of Health and Human Services

38 Why Medications? Some meds & herbal remedies risk of bleeding Echinacea, Garlic, Ginkgo, Ginseng, Kava, Saw Palmetto, St. John s Wort, Valerian Chest 2012; 141:e326S-e350S; JAMA 2008; 300(24): ; Ann Surg 2012; 255(5): ; Arch of Surg 2012; 147(5):

39 Why Medications? Some meds & herbal remedies risk of bleeding Echinacea, Garlic, Ginkgo, Ginseng, Kava, Saw Palmetto, St. John s Wort, Valerian Aspirin can be safely continued Beta-blocker continuation associated with fewer cardiac events and mortality Chest 2012; 141:e326S-e350S; JAMA 2008; 300(24): ; Ann Surg 2012; 255(5): ; Arch of Surg 2012; 147(5):

40 Adjusted Odds Ratio Complications Associated with Smoking Why Smoking? Never Smoker Prior Smoker Current Smoker 0 All Patients Neurosurgery Orthopedic Mary T Hawn et al., The Attributable Risk of Smoking on Surgical Complications, Annals of Surgery 254, no. 6 (December 2011):

41 Post-Operative Outcomes by Pack-Years Smoked Adjusted Odds Ratio Surgical Site Infection Pulmonary 30-day Mortality >60 Mary T Hawn et al., The Attributable Risk of Smoking on Surgical Complications, Annals of Surgery 254, no. 6 (December 2011):

42 Why Nutrition? Malnutrition is prevalent in surgical patients Immunonutrition may improve recovery 42

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44 Nutrition Screening Any YES refer to RD/Nutrition Specialist Ana Isabel Almeida et al. Clinical Nutrition 31 (2012) H.M. Reilly, et al. Clinical Nutrition (1995)

45 Nutrition Screening Any YES refer to RD/Nutrition Specialist 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) H.M. Reilly, et al. Clinical Nutrition (1995)

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47 Risk Stratification Hypoalbuminemia is an independent risk factor for SSI following surgery Hennessey DB, et al. Ann Surg. 2010;252:

48 SCOAP: Albumin & Complications Elective colon/rectal procedures 15.0% Adverse Outcome Rates 12.0% 9.0% 6.0% 3.0% 0.0% < Albumin Levels (g/dl) Re-operation Death 48

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50 Surgery and trauma patients are immune suppressed making them more susceptible to infection due to arginine depletion. Popovich 2006; McClave 2009; Zhu

51 Surgery and trauma patients are immune suppressed making them more susceptible to infection due to arginine depletion. Immune- modulating formulas Arginine + Ω-3 fatty acids + Nucleotides 5 to 7 day regimen, 3 times daily Popovich 2006; McClave 2009; Zhu

52 Literature Review Systematic Review N=3, 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):

53 Literature Review Meta-analysis: 26 RCTs N = Immunonutrition vs 1244 Control (Isocaloric) infection rates by 46% length of stay ~ 2 days Marimuthu K, et al. Ann Surg 2012; 255:

54 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 54

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56 Focus on Four Modifiable Areas: 56

57 Checklists 57

58 Program Implementation Hospital/Clinic Expectations: Change team formation Commitment through postimplementation Strong For Surgery: Workflow Mapping 58

59 Change Team Components 59

60 CHANGE TEAM Executive Sponsors: CMO and CNO 60

61 Raising Awareness a Roadmap 61

62 Raising Awareness a Roadmap 62

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66 Measurable Impact 66

67 Reach 67

68 Global Impact Online Outreach Since Launch 173,519 total page views 122,038 Unique Page views Implementation Guide requests 2013 to sites, 15 countries 68

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71 Media

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75 Effectiveness 75

76 Clinician-led QI using clinical data Focus on quality and cost-effectiveness data Impacts behavior through: Benchmarking Education Standard orders Checklists 76

77 Launched in years before launch: Composite Adverse Event rates for Colorectal Surgery around 19% 3 years after launch: Composite Adverse Event rates for Colorectal Surgery around 9.8% 77

78 SCOAP Immunonutrition Use Q S4S Hospitals 85.4% (540/632) Elective Colorectal Procedures (w/anastomosis) Thornblade L, Varghese T, et al. Dis Col Rectum 2017; 60(1):

79 SCOAP Immunonutrition Use Q S4S Hospitals 85.4% (540/632) Elective Colorectal Procedures (w/anastomosis) Composite Adverse Event Rates (Reintervention, Infection, Anastomotic Leak ± death) [Q to Q4 2014] n=8,680 Patient who did not receive immunonutrition: 9.5% Patients receiving immunonutrition: 7.0%* Thornblade L, Varghese T, et al. Dis Col Rectum 2017; 60(1):68-75 p =

80 SCOAP Immunonutrition Use Propensity Score Matching (346 pts each group) CAE No immunonutrition: 11.6% Immunonutrition use: 7.2% (p=0.05) Length of stay No immunonutrition: 6.9 days Immunonutrition use: 5.8 days (p<0.01) Thornblade L, Varghese T, et al. Dis Col Rectum 2017; 60(1):

81 Decrease in Smoking Rates 25.6% in Q4 of 2011 to 15.8% in Q2 of Percentage of cigarette smokers among spine cases over time % cigarette smokers Q Q2 Procedure Date 81

82 World J Surg ;

83 Peri-Operative Glucose Guidelines Franciscan Health System Harrison Medical Center MultiCare Health System PeaceHealth Southwest Medical Center Providence Regional Medical Center Skagit Valley Hospital Swedish UW Medical Center UW Harborview Medical Center Virginia Mason Presented at Washington State Hospital Association Safe Table on April 23,

84 Optimizing Peri-Operative Glucose 2014 Best Practices 84

85 Adoption 85

86 Collaborators Washington State Medical Association Washington State Hospital Association Washington State Nurses Association Washington State Academy of Nutrition and Dietetics Washington Patient Safety Coalition Washington State Society of Anesthesiologists Washington St. Chapter American College of Surgeons Qualis Health American Lung Association American College of Surgeons 86

87 Pilot Year

88 practices, practices, surgeons surgeons General, Colorectal, Bariatric, Spine, Vascular Surgery 88 General, Colorectal, Plastic, Bariatric, Spine, Thoracic, Vascular Surgery

89 Implementation 89

90 Phases of Implementation Explore Needs Assessment Engage with stakeholders, Form relationships, Identify local barriers 90

91 Phases of Implementation Explore Needs Assessment Engage with stakeholders, Form relationships, Identify local barriers 91

92 Phases of Implementation Explore Needs Assessment Engage with stakeholders, Form relationships, Identify local barriers Initiate Action Convene Change Team Focus on initial team & infrastructure 92

93 Phases of Implementation Explore Needs Assessment Engage with stakeholders, Form relationships, Identify local barriers Initiate Action Convene Change Team Focus on initial team & infrastructure Learn Together Surveillance and Feedback Action plans for maintenance 93

94 Medical Assistants Surgeons +/- Residents, PAs Clinic Nurses Anesthesia/ PreOp Clinic Virtual Check-listing (prior to surgery) 94

95 Clinic Nurses Surgeons +/- Residents, PAs Anesthesia/ PreOp Clinic 95

96 Implementation Factors for Success Recent completed QI projects Leadership support Alignment ERAS SSI programs Change team met at frequent intervals, surveillance & feedback 96

97 Implementation Barriers EMR or other projects competing for staff time & attention Change in Leadership Friction b/w surgeon and hospital Independent surgeon practices 97

98 Maintenance Any Nutrition Intervention Elective Colorectal Procedures: Cumulative Number of Cases Q1 12 Q2 12 Q3 12 Q4 12 Q1 13 Q2 13 Q3 13 Q4 13 Q1 14 Q2 14 Q3 14 Q4 14 Quarter 98

99 Maintenance 99

100 Raising Awareness Changing Practice 100

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105 Pre Op, Immediate Pre Op, Intraoperative, Post Op, Post Discharge 105

106 Pre Op, Immediate Pre Op, Intraoperative, Post Op, Post Discharge 106

107 Pre Op, Immediate Pre Op, Intraoperative, Post Op, Post Discharge 107

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115 National/International Pilot Sites Christus Health Texarcana, TX Horizon Health Network St. John, Canada Wake Forest Baptist Hospital Winston Salem, ND Rochester Regional Hospital Rochester NY 115

116 150 sites from WA state 4 national pilot sites 36 sites accessed the toolkit 40 additional sites nationally registering End of Year Projection: 230 sites implementing S4S 116

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123 Hospital Discussion and Questions Hospital Participants Facilitated by NYSPFP Staff

124 Thank 124

125 NYS PARTNERSHIP FOR PATIENTS Next Steps Contact your project manager to discuss: Using the Strong for Surgery Toolkit to implement pre-operative optimization for elective surgery patients. Hardwiring the Advanced Colon Bundle Elements into workflow and expanding to other types of surgery if you have not already 125

126 Workflow Mapping Maximize patient value + eliminate waste Optimize the flow of services through the system Map out processes Identify value & non-value steps Create implementation bundles incl. Checklists Empower staff 126