Using Your Hospitals Data for Research. Elizabeth C. Wick, MD

Transcription

1 Using Your Hospitals Data for Research Elizabeth C. Wick, MD

2 Disclosure I have no formal training in health services research We are not successful at securing resources

3 6: Wick EC, Hicks C, Bosk CL. Surgical site infection monitoring: are 2 systems better than 1? JAMA Surg Dec;148(12): doi: /jamasurg PubMed PMID: : Melton GB, Vogel JD, Swenson BR, RemziFH, RothenbergerDA, Wick EC. Continuous intraoperative temperature measurement and surgical site infection risk: analysis of anesthesia information system data in 1008 colorectal procedures. Ann Surg Oct;258(4):606-12; discussion doi: /SLA.0b013e3182a4ec0f. PubMed PMID: publications in 2 years 8: Hechenbleikner EM, Makary MA, Samarov DV, Bennett JL, Gearhart SL, Efron JE, WickEC. Hospital readmissionby methodof data collection. J Am CollSurg Jun;216(6): doi: /j.jamcollsurg Epub 2013 Apr 11. PubMed PMID: With Just Our Hospital Data 9: MonnMF, Haut ER, Lau BD, StreiffM, WickEC, EfronJE, GearhartSL. Is venous thromboembolism in colorectal surgery patients preventable or inevitable? One institution's experience. J Am Coll Surg Mar;216(3): e1. doi: /j.jamcollsurg Epub 2013 Jan 9. PubMed PMID: : WickEC, HobsonDB, BennettJL, DemskiR, MaragakisL, GearhartSL, EfronJ, Berenholtz SM, Makary MA. Implementation of a surgical comprehensive unit-based safety program to reduce surgical site infection

4 1: Hicks CW, Frank SM, WaseyJO, EfronJ, Gearhart S, Fang S, Safar B, MakaryMA, Wick EC. A Novel Means of Assessing Institutional Adherence to Blood Transfusion Guidelines. Am J Med Qual Jul 17. pii: [Epub ahead of print] PubMed PMID: : Lucas DJ, Haut ER, Hechenbleikner EM, Wick EC, Pawlik TM. Avoiding Immortal Time Bias in the American College of Surgeons National Surgical Quality Improvement Program Readmission Measure. JAMA Surg Jul 2. doi: /jamasurg [Epub ahead of print] PubMed PMID: : LamoreRF 3rd, HechenbleiknerEM, Ha C, SalvatoriR, Harris LH, MarohnMR, Gearhart SL, Efron JE, Wick EC. Perioperative Glucocorticoid Prescribing Habits in Patients With Inflammatory Bowel Disease : A Call for Standardization. JAMA Surg Mar 19. doi: /jamasurg [Epubahead of print] PubMed PMID: : Johnston FM, TergasAI, Bennett JL, Valero V 3rd, Morrissey CK, Fader AN, Hobson DB, Weaver SJ, Rosen MA, Wick EC. Measuring Briefing and Checklist Compliance in Surgery: A Tool for Quality Improvement. Am J Med Qual Nov 22. [Epub ahead of print] PubMed PMID: : Lee KK, BerenholtzSM, Hobson DB, DemskiRJ, Yang T, Wick EC. Building a business case for colorectal surgery quality improvement. Dis Colon Rectum Nov;56(11): doi: /DCR.0b013e3182a4b973. PubMed PMID:

5 Objectives Outline general hospital data structure and opportunities for research Describe different uses for hospital data for research questions Outline first steps for getting started

6 Audience Question Who has published a QI project? Who has presented a project at a national or regional meeting?

7 This is the type of research we all can do! Most rewarding when you ask questions relevant to your patients Change processes that improve the care of your patients! Win-Win Planning a well-designed study will enable results to be helpful to others Consider including frontline providers who are not traditionally included in research projects OR nurses, hospital finance, pharmacists etc. Share!

8 STEP 1 SITUATIONAL AWARENESS OF AVAILABLE DATA AND PEOPLE BEHIND THE DATA

9 SILOS!!!

10 Data Clinical Epic: challenge Sunrise: challenge Central IT Metavision(anesthesia): Anesthesia data manager Drugs: Pharmacy Pathology (in our hospital, only link to social security death registry) Administrative Datamart(administrative): Hospital Operations UHC (your hospital and comparators) or Premier State data (HSCRC) Other Patient Satisfaction (HCAHPS/PG): Central leadership Finance/Billing: CFO office Registries (NSQIP, STS, UNOS, Trauma, VQI etc)

11 Build Collaborative Relationship Consider data resources as collaborators Seek guidance in data use Include in your projects Acknowledge in presentations and publications

12 STEP 2 THINKING ABOUT YOUR RESEARCH QUESTION

13 Identify Area of Focus Review NSQIP data outcome areas that need improvement SSI: develop longterm program to reduce colorectal SSI UTI: identify risk factors for UTI at our hospital Align with hospital areas of focus Improving value in healthcare: enhanced recovery Decreasing provider variability: standardize perioperative steroid dosing Improving throughput and care coordination: medical surgical care of Crohn s disease patients Follow up on a small piece of a large hospital initiative Readmissions We have used our hospital NSQIP data as a starting point for all of the above projects

14 What is your hypothesis? What gap in knowledge or practice do you want to address: Colorectal CUSP can reduce SSI Medical students placing foleysis associated with increased risk of CAUTI There is wide variability in steroid prescribing practices Administrative and NSQIP data will not align for hospital readmissions

15 Retrospective or Prospective Who do you need on your team? Will you review your practice in area and identify deficiencies? Data abstractor if variables not already captured Data analyst if linkage of datasets required Statistical analysis Will you implement a change in process and measure pre and post intervention? Follow principles of quality improvement Develop your QI team Ensure rigorous data collection Data analyst if linkage of datasets required Statistical analysis

16 What procedure or patient group will you study? Patient list Personal case lists Clinical database maintained by surgeons Procedure NSQIP (CPT code) hospital billing data (APR-DRG or MS-DRG) Diagnosis Hospital billing (ICD-9 code)

17 Data Points Manual data abstraction vs. electronic pull from clinical documentation Clear definitions for each data point EXAMPLE: To establish early post operative resumption of diet 1. Ordered or documentation of consumption? 2. If consumption, volume important?

18 Data Management MS Excel MS Access Database programs Redcap If manual data extraction, sometimes helpful to develop a data abstraction tool Reminder: Most times hospital level data will have patient information (name, MRN). Store data on a secure server and avoid laptops if possible.

19 Patient Information Procedure: Date of Procedure: Surgeon: Surgical Site Infection (SSI) Process Measures Data Collection Anesthesia and Nursing Team Member Compliance Key measures: Name of the primary anesthesia and nursing providers for the procedure? Were they members of the dedicated SSI reduction team? Key measures: What perioperative intravenous antibiotics (ABX) were administered (1 and 2, if applicable)? Anesthesia Provider name: CUSP/SSI team member? Nursing Provider name: CUSP/SSI team member? Antibiotic Selection ABX 1 Name: Appropriate ABX for procedure? ABX 2 Name: Appropriate ABX for procedure? What antibiotic dose was given? Relationship of ABX administration to time of surgical incision? Dose of ABX 1: Appropriate dose? Administered ABX 1 Infusion Stop Time : am/pm Dose of ABX 2: Appropriate dose? Administered ABX 2 Infusion Stop Time : am/pm ABX infusion stop time compared to surgical incision time: Key measures: Antibiotic Redosing if appropriate? Anesthesia Stop Time - ABX 1 st Dose Infusion Stop Time Assess if ABX redosing necessary and if appropriate timing? ABX 2 nd Dose Infusion Stop Time ABX 1 st Dose Infusion Stop Time Continue to check all redoses given accordingly. Key measure: Was forced air warming device started in the preanesthesia holding area? Key measure: What was the patient s temperature at time of surgical incision and on arrival to the recovery room? Key measure: Were chlorhexidine washcloths used prior to surgery? Key measures: What skin preparation was used in the operating room? Who applied the skin preparation? Was this person trained for skin preparation? Key measure: Did the patient use a mechanical bowel preparation with oral antibiotics prior to surgery? Incision Time : am/pm Was ABX 1 given < 60 minutes prior to incision? ABX Infusion Stop Time (ABX 1) of doses: 1 st : am/pm 2 nd : am/pm 3 rd : am/pm Was the ABX redosed if appropriate? Was the ABX redose timing correct? Temperature Management Pre-anesthesia active warming? At Incision: C (Celsius) At Arrival to Recovery room: C Surgical Site Skin Preparation Night before surgery: Incision Time : am/pm Was ABX 2 given < 60 minutes prior to incision? ABX Infusion Stop Time (ABX 2) of doses: 1 st : am/pm 2 nd : am/pm 3 rd : am/pm Was the ABX redosed if appropriate? Was the ABX redose timing correct? Morning of surgery: (Circle all that apply) Chloraprep Duraprep Betadine Other preparation: Name: Title/Role: Dedicated CUSP/SSI team member? Person Trained for skin preparation? Preoperative Bowel Preparation Mechanical bowel preparation: Oral antibiotics: Hechenbleikner et al DCR in press

20 IRB approval Research vs. Quality Improvement Many IRBs have guides Contact office if questions Does my quality improvement project need IRB approval? Chose one of the following categories for your project: (1) All project activities are intended to answer questions that are initiated by a JHHSC hospital or safety committee and concern that entity s own operations, OR the activities address a question that is within the project leader s job description to answer for a JHHS entity s safety or quality purposes. Is the project funded through a grant or NO YES IRB submission not required NO Are any of the following TRUE: The activity uses a fixed clinical protocol that may not be altered by caregivers and staff; The activity has objectives other than producing an improvement in safety or care that will be sustained over time (e.g., study will compare outcomes without a clear intent to implement the superior intervention); The activity involves non-jhhsc sites; The activity involves a randomized intervention, or The activity involves an intervention that poses risks greater than those presented by routine clinical care. YES Submit IRB application (2) The project was initiated by (or will be undertaken in cooperation with) a product manufacturer or other outside entity. Has the JHHS legal department approved a contract or agreement for this project? NO NO Consult JHHS Legal Department YES In the view of JHHS legal, does the project involve human subjects research? NO YES IRB submission not required Submit IRB application (3) The project is limited to analyzing existing data from a QA/QI project previously conducted at a JHHSC entity (data must exist when the project begins). Will the PI or any study team member access identifiable research or clinical records in connection with this project? NO YES IRB submission not required Submit IRB application (4) The project involves an IND/IDE. YES Submit IRB application (5) None of these categories fully describes the project. Consult OHSR for further assistance. IDE= Investigational Device Exemption, IND= Investigational New Drug, IRB= Institutional Review Board, JHHC= Johns Hopkins Health System, JHHSC= Johns Hopkins Health System Corporation, OHSR= Office of Human Subjects Research, QA/QI= Quality Assurance/Quality Improvement

21 Data Analysis Start with average (mean) and median Surprising results (good or bad) take back to relevant providers or patients and try to further understand If no team member proficient with statistical analysis, identify resources in hospital to help

22 Share your findings! Journals For Hospital Quality Projects Journal of the Joint Commission Especially tools Journal of Patient Safety American J. Medical Quality Forums for Presenting Results Hospital meetings Regional ACS, AORN etc NSQIP meeting ACS Surgical Forum (residents)

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24 Pearls 1. If your hospital has a unique visit identifier consider including in one of your custom NSQIP fields 2. If using survey data as part of your study (HCAPS, safety culture etc) print a copy of the survey and review the questions and wording closely for some questions low score is GOOD 3. Engage students, QI specialists, nurse educators etc they may be able to help with manual data collection in exchange for being a team member

25 Challenge for All Rigorously design a hospital QI/ research project and submit an abstract to NSQIP Meeting 2015!!!