Clinical Standardization Joe Sharma, MD, FACS, FACE Associate Professor of Surgery Director, of Endocrine Surgery Chief Quality Officer Emory University School of Medicine
Disclosures Engineer US Navy Surgery
Goals Value of Clinical Standardization in QI Driving Clinical Standardization for improved efficiency
Electrical Engineer Engineering standards are documents that specify characteristics and technical details that must be met by the products, systems and processes that the standards cover.
Healthcare Definition clinical standardization is the establishment of standards and protocols for caregivers to follow when treating patients in order to reduce unnecessary costs, to avoid unwarranted variation in treatment, and to improve patient care and caregiver accountability. Standards Evidence Based Medicine Clinical Pathways Algorithms Variation Reduction Pubmed 4179 Clinical Trials 19013 Surgery Standard Papers 39 Studies on OR Efficiency
Benefits of Standardization Reliable/high quality care Measurable and reproducible care Complex Decision Making Reviewed & Challenged Value-Equation
WHO Goals Priorities Global Patient Safety Intitiative Five High 5s priority risk areas Managing concentrated injectable medicines (concentrated injectables). Assuring medication accuracy at transitions of care (medication reconciliation). Performance of the correct procedure at the correct body sites (correct site surgery). Communication during patient care handovers. Improved hand hygiene to prevent health care-associated infections. International Journal for Quality in Health Care, April 2014
Patient Centered Healthcare & Clinical Practice Guidelines Efficacy Desired Outcome Efficiency Effectiveness Optimization Acceptability Equity Resource Utilization Improved Health Value/balance/spread Expectation Fairness & Distribution
Clinical Practice Standards & ACS Programs
Standard setting research
Variation in Practice Thyroid Cancer
Why do we not see greater application of standards in frontline care?
Standards Adoption on Frontline Lack of Awareness/training Mistrust lack of validation Not Highly Reliable due to human factors (not technologically innovative) Limited shelf-life Culture Infrastructure Implementation
Predicted Outcome Evidence Based Practice Guidelines Proper Implementation Unexpected Outcome Unnecessary Resource Utilization Information is never captured Deviation (Knowledge or Innovation)
Predicted Outcome Evidence Based Clinical Assessment & Standard Management Proper Implementation Unexpected Outcome Unnecessary Resource Utilization Reasonable Deviation Imperfect Involve Clinical workflow
Correlation between SCIP-9 and UTI rates at EUH
Periop Standardization Effectiveness Value Efficiency Outcome Optimized Preop Evaluation Yes Yes Yes No OR Scheduling Yes Yes Yes No Multimodal Pain Control OR Readiness Checklist Structured Handoff s Procedural Equipment Yes Yes No Yes Yes Yes No Yes Yes Yes No Yes Yes No No
Phases of Surgical Care Wound Infection Prevention Process (WIPP) Pre-op Peri-op Intra-op Post-op Patient characteristics Nutrition Previous hospitalizations and transfers Culture nasal swabs Smoking cessation Patient Education Chlorhexidene Showers HgbA1c Bowel Prep Chlorhexidine prep Clippers Antibiotics -redosing Prep Technique Sterile Technique Foot Traffic Home Scrubs Attire Universal Drapes Wound Closure technique (Delayed) TO CLOSE OR NOT TO CLOSE Double Gloving Closing pan Change gown and gloves Glycemic Control Oxygen Saturation Prevent Hypothermia Antibiotic wound irrigation Drains (obese) Surveillance Patient hand hygiene Dressing Standardization and Changes Glycemic Control Prevent Hypothermia
Pre-op Phase Standardized Pre-op Process Goal don t cancel my case Reduce variability in testing and improve patient readiness for surgery Cost reduction, expectation setting, reduced referrals, improved outcomes, streamlined testing
Standardized Pre-op Screening Computerized and Nurse Practitioner driven IN 5866 pts only 218 surgeries were cancelled and 147 cardiology referrals Pre-intervention Post Intervention 30 Day mortality 3.5% 1.9% (p-value = 0.007) Presented at ACS-NSQIP 2014
Patient Education/Expectation 22
Hyperglycemia - 3 million patients, across 575 American hospitals, reported a prevalence of hyperglycemia (BG >180 mg/dl, 10 mmol/l) as 32% in patients - Guidelines for Therapy - SAMBA - APC - ADA/AACE - Endocrine Society - Critical Care Society - STS Anesthesiology. 2017 Mar; 126(3): 547 560.
EUH APC (pre-op) H&P /Labs Airway Functional Assessment PONV/Apfel OSA Screening Cardiac Glycemic Hyperglycemic Risk (28%) 16% Known Diabetics/Pre-diabetics 12% are stress hyperglycemic
Standardization :opportunity for innovation SUGARx app Not (currently) available in public app stores Install the Emory Appstore first: http://mobile.apps.emory.edu/ Dr. Vikas O Reilly-Shah
Basic Practices Special Approaches Unresolved Antibiotics Prophylaxis & Redosing Screening/Decolonization MRSA Preop Chlorhexidine bathing Hair Clippers Antiseptic Wound Lavage Preop Intranasal/pharyngeal chlorhexidene for CT Normoglycemia SSI risk assessment Gentamycin-collagen sponges colorectal and CT Normothermia Tissue Oxygenation Alcohol based skin prep Wound protectors of GI & Biliary surgery WHO Checklist SSI Surveillance Automated Data Ongoing Feedback Compliance testing/survey Education Surgeons/periop Educated Patients Implement best practices Observe/Review OR Personnel - Audits Observe/Review PACU Use of bundles to ensure compliance COLORECTAL WIPP
2013 Colorectal Surgery SSI Reduction 2011
SSI % WIG Colorectal WIPP SSI Trends in Colorectal Surgery 2010-2017 20 18 16 14 12 10 8 6 4 2 0 Observed Expected
Cost Savings with a reduction in SSI For 443 patients who did not get a SSI between 2012-2017 Low estimate = $4,626,249 High estimate = $11,316,878 Cost of WIPP bundle $272 per patient Quality FTE <0.3 A Patient not getting a SSI ; PRICELESS
Do you really need standards to standardize? In WIPP bundle (15 elements) Only 2 elements have level 1 data Consensus Helps with QI
Quality is local but alignment is helpful Disseminated Best Practice Guidelines Local QI Large-Data Registries Daily Clinical Practice