4/7/2013. Disclosures. Learning Healthcare System in Washington State. Objectives. Improving Outcomes through Pre-hospital Checklists

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1 Disclosures Improving Outcomes through Pre-hospital Checklists Thomas Varghese Jr. MD, MS Diane Javelli RD AHRQ, LSDF Funded in part by Nestle HealthCare Nutrition for the development of a process improvement program aimed at improving patient outcomes, not for promoting a specific commercial product UW Patient Safety Innovation Program Objectives Describe the Strong for Surgery program and the role of the RD in this program Identify strategies to participate in the Strong for Surgery public health campaign How Strong for Surgery can reduce complications through preoperative optimization of blood sugar Learning Healthcare System in Washington State Patient Voices Project QI Performance Surveillance Translation of Research into Practice Stakeholder Engagement Research and Development Comparative Effectiveness Research Translational Network 1

2 Before Elective Colorectal Resection, CHARS Clinician-led QI using clinical data Focus on quality and cost-effectiveness Data 17.7±38.2% Impacts behavior through: Benchmarking Education Standard orders Checklists After Elective Colorectal Resection CHARS $22,000 Bending the Cost Curve Average Cost/Case (2009 dollars) $20,000 $18,000 $16,000 $14,000 $12,000 $10,000 Non-SCOAP SCOAP ±29.4% Kwon et al. SCOAP at 5 years. Surgery

3 Bending the Cost Curve SCOAP Surgical Checklist Average Cost/Case (2009 dollars) $22,000 $20,000 $18,000 $16,000 $14,000 $12,000 $10,000 $ 67.3 Million Kwon et al. SCOAP at 5 years. Surgery 2012 Focus on Decision Making PATIENT PATIENT DOCTOR S OFFICE DOCTOR S OFFICE OPERATING ROOM OPERATING ROOM 3

4 Focus on Decision Making in Clinic PATIENT DOCTOR S OFFICE OPERATING ROOM 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 4

5 Why Nutrition? Malnutrition is prevalent in surgical patients. Best determinant of surgical outcome. Modifiable with appropriate intervention. Immunonutrition may improve recovery. Opinions: Nutrition screening is cumbersome/impractical Intervention delays surgery Benefits of intervention modest Immune supplements only for malnourished Can check albumin don t need RD intervention Facts Nutrition Screening Does NOT disrupt surgical practice No delay 2-5 minutes Albumin is not a reliable indicator of nutritional status You need to do more! Immunonutrition benefits ALL patients having major surgery (e.g. GI anastomoses). 5

6 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) H.M. Reilly, et al. Clinical Nutrition (1995) Risk Stratification Hypoalbuminemia is an independent risk factor for SSI following surgery Why are surgeons stuck on albumin? Search for the easy lab test National Veterans Association Surgical Risk Study serum albumin levels were the best preoperative patient characteristic Hennessey DB, et al. Ann Surg. 2010;252: Gibbs J, et al. Arch Surg. 1999;134:

7 Complication Rates by Albumin 60% SCOAP: Albumin & Complications elective colon/rectal procedures 15.0% 50% 40% 30% 20% Adverse Outcome Rates 12.0% 9.0% 6.0% 3.0% 0.0% 10% < Albumin Levels (g/dl) 0% < and above not tested Re-operation Death NSQIP Raising Awareness - Changing Practice SFS goals Educate surgeons and other practitioners why albumin alone is an imperfect tool False values: Inflammation and Edema Need to do screening RD intervention when needed. Jane White et al JPEN J Parenteral Enteral Nutr : 275 Bahn, Le. Practical Gastroenterology October Fuhrman, M., et al. JADA 2004; 104(8) ASPEN guidelines JPEN 2009; 33(3):

8 Surgery and trauma patients are immune suppressed making them more susceptible to infection due to arginine deficiency. Literature Review ArginineDeficiency Syndrome T-Cell Dysfunction Risk of INFECTION 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% 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 2010 Drover JW, et al. JACS 2011; 212 (3): Literature Review Meta-analysis: 26 RCTs N = Immunonutrition vs 1244 Control (Isocaloric) infection rates by 46% length of stay ~ 2 days 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 Marimuthu K, et al. Ann Surg 2012; 255:

9 Checklists 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 %-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 % 80% 60% 40% 20% 0% Blood Glucose Monitoring among Diabetics (81) (44) (30) (48) (2) (26) (49) (15) (15) (27) (34) (2) (12) (1) 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 SCOAP Avg Hospital Rate 36 9

10 100% 80% 60% 40% 20% 0% Insulin used for PBG 200* 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 (14) (9) (3) (13) () (4) (8) (1) (4) (2) (6) () (1) () SCOAP Avg Hospital Rate * Includes non-diabetic 37 Chest 2012; 141:e326S-e350S JAMA 2008; 300(24): Ann Surg 2012; 255(5): Arch of Surg 2012; 147(5): % 80% 60% 40% 20% 0% Beta Blockers continued post-op (92) (57) (49) (46) (2) (21) (70) (15) (19) (29) (40) (5) (16) (5) Why Smoking? Smoking is prevalent 1/3 of all patients Smokers have risk of complications Pulmonary Circulatory Infectious Impaired wound healing SCOAP Avg Hosp Rate 39 10

11 426 patients followed prospectively for 2 years after a lumbar spinal fusion Key Points Smoking doubled the risk of getting a nonunion Smoking cessation lowered the risk to a level comparable with nonsmokers Why a Public Health Campaign? 11

12 Generation of Evidence Surveillance Outcomes Education and Feedback Clinical Trials, CER Studies Guidelines Average of 17 years before new knowledge from randomized clinical trials is incorporated into widespread clinical practice! Performance Indicators Public Health Campaign Statewide awareness Media events Website Mobilizing the community Strategic partnerships Surveillance and Feedback Change in behavior 12

13 Strategic Partnerships WSMA WSNA WSAND American College of Surgeons Qualis Northwest Colorectal Surgeons 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 13

14 Site Activities Pre-Assessment Workflow Mapping Assessment of Resource Needs Intervention Plan Education Resources Clinical Protocols Access to supplements, etc. Feedback clinicians and staff Post-Assessment Ideal Change Team Members Administration and leadership Surgeons Practice Manager RNs MAs Dietitians Other office staff What is the Role of the RD in Strong for Surgery? Role of RD in Strong for Surgery Raising Awareness Changing Practice 14

15 Role of the RD in Strong for Surgery Work with clinicians to bring attention to the importance of nutrition intervention before surgery. Educate about implementing nutrition screening and nutritional assessment. Build referral network for outpatient visits. Role of the RD in Strong for Surgery Educate about proper diagnosis of malnutrition Provide education regarding value of immunonutrition Establish protocol for RD intervention in long term blood glucose management. Attend Strong for Surgery RD stakeholder meetings Barriers: Lack of established relationship between surgical team and nutrition team. Inadequate outpatient staffing. Poor reimbursement for RD services. Empowering the people of Washington to improve health with safe, effective and reliable food and nutrition information. Our Vision: Optimize the health and well being of Washington State individuals through food & nutrition. Our Mission: Empower members to be Washington State s food and nutrition leaders. 15

16 Get Involved Attend Campaign Events (RD stakeholder meeting) Inform Your Colleagues and Constituents THANK YOU! Visit the website: 16