Efforts to Improve Outcomes of In-Hospital Cardiac Arrest in the VA

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Transcription:

Efforts to Improve Outcomes of In-Hospital Cardiac Arrest in the VA Steven M. Bradley, MD, MPH VA Eastern Colorado Health Care System, Denver, CO University of Colorado School of Medicine, Aurora, CO

Disclaimer The views expressed are my own and do not necessarily represent the official views, position, or policy of the Department of Veterans Affairs, or the United States government. No additional disclosures

Objectives Importance of in-hospital cardiac arrest (IHCA) to VA Challenges and opportunities in the VA CART Program as a model Future of IHCA QA/QI in the VA (and elsewhere)

Objectives Importance of in-hospital cardiac arrest (IHCA) to VA Challenges and opportunities in the VA CART Program as a model Future of IHCA QA/QI in the VA (and elsewhere)

What is the VHA? Largest U.S. integrated healthcare system Serves 8.76 million Veterans annually Over 1,700 sites of care Complex multimorbidity patients 1 Average of 3 chronic medical conditions More than 1 in 4 with a disability High quality of care 2 1. Long JA, et al. Am J Public Health. 2005;95:2246-51. 2. Ross JS, et al. Arch Intern Med. 2008;168:950-958.

VA Attention to IHCA Prevalence and survival of IHCA varies within the VA 14 30 Rate (per 1000 Admissions) 12 10 8 6 4 2 0 0 50 100 Hospital Rank Number of Hospitals 25 20 15 10 5 0 Percent of IHCA Surviving to Discharge

VA Attention to IHCA VHA Directive 2008-063 Mandatory VHA policy Calls for IHCA data to be: aggregated, analyzed, compared internally over time and externally (benchmarking) used to identify and implement desired changes

Objectives Importance of in-hospital cardiac arrest (IHCA) to VA Challenges and opportunities in the VA CART Program as a model Future of IHCA QA/QI in the VA (and elsewhere)

Challenges in the VA National Directives Regional Implementation VISN 1 alone has 11 medical centers Edith Nourse Rogers Memorial Veterans Hosp. Manchester VA Medical Center Providence VA Medical Center VA Boston Healthcare System, Brockton VA Boston Healthcare System, Jamaica Plain VA Boston Healthcare System, West Roxbury VA Central Western Massachusetts VA Connecticut Healthcare System, Newington VA Connecticut Healthcare System, West Haven VA Maine Healthcare System Togus White River Junction VA Medical Center

Challenges in the VA Data available vs. Data needed Available Patient characteristics Demographics Comorbid conditions Vitals signs Laboratory Survival Needed Resuscitation care Witnessed or monitored Time to therapies Resuscitation process Team structure Feedback/debriefing Health status outcomes

Opportunities in the VA Integrated healthcare setting Network for dissemination of strategies that work Longitudinal data capture Lower burden for data collection Longitudinal outcomes assessment

Objectives Importance of in-hospital cardiac arrest (IHCA) to VA Challenges and opportunities in the VA CART Program as a Model Future of IHCA QA/QI in the VA (and elsewhere)

The CART Model The Problem No QA/QI program for VA cath lab procedures >50,000 procedures annually Documentation in dictated or typed notes adequate for clinical care, unable to leverage for QA/QI The Opportunity Integrate with VA Electronic Health Record Standardized data collection and clinical reporting Support data collection for local and national QA/QI efforts

VA CART Program National clinical quality program for all VA cath labs Point-of-care data collection for all PCIs performed in the VA Linked to VA electronic health record and administrative data

Typical QA/QI Programs vs CART Typical QA/QI Data abstraction Timely, costly Retrospective Delayed feedback Limited data linkage CART Program Point-of-care data Routine clinical care Real-time Rapid feedback Longitudinal linkages Higher quality data 1 Validity, completeness, timeliness 1. Byrd JB. Am Heart J. 2013 Mar;165(3):434-40.

CART Accomplishments and Future Standardized data capture Supports benchmarking of cath lab procedures Major adverse events review Real-time identification and review of care processes Proactive medical device surveillance Unexpected device problems reviewed with FDA Future targets for QA and QI Clinical decision support Patient-reported health status capture

CART - Resuscitation Document clinical care Capture structured data

Summary Point #1 1. Support integrated data capture for IHCA as part of routine care delivery Reduce data capture burden Improve quality of data capture Facilitate rapid feedback

What data do we REALLY need? GWTG-Resuscitation 100s of data elements; hours per average chart Many elements have never been applied to research or quality improvement efforts Revised Utstein Templates Concise data capture Focused on specific questions of interest

IOM Priorities for Comparative Effectiveness Research Iglehart JK. N Engl J Med 2009;361:325-328

Summary Point #2 2. Identify the priority questions of interest for IHCA Recognize IHCA is different that OHCA Pre-arrest, resuscitation, and post-resuscitation care Training, code team structure, feedback Guide the critical data that needs collecting

Objectives Importance of in-hospital cardiac arrest (IHCA) to VA Challenges and opportunities in the VA CART Program as a model Future of IHCA QA/QI in the VA (and elsewhere)

Learning Healthcare System Generating and using real-time knowledge to improve outcomes Engaging patients, families, and communities Achieving and rewarding high-value care Creating a new culture of care

Learning Healthcare System Generating and using real-time knowledge to improve outcomes Engaging patients, families, and communities Achieving and rewarding high-value care Creating a new culture of care

Generating and Using Real-Time Knowledge Transactional Quality Improvement Closing the loop of data capture and quality improvement at the point-ofcare Rapid Cycle Pragmatic Trials Organizational Culture

Summary Point #3 3. Apply the model of a learning healthcare system Real-time access to knowledge Rapid cycle pragmatic trials Organizational structure and culture

Summary Recommendations 1. Support integrated data capture for IHCA as part of routine care delivery 2. Identify the primary questions of interest for IHCA 3. Apply the model of a learning healthcare system

Thank you VA CART Program John S. Rumsfeld, MD, PhD VA Office of Analytics and Business Intelligence Stephen D. Fihn, MD, MPH VA Resuscitation Education Initiative Phil Hargreaves

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