Getting national guidelines into practice: It takes more than education AI Collaborative Group 2 September 12, 2017 Lynette M. Wachholz, MN, ARNP, CPHQ Email: lwachholz@everettclinic.com
The Everett Clinic Established in 1924 4 th largest private employer in Snohomish County The Boeing Co. is #1 355 physicians & 140 Advanced Practice Clinicians Multi-specialty clinic 45+ specialties
The Everett Clinic 20 practice sites Admit to a community hospital Patient base: 315,000+ patients Visits: 942,000+ annually EMR: Epic Go Live 2006
1. National Guideline National Guideline into Practice 6. Clinical Decision Support Tools 5. Patient Education 2. Primary Care Quality Advisory Committee 3. Clinic Guideline 4. Provider & Staff Education 4
National Guidelines Abdominal Aortic Aneurysm (AAA)Screening HIV Screening Hepatitis C Screening Pneumococcal (PPSV23) Vaccination in Patients with Chronic Conditions
Abdominal Aortic Aneurysm
Abdominal Aortic Aneurysm Repair
USPSTF Recommends Screening TEC Screening Guideline Approved Recommends One-Time Screening for Men 65-75 Years of Age with Hx of Smoking or Family Hx of AAA in 1 st Degree Relative May Primary Care Practice Updates February & March 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 AAA Screening Recommendations July Health Maintenance Prompt Goes Live
Post-Health Maintenance Prompt Population: 4756 eligible men July 2015 Jan 2017 73% of men have been screened
Human Immunodeficiency Virus (HIV) Infection Estimated 1.1 million people in the U.S. living with HIV infection ~1 in 5 infected individuals unaware of their diagnosis 40% of new cases each year due to transmission from those who don t know they re infected Identifying individuals with undiagnosed HIV has the potential to Improve disease outcomes Live with rather than die from HIV Reduce incidence of new infections
CDC Recommends HIV Screening in Adults USPSTF Recommends HIV Screening in Adults TEC Guideline Approved One- Time Screening in Adults 18-65 Years of Age December Primary Care Practice Updates February & March 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 HIV Screening Recommendations May Health Maintenance Prompt Goes Live
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Hepatitis C Virus Infection ~3.2 million individuals living with Hep C infection in the U.S. Estimated 16,500 new cases of Hep C infection each year 75% of adults in U.S. living with chronic Hep C infection were born between 1945 and 1965 May have chronic Hep C infection for decades before symptoms develop Often unaware of their diagnosis Places patients at risk for liver cancer, cirrhosis, and end-stage liver disease liver transplant or death Curable
CDC Recommends Routine Screening of Adults USPSTF Recommends Routine Screening of Adults TEC Screening Guideline Approved One Time Screening Adults Born 1945-1965 & Injection Drug Users December Primary Care Practice Updates March & April 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Hepatitis C Screening Recommendations May Health Maintenance Prompt Goes Live for Birth Cohort
Pneumococcal Disease Streptococcus pneumoniae Non-invasive Pneumonia Sinusitis Otitis media Invasive Empyema Meningitis Septicemia Case fatality rate for pneumococcal bacteremia 20% all adults As high as 60% among elderly
ACIP Recommendations Pneumococcal Vaccines Year Vaccine Indications 1987 PPSV23 > 65 yr 19-64 yr Chronic illnesses (incl CSF leaks) Functional or anatomic asplenia Immunocompromised Living in LTC facilities Alaska Natives/Native Americans 2002 PPSV23 Cochlear implants 2010 PPSV23 19-64 yr with asthma 19-64 yr smokers 2012 PCV13 19-64 yr Immunocompromised Functional or anatomic asplenia CSF leaks Cochlear implants 2014 PCV13 > 65 yr
PPSV23 Vaccine for Patients with Chronic Conditions ACIP Recommendation PPSV23 for 65+ Years & Chronic Conditions ACIP Updated Recommendation PPSV23 for Chronic Conditions Primary Care Practice Updates ACIP February & Recommendation March - PCV13 for 65+ Years 1987 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Epic Goes Live with a Basic Health Maintenance Prompt for PPSV23 at 65 years Sequential Health Maintenance Prompt for Age-Based Pneumococcal Vaccinations Goes Live January Health Maintenance Prompt for PPSV23 for Chronic Conditions Goes Live
Summary Takes a long time for a national guideline to be adopted Teaching providers & staff the why alone does not drive change in behavior Health Maintenance prompts (CDS) make it easy for teams to do the right thing Health Maintenance prompts (CDS) make it more difficult to do the wrong thing Delivering high-quality care that the patients deserve takes a collaborative effort IT EMR Data warehouse Imaging Lab Materiel Management Quality Point-of-care teams Having a system in place helps to drive improvement