Post on 04-Apr-2022
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Objectives
• Develop key quality metrics that are easily measured
and comparable
• Identify set targets for measureable patient outcomes
• Discuss options for formal provincial reporting
April 30, 2018
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Dimensions of Quality
Accessible
• Right care at the right time
Effective
• Evidence based practices
Safe
• Avoid harm
Patient centred
• Needs and preferences of the patient
Equitable
• Same level of care for every patient
Efficient
• Maximize resource use, minimize waste
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Structure Process
Outcome
• Was medicine
properly
practiced?
• Staff, physical
resources, policies
• Modifiable
Donabedian approach to quality
assessment
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What is a good quality indicator?
• Important
– Must apply to a large number of patients OR
– Involve a high risk condition
• Scientifically acceptable
– Reliable – same result on repeated measures
– Valid – does it measure what its supposed to measure
• Feasibility
– Data must be readily available (opportunity costs)
• Usability
– Must be understood by intended audience to ensure PI can
happen
• Modifiable
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MHP Policy Effective care
• Hospitals should have a protocol to guide the
management of the severely bleeding patient
– Structural measure
• Hospitals should have a multidisciplinary QA committee
to review MHP activation
– Structural measure
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…. ….that reports to the hospital Quality of Care
Committee [MAC]
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Benefits of standardization
• Clarifies the process
• Documents the best way to achieve a goal
• Reduces variation
• Facilitates training
• Provides the baseline for improvement
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TXA administration
Effective care
• The proportion of patients receiving 2 g of tranexamic
acid within 1 hour of injury/onset of hemorrhage
– Process measure
– Modifiable
• Should it be time of onset of hemorrhage/injury or
recognition of hemorrhage – not usable in current form
• Is it 2 gm or first dose of TXA?
• Suggested: The proportion of patients receiving 1 g of
tranexamic acid within 30 min of activation of MHP
• Amenable to provincial reporting
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Timely transfusion Accessibility
• The proportion of patients issued red cells either before
or within 10 minutes of protocol activation
• Process measure
– Is “issuing blood” the relevant measure?
• Blood might be issued and take 30 min to get to the patient
– Should it be time to bedside? Time to transfusion?
– Consider: The proportion of patients in whom transfusion is
initiated within 15 min of protocol activation
– Modifiable, measurable, relatively independent of case mix –
acceptable for provincial reporting
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Hemorrhage control
Access
• The proportion of patients (of patients requiring transfer
for definitive care) with initiation of call for transfer within
15 minutes of protocol activation
– Process measure
• Modifiable? – very tight window, context dependent
• Activation might precede identification of source of
hemorrhage
– Might be faster to treat locally then transfer patient
• Acceptable for internal QI, not for provincial reporting
• Suggest extend window to an hour
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Timely access to hemorrhage
control
• Additional consideration
• The proportion of patients with initiation of hemorrhage
control (where possible) within 60/90(?) min of protocol
activation
– Time to operative intervention, time to angioembolization,
endoscopic control, etc
– Modifiable, independent of case mix
• Acceptable for provincial reporting
April 30, 2018
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Is one hour reasonable?
• PROPPR Study – 28 min to operating room
• Haas and Nathens, J Am College of Surgeons, 2009
– Time to OR among patients with penetrating truncal injury
presenting with shock – 1 hour in trauma centres, 50 min
in non-trauma centres
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Pelvic angioembolization
TQIP experience
• Time to angiography from ED arrival among patients who
had this as their FIRST intervention
• Median 3.1 hours, most (75%) between 2-4 hrs; 1%
within 30 minutes
• Non-teaching hospital – 33 minutes quicker
• Higher volume centers (>10 per year) - 20 min shorter
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Management of hypothermia Safe, effective care
• The proportion of patients achieving a temperature
>35⁰C at termination of the protocol
– Outcome measure
– Modifiability a challenge
– Risk adjustment would be necessary for provincial
reporting • GI bleed vs obstetrical hemorrhage, vs traumatic hemorrhage
• Dependent on exposure, extent/volume of resuscitation
• Acceptable for internal QI, not for provincial reporting
April 30, 2018
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Transition to group specific
blood - efficiency
• The proportion of patients transitioned to group specific
blood within 90 minutes of arrival/onset of hemorrhage
– Process measure
• Needs more precision to ensure reliability and
usability….within 90 minutes of MHP activation
• Reflects ability of the provider(s) to obtain blood sample
& timely submission to lab
• Independent of case mix
• Case mix independence, modifiability suggest an
appropriate indicator for provincial reporting
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Hemoglobin targets
• The proportion of patients with hemoglobin levels
maintained between 60-110 g/L during protocol activation
– Outcome measure
• Ability to achieve this target highly dependent on:
– Rate of bleeding (case mix)
– Ease with which hemorrhage control can be achieved (case
mix +/-)
– Turnaround time of labs (modifiable)
– Use of lab data (modifiable)
• Given case mix issues, not ideal for provincial reporting but
might have value for internal QI
April 30, 2018
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Avoiding wastage
Efficient care
• The proportion of activations without any blood product
wastage (including plasma that is thawed and not used
within the 5 day limit on another patient)
– Outcome measure
• Some modifiability on the provider’s part but potentially case
mix dependent - early death, early hemorrhage control
• Incentivizes administration of product when it might not be
necessary
• As written, brings in other case mix issues (plasma thawed
to be used on another patient)
• Might be acceptable for internal QI only
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Appropriateness of MHP activation Effectiveness, Efficiency
• The proportion of patients with appropriate activation
(non-survivors with hemorrhagic death transfused <6
units and patients transfused >6 RBC units)
• Process measure
• Needs element of time….within 4 hours
• True positive: activation among those who received>6
units in 4 hours or activation among those who received
transfusion yet died with hemorrhagic death within 4
hours
• False positive: activation among survivors who received
<6 units in 4 hrs
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Appropriateness
• Appropriateness becomes the positive predictive value:
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• PPV is influenced by case mix (prevalence)
• Not ideal for province wide reporting; good for internal
use and to track over time within specified populations
– E.g. trauma vs obstetric vs surgical
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Appropriateness
• What happens if we never activate MHP and we should?
• Balancing measure would be “Negative predictive value”
April 30, 2018
• TN = very large, undifferentiated population
• TN=any transfused patient? Any transfused patient
meeting specific criteria?
• Province wide reporting would be challenging
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Appropriateness
• As part of the MHP quality assurance process, reviews
should be undertaken for every patient in whom MHP is
activated and for every patient who receives >6 units of
pRBC’s within 4 hours in whom MHP is not activated
• Reviews should address
– Appropriateness of activation (or lack of activation)
– Timeliness of activation and termination
– Administration of products and adjuncts (Ca, TXA)
– Avoidance of hypothermia
– Timeliness of hemorrhage control/transfer
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Do quality indicators improve
care
• Providers need to have confidence in the data, its validity
and there must be a perceived component of
modifiability
• Most provincial reports get little air time
– No confidence
– Data reviewed in wrong forum
• Even if the data are correct and there is opportunity for
improvement, most don’t know how to affect change
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NSQIP Experience
• VA NSQIP
– Mortality: 3.16% to 1.7%
– Morbidity: 45% lower
• ACS NSQIP (2005-2008)
– Morbidity: 82% of centers improve
– Mortality: ~66% of centers improve
– Improvements identified in all groups
• High, low, and average performers
• Low performers improved the most
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Quality Collaboratives
• Accelerate improvements
• Peers hold others
accountable for change
• Goal setting, sharing of
ideas, resources
• Sharing of successful
change strategies
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Summary
• Several QI indicators acceptable for provincial reporting
– Current MHP policy
– TXA administration
– Timely transfusion
– Timely access to hemorrhage control
– Transition to group specific blood
• Others built into internal QI process with mandate for
review
• Empower providers to affect change through collaboratives
April 30, 2018