Defining the Problem

TEACH Level II Workshop 1

NYAM

August 7th, 2013

Craig A Umscheid, MD, MSCE, FACP

Assistant Professor of Medicine and Epidemiology

Director, Center for Evidence-based Practice

University of Pennsylvania

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Outline

A Case Using Evidence to Define the Problem Building a Team to Define and Address the Problem Consumer Involvement Framing Options to Address the Problem

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A Case: Surgical Site Infections

You’re the Chair of the Department of Surgery Quality Committee at your medical center, and you receive a call from your Chief Medical Officer regarding a report that your state just released about SSI rates at medical centers across the state. It’s not good news. Your medical center had the highest rate of SSIs in the state.

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Using evidence to define the problem

Does it warrant attention? Is it a misperception?

Local evidence• Anecdote vs. data• Compare over time, across units, across institutions• Structure, process, outcome

Peer-reviewed evidence• National estimates• Compare local practices to national recommendations• Published QI initiatives

Mitchell MD, et al. Integrating local data into hospital-based healthcare technology assessment: two case studies. Int J Technol Assess Health Care. 2010;26(3):294-300.

Lavis JN, et al. Using research evidence to clarify a problem. Health Research Policy and Systems. 2009, 7(Suppl 1):S4 doi:10.1186/1478-4505-7-S1-S4.

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HAIHAIs(N)

Deaths(N)

Reductionin infectionrisk with QI

Preventableinfections

(N)

Preventabledeaths

(N)

Estimatedcost

per infectioncase

(2009 dollars)

AvoidableInfection

Costs(millions of

2009 dollars)

SSI 290,485 8,205 26%–54% 75,526–156,862

2,133–4,431 $2,100 $159M-

$329M

Summary estimates of annual rates of preventable infections, deaths, and costs for SSIs

Klevens RM, Edwards JR, Richards CL, Jr, et al. Estimating healthcare-associated infections and deaths in US hospitals, 2002. Public Health Rep. 2007 Mar-Apr; 122(2): 160-6.

Umscheid CA, Mitchell MD, Doshi JA, Agarwal R, Williams K, Brennan PJ. Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Infect Control Hosp Epidemiol. 2011; 32(2):101-14.

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National Standards

CMS Partnership for Patients• Nine core areas of focus, four areas are HAIs:

– SSI– CAUTI– CABSI– VAP

Joint Commission’s 2011 National Patient Safety Goals• NPSG.07.05.01

– Use proven guidelines to prevent infections after surgery• NPSG.07.04.01

– Use proven guidelines to prevent infection of the blood from central lines

• NPSG.07.06.01– Use proven guidelines to prevent indwelling catheter-associated

urinary tract infections

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SCIP Measures

SCIP-Inf-1: Prophylactic Antibiotic Received Within 1 Hour Prior to Surgical Incision

SCIP-Inf-2: Prophylactic Antibiotic Selection for Surgical Patients

SCIP-Inf-3: Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery Ends

SCIP-Inf-4: Cardiac Surgery Patients With Controlled 6 A.M. Postop Blood Glucose

SCIP-Inf-6: Surgery Patients with Appropriate Hair Removal

SCIP-Inf-10: Surgery Patients with Periop Temperature Management

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SSI prevention practices from studies included in review of HAI preventability

Appropriate use of perioperative antibiotics Decreased use of preoperative shaving Improvement in perioperative glucose control

Clinician education, reminders, and audit and feedback Patient education

Dellinger EP, Hausmann SM, Bratzler DW, et al. Hospitals collaborate to decrease surgical site infections. Am J Surg. 2005;190(1):9-15.

Lutarewych M, Morgan SP, Hall MM. Improving outcomes of coronary artery bypass graft infections with multiple interventions: Putting science and data to the test. Infect Control Hosp Epidemiol. 2004;25(6):517-9.

Rao N, Schilling D, Rice J, Ridenour M, Mook W, Santa E. Prevention of postoperative mediastinitis: A clinical process improvement model. J Healthc Qual. 2004;26(1):22-7.

Umscheid CA, Mitchell MD, Doshi JA, Agarwal R, Williams K, Brennan PJ. Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Infect Control Hosp Epidemiol. 2011; 32(2):101-14.

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Building a team to define and address the problem

Key stakeholders

Multidisciplinary

Champions

Executive leadership (credibility, resources, influence)

Conflicts of interest

Harris C, Turner T and Wilkinson F. Guideline Development Toolkit. (2008) The Centre for Clinical Effectiveness, Southern Health, Melbourne, Australia.

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Consumer Participation In Evaluation (PIE) Matrix

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Framing options to address the problem

Frame or “fit” problem within priorities of leadership to motivate support and solutions

Lavis JN. Using research evidence to clarify a problem. Health Research Policy and Systems. 2009, 7(Suppl 1):S4 doi:10.1186/1478-4505-7-S1-S4

MonitorMonitorKnowledgeKnowledge

UseUse

SustainSustainKnowledgeKnowledge

UseUse

EvaluateEvaluateOutcomesOutcomes

AdaptAdaptKnowledgeKnowledge

to Local Contextto Local Context

AssessAssessBarriers to Barriers to

Knowledge UseKnowledge Use

Select, Tailor,Select, Tailor,ImplementImplement

InterventionsInterventions

Identify ProblemIdentify Problem

Identify, Review,Identify, Review,Select KnowledgeSelect Knowledge

Products/Products/ToolsTools

SynthesisSynthesis

Knowledge Knowledge InquiryInquiry

Tailo

ring K

nowl

edge

KNOWLEDGE CREATIONKNOWLEDGE CREATION