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
2
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
3
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.
4
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.
5
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.
6
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
7
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
8
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.
9
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.
10
Consumer Participation In Evaluation (PIE) Matrix
11
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