Thomas Varghese Jr. MD, MS, FACS

DRAFT – final pending AHRQ approval

Join SUSP Affinity Groups!Learn from experts and other SUSP hospital teams who are working on what you’re working on

Early recovery protocol (ERP)

Preop care coordination

SCIP measures Environmental management

Pain management, fluid management, postop mobility

Glucose control, bowel prep, oral antibiotics

Antibiotic prophylaxis, normothermia, skin prep

OR traffic, sterile technique, surface contamination

Traci Hedrick, MDUniversity of Virginia

Melanie Morris, MDUniversity of Alabama

Skandan Shanmugan, MDUniversity of Pennsylvania

Mariana PeharJohns Hopkins Hospital

Coaching calls every other month Quarterly Coaching Calls

Click this link SUSP Affinity Group Registration Link to register for an affinity group by Tuesday, May 20th!

Thomas Varghese Jr. MD, MS, FACS

Objectives of Strong For Surgery

• Identify and evaluate evidence-based practices to optimize the health of patients prior to surgery

• Outline key factors in pre-surgical care that can improve post-operative outcomes

• Apply quality improvement tools to implement best practices toward optimizing patient health

Funding

• Agency for Healthcare Research and Quality• Life Sciences Discovery Fund• Nestle HealthCare Nutrition• UW Patient Safety Innovation Program• UW Department of Surgery

Our Shared Project Goals

To achieve significant reductions in surgical site infection and surgical complication rates

To achieve significant improvements in safety culture

Why is Your SUSP Work Important?

1 in 25 people will undergo surgery

7 million (25%) complications follow in-patient surgeries

1 million (0.5 – 5%) deaths follow surgery

50% of all hospital adverse events are linked to surgery AND are avoidable

Problems

Every year there are 210,000 Preventable Deaths• $30 billion per year

J Patient Safety Sept 2013; 9(3): 122-128

Problems

Every year there are 210,000 Preventable Deaths• ½ associated with an operation• $30 billion per year

1 in 4 colon resections readmitted within 90 days• $300 million per year

Soft Tissue Surgical Site Infections• $3 billion in direct costs

J Patient Safety Sept 2013; 9(3): 122-128Wick EC, et al. 2011; 54(12):1475-1479Eappen S JAMA. 2013;309(15):1599-1606

It takes an average of 17 years before new knowledge from randomized clinical trials is incorporated into widespread clinical practice!

JAMA 1999; 282: 1458-1465; Health Professions Education 2003J Am Med Inform 2001; 8(4):398-399N Engl J Med 2003; 348:2635-2645

Healthcare System in Washington State

QI Performance Surveillance

Translation of Research into Practice

Research and Development

• Clinician-led QI using clinical data

• Focus on quality and cost-effectiveness data

• Impacts behavior through:• Benchmarking• Education• Standard orders• Checklists

BeforeElective Colorectal Resection, CHARS 2000-2003

17.7±38.2%

After Elective Colorectal Resection CHARS 2006-2009

9.6±29.4%

Evidence Generation

Clinical PracticePartners

Dissemination & Implementation

Clinician Offices

Long-term CareFacilities

Hospitals

Evidence Generation

Clinical PracticePartners

Dissemination & Implementation

Healthcar

eData

Patient Voices

StakeholderInput

Clinician Offices

Long-term CareFacilities

Hospitals

Evidence Generation

Clinical PracticePartners

Dissemination & Implementation

Healthcar

eData

Patient Voices

StakeholderInput

Clinician Offices

Long-term CareFacilities

Hospitals

Focus on Decision Making

PATIENT

DOCTOR’S OFFICE

OPERATING ROOM

PATIENT

DOCTOR’S OFFICE

OPERATING ROOM

PATIENT

DOCTOR’S OFFICE

OPERATING ROOM

Focus on Decision Making in Clinic

What is Strong for Surgery?

Public health campaign focused on surgeons, patients and other important stakeholders

• Interactive tools to help optimize patients prior to surgery  

• Messaging• Surveillance, data feedback, public reporting

Current Checklists

Nutrition• Screening for malnutrition• Albumin test for risk stratification• Immunonutrition supplementation

Smoking• Smoking habits and history• Establish and document quit plan

Blood Sugar• Diabetes risk screening• Blood sugar control screening• Perioperative glucose management

Medications• Identify drugs that could cause

bleeding and cardiac risks• Herbal medication reconciliation

See full version of the checklists at www.strongforsurgery.org

Why Blood Sugar?• Hypergycemia doubles the risk of SSI

• In some studies 47% of hyperglycemic episodes were in nondiabetics!

Latham. Inf Contr Hosp Epidemiol. 2001;22:607Dellinger. Inf Contr Hosp Epidemiol. 2001;22:604

Why Blood Sugar?• Hypergycemia doubles the risk of SSI

• In some studies 47% of hyperglycemic episodes were in nondiabetics!

• 470 million people worldwide will have prediabetes by 2030

• 35% of US adults older than 20 yrs of age and 50% greater than 65 years had prediabetes in 2005-2008

Latham. Inf Contr Hosp Epidemiol. 2001;22:607Dellinger. Inf Contr Hosp Epidemiol. 2001;22:604Lancet 2012; 2279-22902011 US Department of Health and Human Services

• > 65 years• 1 in 4 will have diabetes• 2 in 4 are prediabetic

2011 US Department of Health and Human Services

Why Blood Sugar?

Why Medications?

• Some medications and herbal remedies increase risk of bleeding• Echinacea, Garlic, Ginkgo, Ginseng, Kava, Saw

Palmetto, St. John’s Wort, Valerian ↑ risk

• Aspirin can be safely continued

Chest 2012; 141:e326S-e350S; JAMA 2008; 300(24):2867-2878; Ann Surg 2012; 255(5):811-819

Why Medications?

• Some medications and herbal remedies increase risk of bleeding• Echinacea, Garlic, Ginkgo, Ginseng, Kava, Saw

Palmetto, St. John’s Wort, Valerian ↑ risk• Aspirin can be safely continued

• Beta-blocker continuation associated with fewer cardiac events and mortality

Chest 2012; 141:e326S-e350S; JAMA 2008; 300(24):2867-2878; Ann Surg 2012; 255(5):811-819; Arch of Surg 2012; 147(5):467-473

Why Nutrition?

• Malnutrition is prevalent in surgical patients• Best determinant of surgical outcome

Why Nutrition?

• Malnutrition is prevalent in surgical patients• Best determinant of surgical outcome

• Modifiable with appropriate intervention• Immunonutrition may improve recovery

SCOAP: Albumin & ComplicationsElective colon/rectal procedures 2011

<2.0 2.0-2.4 2.5-2.9 3.0-3.4 3.5-3.9 4.0+0.0%

3.0%

6.0%

9.0%

12.0%

15.0%

Re-operation Death

Albumin Levels (g/dL)

Adve

rse

Out

com

e Ra

tes

Arginine Depletion

T-Cell Dysfunction

Risk of INFECTION

Surgery and trauma patients are immune suppressed making them more susceptible to infection due to arginine depletion.

Popovich 2006; McClave 2009; Zhu 2010

Arginine Depletion

T-Cell Dysfunction

Risk of INFECTION

Surgery and trauma patients are immune suppressed making them more susceptible to infection due to arginine depletion.

Immune- modulating formulas Arginine + Ω-3 fatty acids + Nucleotides 5 to 7 day regimen, 3 times daily

Popovich 2006; McClave 2009; Zhu 2010

Literature Review• Systematic Review

N=3,43835 studies focused on elective surgeryProcedure types

25 GI: 18 upper; 2 lower; 5 mixed 10 non-GI

• 23 – used arginine-based supplementsPre-Op Use: ↓ Infectious complications 43%

Drover JW, et al.JACS 2011; 212 (3):385-399

All Patients Neurosurgery Orthopedic0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

Never SmokerPrior SmokerCurrent Smoker

Why Smoking?

Mary T Hawn et al., “The Attributable Risk of Smoking on Surgical Complications,” Annals of Surgery 254, no. 6 (December 2011): 914–920.

Adju

sted

Odd

s Rati

oCo

mpl

icati

ons A

ssoc

iate

d w

ith S

mok

ing

Post-Operative Outcomes by Pack-Years Smoked

Surgical Site Infection Pulmonary 30-day Mortality0.8

1

1.2

1.4

1.6

1.8

2

0 1-20 21-40 41-60 >60

Adju

sted

Odd

s Rati

o

Mary T Hawn et al., “The Attributable Risk of Smoking on Surgical Complications,” Annals of Surgery 254, no. 6 (December 2011): 914–920.

Checklists

Raising Awareness

Changing Practice

Raising Awareness

Public Health Campaign

• Understanding clinic and patient needs• Checklists• Tracking outcomes• Strategic partnerships

• Community Engagement• Outreach events• Website content

www.strongforsurgery.org

Publications

OR MANAGER

By Laura Landro

Collaborators

• Washington State Medical Association• Washington State Hospital Association• Washington State Nurses Association• Washington State Academy of Nutrition and Dietetics• Washington Patient Safety Coalition• Washington State Society of Anesthesiologists• Washington St. Chapter – American College of Surgeons• Qualis Health• American Lung Association

Social Media Presence

2014 to date• 2,375 Total Hits• 1,803 Unique

Hits

• 126 “Likes”• Frequency 2-3

posts/week

• Discussion post 1-2/month

www.strongforsurgery.org

Implementation Guide requests 2013: 113 sites, 34 states, 7 countries

• 14.1 K Tweets• 2,678 Followers• 2,495 Following• Frequency

~70/week

@Strong4Surgery@TomVargheseJr

Changing Practice

The SUSP Team

Understands that patient safety culture is LOCAL

Composed of engaged frontline providers who take ownership of patient safety

Includes staff members who have different levels of experience

Tailored to include members based on clinical intervention

SUSP Teams’ Group Processes

Effective Group

Processes

Norms

Role Clarity

Effective Team Communication

Conflict Resolution

Education and

Engagement

Leadership Buy-in and

Support

Site Expectations

• Change team formation and support champion• Commitment through post-implementation• Checklist adoption• Data abstraction and sharing• Stakeholder calls attendance• Feedback for improvement

Site Activities

• Pre-Assessment• Workflow Mapping• Assessment of Resource Needs• Feedback – clinicians and staff• Post-Assessment

For More Information

• Visit the website: http://www.strongforsurgery.org• Review the literature• View our checklists• Request the implementation guide

• E-mail us: strongforsurgery@becertain.org

@TomVargheseJr@Strong4SurgeryStrongforSurgery

DRAFT – final pending AHRQ approval

Join SUSP Affinity Groups!Learn from experts and other SUSP hospital teams who are working on what you’re working on

Early recovery protocol (ERP)

Preop care coordination

SCIP measures Environmental management

Pain management, fluid management, postop mobility

Glucose control, bowel prep, oral antibiotics

Antibiotic prophylaxis, normothermia, skin prep

OR traffic, sterile technique, surface contamination

Traci Hedrick, MDUniversity of Virginia

Melanie Morris, MDUniversity of Alabama

Skandan Shanmugan, MDUniversity of Pennsylvania

Mariana PeharJohns Hopkins Hospital

Coaching calls every other month Quarterly Coaching Calls

Click this link SUSP Affinity Group Registration Link to register for an affinity group by Tuesday, May 20th!