IOM Workshop on Standards for Clinical Guidelines Monday, January 11, 2010 Elizabeth Mort, MD, MPH Massachusetts General Hospital Partners HealthCare, Inc.
Jan 12, 2016
IOM Workshop on Standards for Clinical Guidelines
Monday, January 11, 2010
Elizabeth Mort, MD, MPHMassachusetts General HospitalPartners HealthCare, Inc.
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Integrated, academic health system founded in 1994 by Brigham and Women’s Hospital and Massachusetts General Hospital
Four-part mission is patient care, teaching, research, and community service
1.7 million patients receive care from Partners institutions and physicians
170,000 hospital inpatient discharges annually
4.3 million outpatient and physician visits annually
We are a large consumer of clinical guidelines
Partners HealthCare, Inc.
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Partners HealthCare Hospitals
Martha’s Vineyard Hospital
Nantucket Cottage Hospital
Rehab Hospital of the Cape and Islands
Faulkner Hospital
Newton-Wellesley Hospital
McLean Hospital
Massachusetts General Hospital
Spaulding Rehabilitation
Hospital
Shaughnessy-Kaplan
Rehabilitation Hospital
North Shore Medical Center -
Union
North Shore Medical Center -
Salem
Non-Acute Hospital
Acute Care HospitalH
Brigham and Women’s Hospital
Partners HealthCare
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Role of guidelines at Partners HealthCare, Inc
Goal is to assure that all patients get the highest quality care, reliably delivered anywhere in the system.
Identify priority areas for system-wide improvement.
Review clinical guidelines using clinical experts and develop system-wide approaches.
Implement guidelines using high reliability design, leveraging system resources such as electronic medical record, registries, clinical decision support rules, etc.
Measure compliance transparently and study failures/variance.
Refine as needed
http://qualityandsafety.partners.org/
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Recommendations for guideline standards
1. Concur with many of the presenters today that describing the level of the evidence and the strength of the recommendation is critical. Agree with developing a standard taxonomy to simplify.
2. Describe the exact nature of and the probability of obtaining the benefit and risks. (Allows prioritization of action at all levels, from the system to the individual patient.)
3. Highlight areas of controversy.
4. Develop an organized, transparent, accountable, and safe approach to provide consensus opinion and expert opinion on the management of populations or situations that are not explicitly addressed in the clinical practice guidelines.
5. Provide guidance to facilitate implementation if available and suggest performance measures if appropriate.
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Additional FAQs – Care of the elderly, pts with renal failure, who have CHF, what about CDEs, etc.
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Patient arrives atED triage
Is there apre-hospital ECG
indicatingSTEMI?
ED initiatestreatment and
consent forcath lab
yes
ED does ECG andgives it to ED
physician in 10mins
no
Is STEMIconfirmed?
Continue EDwork-up and cancelcath lab, as needed
no
ED transportspatient to cath lab
ED calls operatorto page cath lab
staff andinterventionalist
yes
EMS does ECG
EMS notifies ED ofSTEMI, starts IV,and draws blood
ED calls operatorto page cath lab
staff andinterventionalist
Are pagesconfirmed?
Cath lab staff andinterventionalistarrive and scrubwithin 30 mins
yes
Are pagesconfirmed?
Cath lab staff andinterventionalistarrive and scrubwithin 30 mins
yes
no*
*if no response within 10 mins,go to next one on on-call list
Patient arrives inED without
pre-hospital ECG
Patient hassymptoms and
calls EMS
Startprocedure
Is STEMIsuspected?
no*
yes
PATH #2
PATH #1
Admit patientto CCU
ED communicateswith cath lab to
determinereadiness to
receive patient
Is PCIindicated?
yes
no
no
Final checklist andwritten consent
completed
Include guidance on implementation: STEMI
Bradley, E. et. al; Reducing door-to-balloon times to meet quality Bradley, E. et. al; Reducing door-to-balloon times to meet quality guidelines: How do successful hospitals do it? guidelines: How do successful hospitals do it? CirculationCirculation 2004 2004
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Time for staff to arrive: 35 min
Triage Time: 10 min
Lab arrival to reperfusion: 30 min.
Step
1 Patient arrives in ED, ECG is completed, and ED physician diagnoses STEMI
2 ED calls operator to page on-call cath lab staff and interventionalist
3 ED stabilizes patient; initiates MI protocol; communicates w ith cath lab
4 Cath lab staff and interventionalist go to and arrive at cath lab
5 ED transports patient to cath lab
6 Final checklist for PCI and w ritten consent
7 Catheterization and PCI
Figure 3. Path #2 -- Steps and timeline for acute reperfusion: patients who arrive in ED without pre-hospital ECG
65 70 75 8045 50 55 60Minutes
0 5 10 15 20 25 30 35 40
Patient arrives in cath lab
Patient reperfusion
Pt arrives in ED
DTB DTB cancan be be < 80 < 80
minutesminutes
DTB DTB cancan be be < 80 < 80
minutesminutes
Include guidance on implementation: STEMI
Bradley, E. et. al; Reducing door-to-balloon times to meet quality Bradley, E. et. al; Reducing door-to-balloon times to meet quality guidelines: How do successful hospitals do it? guidelines: How do successful hospitals do it? CirculationCirculation 2004 2004
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Recommendations for guideline standards
1. Concur with many of the presenters today that describing the level of the evidence and the strength of the recommendation is critical. Agree with developing a standard taxonomy to simplify.
2. Describe the exact nature of and the probability of obtaining the benefit and risks. (Allows prioritization of action at all levels, from the system to the individual patient.)
3. Highlight areas of controversy.
4. Develop an organized, transparent, accountable, and safe approach to provide consensus opinion and expert opinion on the management of populations or situations that are not explicitly addressed in the clinical practice guidelines.
5. Provide guidance to facilitate implementation if available and suggest performance measures if appropriate.