Surgery SCN Newsletter December 2015

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SURGERY STRATEGIC CLINICAL NETWORK

Our Mission:

“Bringing patients, clinicians,

administrators and policymakers

together to advance surgical

care in Alberta”

In This Issue

NSQIP Takes Flight In Alberta

Surgery SCN Staff & Project

Updates

ERAS Update

ERAS Symposium

Improving Quality of Care for

Patients With Rectal Cancer

Evidence Decision Support

Program

Safety in the OR: Understanding and Managing

Exposure to Formalin

Research & Innovation: SEED

Grant Program Update

Coordinated Surgical Care: A Patient’s Vision for Surgery

in Alberta

Adult Surgical Skin Preparation in the Operating Room/Treatment Areas: AHS Surgical Skin Preparation

Policy

CPSI Surgical Site Infection

National Audit

Volume 3, Issue 3 December 2015

National Surgery Quality Improvement Program (NSQIP) Takes Flight in Alberta! In October 2014, the Surgery SCN launched the National Surgery Quality Improvement Program (NSQIP) project at five sites across the province. What is NSQIP? Developed by the American College of Surgeons (ACS), NSQIP:

helps us to understand when, where and why surgical complications happen;

helps us to understand how the surgical care provided in Alberta “measures up” to other sites around the world; and

builds site-based teams and brings them across Alberta to share best practises for improving surgical quality and patient experience.

Teams will collect and analyze surgical data and use this information to develop and implement quality improvements within each site. These initiatives will be led by a surgeon champion, anesthesia champion and Surgical Clinical Reviewer (SCR). In July, four physician champions and four SCRs from Alberta joined more than 1500 attendees from 15 countries at the ACS NSQIP Conference in Chicago. The team was able to network and learn from teams who have successfully improved surgical care by measuring reductions in surgical complications using NSQIP. As the sponsor of this work, the Surgery SCN will apply a Learning Collaborative approach to optimize the benefits of NSQIP provincially. NSQIP teams came together in Calgary on November 17th to review their first Interim Semi-Annual Risk Adjusted Report and identify opportunities for improvement and set goals in alignment with the six dimensions of quality defined in the Alberta Quality Matrix for health (HQCA, 2015). For more information about the NSQIP project, please contact Stacy Kozak, Manager, Surgery SCN at [email protected].

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Adult Coding Access Targets for Surgery (aCATS) Update

Adult Coding Access Targets for Surgery (aCATS); is a provincial project aimed at helping surgeons deliver surgical care in a safe and timely manner. The aCATS coding is will support and prioritize the booking of

surgeries, dependent on a patient’s diagnosis. For physicians, this means they can deliver the right treatment at the right time.

SPREAD AND OPTIMIZATION

The following sites have recently implemented aCATS or are starting soon:

Peace River – first week of November

Camrose – November/December

Drumheller – November/December

Stettler – November/December

FMC (Respirology) – November

Medicine Hat (General Surgery) – November

Lethbridge – mid November

Additionally, to support the scale and spread of aCATS, two newly revised surgeon waitlist reports were trialed and completed in Edmonton.

In Central Zone, the Surgeon Summary and Detail Reports will be released on November 12, 2015.

For additional information about these reports or the code review, please contact your local aCATS Lead.

Contact Information:

http://www.albertahealthservices.ca/11025.asp

Surgery SCN Staff and Project Updates

Stacey Litvinchuk—Executive Director,

Surgery SCN

Stacey Litvinchuk joined our team as our Executive Director on October 13, 2015.

Stacey has almost 20 years of progressive healthcare leadership experience; with a background in clinical practice, administration and strategic planning. Her experience spans across acute and primary care with previous roles that include front line nursing, management, education

and planning in Emergency, Trauma and Intensive Care. She most recently comes from the Provincial Rural Health Service Planning Division in the Provincial Primary Health Care Program where she spearheaded the development of the rural surgical and obstetrical service planning guidelines. She’s also been a dedicated member of the Surgery SCN core committee for well over 2 years!

Stacey has an Undergraduate and Graduate Nursing Degree from the University of Calgary. She is passionate about healthcare and has published articles on clinical practice and strategic planning in rural and urban settings. She is also the Vice Chair for the Canadian College of Health Care Leaders Southern Alberta Chapter.

Jillian Bates, Senior Consultant, Surgery

SCN

Jillian Bates joined our team as our Senior Consultant on October 19, 2015.

Prior to moving to Calgary Jillian worked in the role of Quality Leader for 12 years at The Hospital for Sick Children, Toronto, in Oncology, Haematology and Bone Marrow Transplant. Jillian’s primary areas of focus were quality

improvement, process improvement, evidence based care, policy procedure/guideline creation and validation, patient safety, and Accreditation. Jillian also has previous experience in Quality Management in Diagnostic Imaging and in Risk Management.

Jillian joined AHS in January 2015 as a Process Improvement Consultant. During this time, Jillian has been an educator in AHS’ Alberta’s Improvement Way and led several initiatives resulting in a reduction in patient wait times and centralized scheduling processes.

Jillian has a Bachelor of Science and a Masters of Health Administration. Jillian is also Lean Green Belt and Six Sigma Green Belt Certified.

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Enhanced Recovery After Surgery is moving beyond Colorectal surgeries into new pathways. Whipple Surgery, Total Pancreas, and Distal Pancreas order sets, data auditing, and patient recovery partnership education is being launched at three ERAS sites. The ERAS work within Colorectal is starting to produce more opportunities for clinical research. We are happy to share the below study done at the Grey Nuns Community Hospital by Dr. Cliff Sample, Dr. Michael Chatenay and Dr. Simon Byrns.

Enhanced Recovery After Surgery (ERAS) Update

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Many rectal cancer patients in Alberta receive excellent care that is evidence-based from diagnosis to treatment to follow-up. However, a review of Alberta data from 2013 and earlier revealed that some patients have inadequate surgical and oncologic therapy, sub-optimal MRI provision and pathologic assessment, and inconsistent clinical documentation. The specific gaps in care are as follows:

Only 50% of patients received an MRI before surgery;

Only 53% of stage II and 65% of stage III patients received neoadjuvant therapy ;

Lower 5-year recurrence rates and better 5-year disease free survival rates were associated with a surgeon case volume of

>9 rectal cancer surgeries per year; and

Only 78% of rectal cancer specimens were assessed for completeness (grade) of total mesorectal excision (TME).

To address these gaps in care, Drs. Todd McMullen and Don Buie initiated work in early 2013 on a rectal cancer clinical pathway in collaboration with the Cancer and Surgery Strategic Clinical Networks. A group of multidisciplinary physicians was assembled to work together to design the pathway and strategies for implementation. This 3-year initiative is funded by an Alberta Innovates – Health Solutions’ Partnership for Research and Innovation in the Health System (PRIHS) grant. The rectal cancer clinical pathway includes standards of care for pre-operative staging, neoadjuvant and adjuvant therapy, surgical therapy, and pathologic assessment. To implement these standards of care, this initiative is:

Engaging multidisciplinary physician groups across the province in understanding local challenges to implementing the

clinical pathway;

Delivering physician education opportunities to reinforce optimal care and highlight pitfalls in practice. This included a CME-

accredited education session attended by a total of 20 Alberta Surgeons across 12 different facilities, a province-wide pathology medical round delivered by internationally-renowned rectal cancer pathologist, Dr. Phil Quirke;

Implementing synoptic reporting for rectal cancer MRI and surgery. Cancer Surgery Alberta has been engaged in

development of an updated rectal cancer surgical synoptic report. Radiology groups have been engaged in implementation of a provincial synoptic MRI report for rectal cancer;

Developing a measurement and reporting system to provide physicians managing rectal cancer care ongoing feedback on

individual performance and outcomes. Cancer Surveillance and Reporting (C-MORE) has been engaged to lead the development of integrating multiple data systems into a provincial reporting system; and

Creating tools for establishment of multidisciplinary tumor boards to ensure provision of care according to clinical practice

guidelines.

The cost of advanced recurrent disease with additional surgery and extended chemotherapy is in the order of 250% more than the cost for patients undergoing optimal, pathway driven care. With successful implementation of a provincial pathway that reduces local recurrence rates for rectal cancer in Alberta to less than 5%, preliminary economic analyses show that upwards of $400,000 per year in cost savings could be generated. We are working to make the pathway sustainable beyond the life of the grant by engaging Zone Leaders and clinical operations teams to embed the pathway into existing work flow. Over the coming months, Drs. Don Buie and McMullen will be meeting with multidisciplinary groups of Surgeons, Oncologists, Radiologists, and Pathologists across the province to review current outcomes for rectal cancer patients and gather input on local barriers to implementation and feedback on plans to provide individual physician feedback on outcomes and performance for rectal cancer.

For questions or comments, please contact Adam Elwi, Senior Project Manager, Alberta Rectal Cancer Initiative at [email protected].

Improving Quality of Care for Patients With Rectal Cancer

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Surgery SCN Evidence Decision Support

Program

The Surgery SCN Evidence Decision Support Program (EDSP) provides a model to make evidence-informed decisions about whether and under what conditions, adoption of innovations should be implemented. The Program consists of a standing multidisciplinary committee (consisting of scientists, clinicians, nurse managers and administrators) and uses standardized forms and processes to gather both context-free and context-sensitive evidence on new technologies being considered. The objective is to review the evidence and make recommendations. The program sits at the interface between Evidence Based Medicine, Health Economics, Organizational Impact, Values and Decision making. The goal is to ensure patients receive optimal treatment while safety, training/credentialing, resources, and other organizational issues are considered. The team has also been invited to author a book entitled “The Evidence Decision Support Program (EDSP) within the Surgery SCN of AHS”, part of the book entitled “Hospital-Based Health Technology Assessment”, commissioned by Springer. The EDSP team is also excited to announce that they have received a “Knowledge To Action” (KTA) grant from Alberta Innovates- Health Solutions (AI-HS) to roll out the SSCN-EDSP framework to other SCNs including the Cardiovascular health and Stroke, Critical Care and Kidney SCNs. The team hosted a first SCNs retreat on Friday October 23rd and garnered strong interest and commitments for rolling out and testing the EDSP.

Staff safety is of paramount importance to achieving the AHS Mission: “To provide a patient-focused, quality health system that is accessible and sustainable for all Albertans.” When members of the Surgical Operations Support Group (SOS) group brought forward concerns about the potential risks for OR Staff who pour formaldehyde, they partnered with Workplace Health and Safety to investigate. Formaldehyde is a suspected human carcinogen that is linked to nasal cancer and lung cancer. Formalin is an aqueous solution containing 10%-37% formaldehyde that is used as a tissue preservative and fixative.

In June and July of 2015, Elaine Benoit, Occupational Hygiene Advisor, visited four sites across four zones to assess the level of formaldehyde exposure related to routine pouring of formalin. At each site, staff wore diffusion badges, places within their breathing zone. All sampling media were sent to the American Industrial Hygiene Association-accredited Cassen Testing Laboratories in Toronto, under chain of custody and analyzed using high performance liquid chromatography. Elaine was happy to report that the exposure levels were much lower than the legislated allowable limit, leaving the SOS group pleased that the current practices are effectively keeping staff safe.

Recommendations identified to reduce risk were:

1. Ensure that air exchanges meet the CSA Standard. 2. Ensure containers have appropriate WHMIS label. 3. Consider screw top lids rather than those which snap shut. 4. Use absorbent pads underneath containers of formalin to

absorb leaks or drips. 5. Spill kit supplies should be routinely checked (monthly) for

expired neutralizer. 6. Conduct “mock spill drills” regularly. 7. Develop Standard Operating Procedures (SOPs)

describing how to store, pour and transport. 8. Line sink with absorbent pad If pouring over a sink. 9. Store containers at or below eye level. 10. Avoid stacking of filled containers. 11. Consider limiting the quantities of containers being stored

and filled. 12. Retrieve pre-filled containers from the decontamination

room when required rather than in advance. 13. Use hand, eye and skin protection when pouring. 14. Consider having full face respirators on hand in the event

of a spill. If you have any questions about this initiative, please contact Stacy Kozak ([email protected]) or Elaine Benoit ([email protected]).

Safety in the OR: Understanding and

Managing Exposure to Formalin

Get the latest surgical research from the Surgery SCN Knowledge Resource Service at http://krs.albertahealthservices/surgery

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Adult Surgical Skin Preparation in the Operating Room/Treatment Areas: AHS Surgical Skin Preparation Policy

To minimize the risk of surgical site infections, the Surgery SCN developed the Adult Surgical Patient Skin Preparation in the Operating Room and Treatment Areas Practice Direction Manual and Adult Surgical Skin Preparation Practice

Direction Manual Policy.

These were developed to minimize the risk of surgical site infections and associated patient morbidity, and improve patient safety by standardizing surgical skin preparation with approved antiseptic agents across AHS surgical facilities.

The manual assists providers in making the right antiseptic selection for patients undergoing surgery, and provides the option to use different antiseptic agents based on patient characteristics and operative site.

Please review your current practices and implement required changes in light of this policy.

Questions or concerns? Contact

[email protected]

Leslie Deuchar has been a patient advisor on the Surgery Strategic Clinical Network (SSCN) since 2012 and in his tenure as an advisor he has seen many projects implemented that have positively influenced surgical care for all Albertans. Les, a retired farmer living in Northern Alberta, joined the Network because he believed in the vision of the SSCN of ensuring that patients have the “right surgical care, at the right place and time for all Albertans” (SSCN 2015-2018; Transformational

Road Map). Over the past 3 years Les feels projects like the Safe Surgery Checklist have supported this vision through guaranteeing the safety and quality of surgical service to patients like him. Les believes that the Network brings nurses, doctors, administrators and patients together to develop a community, in which issues of safety, quality and access can be explored and solutions developed in a supportive environment. Les states, “If an issue or concern is brought forward by a patient or clinician, the Network openly discusses solutions and supports each other. This is a great environment and as a patient, you really feel like everyone is working together to improve care.” Although the Network has made great strides, Les still feels there is more work to do. His personal vision for surgery in Alberta would see patients receiving seamless coordinated care throughout their surgical journey. Living in rural Alberta, Les understands the challenges of access to surgical care and follow up. In a presentation to the Network, Les identified that coordination of services across the patient surgical journey are a challenge for many Albertans. Speaking to personal experience in his presentation to the Network, Les commented that, “Too often it feels like no one is talking to each other and you have to drive to the city many days in a row for a short appointment. Can we coordinate surgeon specialties and tests both before and after surgery?” This is a hardship to many Albertans that can have financial and personal impact to their surgical experience. However, despite these challenges, Les is inspired by the Network and knows that some day his vision for seamless care and access for all Albertans will be a reality.

Interested in sharing a story in our next newsletter? Please contact [email protected]

MORE INFORMATION: In the coming months we will keep you posted on the work of our Surgery SCN. If you wish to learn more, or become more involved, please contact : [email protected] or [email protected]

COORDINATED SURGICAL CARE: A PATIENT’S VISION FOR SURGERY IN ALBERTA

CPSI Surgical Site Infection National Audit Opportunity

Safer Healthcare Now! A program of the Canadian Patient Safety Institute (CPSI) along with our partners Alberta Health Services-Surgery Strategic Clinical Network, Atlantic Health Quality & Patient Safety Collaborative, BC Patient Safety & Quality Council, Health Quality Ontario, and Saskatchewan Ministry of Health- Patient Safety Unit, invite you to participate in the Canadian Surgical Site Infection (SSI) Prevention Audit, designed to establish a national baseline for compliance with best practices in the prevention of SSI. http://www.patientsafetyinstitute.ca/en/Events/SSIAudit/Pages/default.aspx