1. Improving Outcomes through Pre-hospital Checklists Thomas Varghese Jr. MD, MS Presented at Washington State Hospital Association Safe Table, July 31, 2013

2. Healthcare System in Washington State QI Performance Surveillance Translation of Research into Practice Research and Development Presented at Washington State Hospital Association Safe Table, July 31, 2013

3. Clinician-led QI using clinical data Focus on quality and cost-effectiveness Data Impacts behavior through: Benchmarking Education Standard orders Checklists Presented at Washington State Hospital Association Safe Table, July 31, 2013

4. Before Elective Colorectal Resection, CHARS 2000-2003 Presented at Washington State Hospital Association Safe Table, July 31, 2013

5. After Elective Colorectal Resection CHARS 2006-2009 Presented at Washington State Hospital Association Safe Table, July 31, 2013

6. Evidence generation CER/PCOR Partners in QI and Research Evidence into Practice Leverage Healthcare Data Patient Voices Stakeholder Input Clinician Offices Long-term Care Hospitals Presented at Washington State Hospital Association Safe Table, July 31, 2013

7. Focus on Decision Making PATIENT DOCTOR’S OFFICE OPERATING ROOM Presented at Washington State Hospital Association Safe Table, July 31, 2013

8. PATIENT DOCTOR’S OFFICE OPERATING ROOM Presented at Washington State Hospital Association Safe Table, July 31, 2013

9. PATIENT DOCTOR’S OFFICE OPERATING ROOM Focus on Decision Making in Clinic Presented at Washington State Hospital Association Safe Table, July 31, 2013

11. What is Strong for Surgery? State-wide public health campaign  Evidence-based practices to optimize the health of patients prior to surgery  5 Pilot sites:  Virginia Mason  Swedish  Skagit Valley Medical Center  Harborview  UW Medical Center Presented at Washington State Hospital Association Safe Table, July 31, 2013

12. Optimizing nutrition Smoking Cessation Medications Blood sugar control Presented at Washington State Hospital Association Safe Table, July 31, 2013

13. Why Nutrition? Malnutrition is prevalent in surgical patients. Best determinant of surgical outcome. Modifiable with appropriate intervention. Immunonutrition may improve recovery. Presented at Washington State Hospital Association Safe Table, July 31, 2013

14. Why Blood Sugar? Link between high blood sugar levels and SSIs Hyperglycemia - doubled risk of SSI In some studies 47% of hyperglycemic episodes were in nondiabetics ! 470 million people worldwide will have prediabetes by 2030 5%-10% per year will progress to diabetes 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;22:607 Dellinger. Inf Contr Hosp Epidemiol. 2001;22:604 Lancet 2012; 2279-2290 2011 US Department of Health and Human Services Presented at Washington State Hospital Association Safe Table, July 31, 2013

15. Why Blood Sugar? > 65 years 1 in 4 will have diabetes 2 in 4 are prediabetic 2011 US Department of Health and Human Services Presented at Washington State Hospital Association Safe Table, July 31, 2013

16. Why Medications? Some medications and Herbal remedies ↑ risk of bleeding 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 Presented at Washington State Hospital Association Safe Table, July 31, 2013

17. Why Smoking? Smoking is prevalent 1/3 of all patients Smokers have ↑ risk of complications  Pulmonary  Circulatory  Infectious  Impaired wound healing Presented at Washington State Hospital Association Safe Table, July 31, 2013

19. Nutrition Screening Any YES  refer to RD 1.Is BMI less than 19? 2.Has patient had unintentional weight loss of >8 pounds in 3 months? 3.Has the patient had a poor appetite eating less than half of meals or fewer than two meals per day? 4.Is the patient unable to take food orally due to dysphagia or vomiting? Ana Isabel Almeida et al. Clinical Nutrition 31 (2012) 206-211. H.M. Reilly, et al. Clinical Nutrition (1995) 14 269-273.

21. Risk Stratification Hypoalbuminemia is an independent risk factor for SSI following surgery Hennessey DB, et al. Ann Surg. 2010;252:325–329. Presented at Washington State Hospital Association Safe Table, July 31, 2013

22. SCOAP: Albumin & Complications elective colon/rectal procedures Presented at Washington State Hospital Association Safe Table, July 31, 2013

24. Arginine Deficiency Syndrome T-Cell Dysfunction Risk of INFECTION Surgery and trauma patients are immune suppressed making them more susceptible to infection due to arginine deficiency. Immune- modulating formulas containing arginine, n-3 fatty acids, and nucleotides have been specifically designed to help meet the unique nutritional needs of the surgery and trauma population. Popovich 2006; McClave 2009; Zhu 2010 Presented at Washington State Hospital Association Safe Table, July 31, 2013

25. Systematic Review N=3,438 35 studies focused on elective surgery Procedure types 25 GI: 18 upper; 2 lower; 5 mixed 10 non-GI 23 – used arginine-based supplements Pre-Op Use: ↓ Infectious complications 43% Literature Review Drover JW, et al. JACS 2011; 212 (3):385-399 Presented at Washington State Hospital Association Safe Table, July 31, 2013

26. Literature Review Meta-analysis: 26 RCTs N = 2496 1252 Immunonutrition vs 1244 Control (Isocaloric) ↓ infection rates by 46% ↓ length of stay ~ 2 days Marimuthu K, et al. Ann Surg 2012; 255:1060-1068 Presented at Washington State Hospital Association Safe Table, July 31, 2013

27. Goals of Nutrition Target Universal measurement of albumin Pre-operative screening for malnutrition Increase the use of appropriate, evidence-based nutritional support Malnourished Complex Surgery Presented at Washington State Hospital Association Safe Table, July 31, 2013

29. Checklists

30. Public Health Campaign Statewide awareness Media events Website Mobilizing the community Strategic partnerships Surveillance and Feedback Change in behavior Presented at Washington State Hospital Association Safe Table, July 31, 2013

31. www.strongforsurgery.org Presented at Washington State Hospital Association Safe Table, July 31, 2013

32. Building a Public Health Campaign: Developing a Social Media Presence 85 “Likes” across 5 states (and South Africa!) 115 Posts Frequency 3/week 7406 Total Hits 5123 Unique Hits 11% of Total Hits in last month Group shared with CERTAIN Discussion post 1-2/month 139 Tweets 226 Followers 902 Following Frequency 6/week 824 Tweets 267 Followers 246 Following Frequency ~30/week Presented at Washington State Hospital Association Safe Table, July 31, 2013

33. Initiating a Public Health Campaign Publications OR MANAGER Presented at Washington State Hospital Association Safe Table, July 31, 2013

35. An electronic system to capture checklist components, pre-op optimization plan, and patient compliance Nutrition and Smoking Cessation Easy linking to SCOAP and other datasets Purpose Available for all SCOAP/S4S clinics Integration with EHRs Personalized dashboards for individual patient risk assessment, outcomes evaluation, and care planning Long-term Goals Presented at Washington State Hospital Association Safe Table, July 31, 2013

36. Patient completes S4S Checklists online prior to preoperative clinic visit, either at home or in the clinic A report of the patient’s answers is delivered to the clinician electronically The clinician reviews with the patient, and documents the preoperative optimization plan The patient is sent reminders about preoperative plan up until the day of surgery Data is linked to SCOAP for surgical outcomes evaluation and sent back to the clinicians’ office Presented at Washington State Hospital Association Safe Table, July 31, 2013

37. Height: Feet, Inches Weight Weight Loss Poor appetite PO Intolerance Inpatient operation? Complex surgery? BMI Calculation BMI <19? Yes No Yes No Yes No Dietitian Referral Check Albumin Immunonutrition ELECTRONIC CHECKLIST COMPONENTS - NUTRITION Patient Identifiers to Link to SCOAP PATIENT INPUT CLINICIAN INPUT Presented at Washington State Hospital Association Safe Table, July 31, 2013

38. ELECTRONIC CHECKLIST COMPONENTS - SMOKING Ever Smoked? Smoked Within the Last 30 Days? Total Years Smoked Packs Per Day Quit >24h Yes to either No Yes No Done Discussion About Quitting Consider: Quit Line Consider: NRT Consider: Rx Set Quit Date Motivation to quit Low Med High How long ago? Longest time without smoking? Time since quitting Other tobacco? Presented at Washington State Hospital Association Safe Table, July 31, 2013

39. Change System/Individual Behavior Education Surveillance and Feedback Administrative Changes Peer to peer forces Penalties Rewards Presented at Washington State Hospital Association Safe Table, July 31, 2013

40. Education Surveillance and Feedback Administrative Changes Peer to peer forces Penalties Rewards Presented at Washington State Hospital Association Safe Table, July 31, 2013

41. Get Involved Attend Campaign Events E-mail: tkv@uw.edutkv@uw.edu strongforsurgery@becertain.org Inform Your Colleagues and Constituents Visit the website: http://www.strongforsurgery.org http://www.strongforsurgery.org Presented at Washington State Hospital Association Safe Table, July 31, 2013

42. THANK YOU! Presented at Washington State Hospital Association Safe Table, July 31, 2013