1. 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 measuresEnvironmental 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, MD University of Virginia Melanie Morris, MD University of Alabama Skandan Shanmugan, MD University of Pennsylvania Mariana Pehar Johns 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 20 th !SUSP Affinity Group Registration Link Click this link SUSP Affinity Group Registration Link to register for an affinity group by Tuesday, May 20 th !SUSP Affinity Group Registration Link

2. Thomas Varghese Jr. MD, MS, FACS

3. 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

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

5. Our Shared Project Goals To achieve significant reductions in surgical site infection and surgical complication rates To achieve significant improvements in safety culture

6. 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

8. Problems Every year there are 210,000 Preventable Deaths $30 billion per year J Patient Safety Sept 2013; 9(3): 122-128

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

10. 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 2003 J Am Med Inform 2001; 8(4):398-399 N Engl J Med 2003; 348:2635-2645

11. Healthcare System in Washington State QI Performance Surveillance Translation of Research into Practice Research and Development

12. Clinician-led QI using clinical data Focus on quality and cost-effectiveness data Impacts behavior through: Benchmarking Education Standard orders Checklists

13. Before Elective Colorectal Resection, CHARS 2000-2003

14. After Elective Colorectal Resection CHARS 2006-2009

15. Evidence Generation Clinical Practice Partners Dissemination & Implementation Clinician Offices Long-term Care Facilities Hospitals

16. Evidence Generation Clinical Practice Partners Dissemination & Implementation Healthcare Data Patient Voices Stakeholder Input Clinician Offices Long-term Care Facilities Hospitals

17. Evidence Generation Clinical Practice Partners Dissemination & Implementation Healthcare Data Patient Voices Stakeholder Input Clinician Offices Long-term Care Facilities Hospitals

18. Focus on Decision Making PATIENT DOCTOR’S OFFICE OPERATING ROOM

19. PATIENT DOCTOR’S OFFICE OPERATING ROOM

20. PATIENT DOCTOR’S OFFICE OPERATING ROOM Focus on Decision Making in Clinic

22. 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

23. 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

24. 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;22:607 Dellinger. Inf Contr Hosp Epidemiol. 2001;22:604

25. 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;22:607 Dellinger. Inf Contr Hosp Epidemiol. 2001;22:604 Lancet 2012; 2279-2290 2011 US Department of Health and Human Services

26. > 65 years 1 in 4 will have diabetes 2 in 4 are prediabetic 2011 US Department of Health and Human Services Why Blood Sugar?

27. 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

28. 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

29. Why Nutrition? Malnutrition is prevalent in surgical patients Best determinant of surgical outcome

30. Why Nutrition? Malnutrition is prevalent in surgical patients Best determinant of surgical outcome Modifiable with appropriate intervention Immunonutrition may improve recovery

31. SCOAP: Albumin & Complications Elective colon/rectal procedures 2011

32. 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

33. 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

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

35. 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. Adjusted Odds Ratio Complications Associated with Smoking

36. Post-Operative Outcomes by Pack-Years Smoked Mary T Hawn et al., “The Attributable Risk of Smoking on Surgical Complications,” Annals of Surgery 254, no. 6 (December 2011): 914–920.

37. Checklists

43. Raising Awareness Changing Practice

44. Raising Awareness

45. Public Health Campaign Understanding clinic and patient needs Checklists Tracking outcomes Strategic partnerships Community Engagement Outreach events Website content www.strongforsurgery.org

47. Publications OR MANAGER

48. By Laura Landro

51. 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

52. 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

53. Changing Practice

54. 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

55. SUSP Teams’ Group Processes Effective Group Processes Norms Role Clarity Effective Team Communication Effective Team Communication Conflict Resolution Education and Engagement Education and Engagement Leadership Buy-in and Support Leadership Buy-in and Support

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

57. Site Activities Pre-Assessment Workflow Mapping Assessment of Resource Needs Feedback – clinicians and staff Post-Assessment

58. For More Information Visit the website: http://www.strongforsurgery.org http://www.strongforsurgery.org Review the literature View our checklists Request the implementation guide E-mail us: strongforsurgery@becertain.orgstrongforsurgery@becertain.org @TomVargheseJr @Strong4Surgery StrongforSurgery

59. 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 measuresEnvironmental 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, MD University of Virginia Melanie Morris, MD University of Alabama Skandan Shanmugan, MD University of Pennsylvania Mariana Pehar Johns 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 20 th !SUSP Affinity Group Registration Link Click this link SUSP Affinity Group Registration Link to register for an affinity group by Tuesday, May 20 th !SUSP Affinity Group Registration Link