1. Defining the Problem TEACH Level II Workshop 1 NYAM August 7 th, 2013 Craig A Umscheid, MD, MSCE, FACP Assistant Professor of Medicine and Epidemiology Director, Center for Evidence-based Practice University of Pennsylvania

2. 2 Outline  A Case  Using Evidence to Define the Problem  Building a Team to Define and Address the Problem  Consumer Involvement  Framing Options to Address the Problem

3. 3 A Case: Surgical Site Infections You’re the Chair of the Department of Surgery Quality Committee at your medical center, and you receive a call from your Chief Medical Officer regarding a report that your state just released about SSI rates at medical centers across the state. It’s not good news. Your medical center had the highest rate of SSIs in the state.

4. 4 Using evidence to define the problem  Does it warrant attention? Is it a misperception?  Local evidence Anecdote vs. data Compare over time, across units, across institutions Structure, process, outcome  Peer-reviewed evidence National estimates Compare local practices to national recommendations Published QI initiatives Mitchell MD, et al. Integrating local data into hospital-based healthcare technology assessment: two case studies. Int J Technol Assess Health Care. 2010;26(3):294-300. Lavis JN, et al. Using research evidence to clarify a problem. Health Research Policy and Systems. 2009, 7(Suppl 1):S4 doi:10.1186/1478-4505-7-S1-S4.

5. 5 HAI HAIs (N) Deaths (N) Reduction in infection risk with QI Preventable infections (N) Preventable deaths (N) Estimated cost per infection case (2009 dollars) Avoidable Infection Costs (millions of 2009 dollars) SSI290,4858,20526%–54% 75,526– 156,862 2,133– 4,431 $2,100 $159M- $329M Summary estimates of annual rates of preventable infections, deaths, and costs for SSIs Klevens RM, Edwards JR, Richards CL, Jr, et al. Estimating healthcare-associated infections and deaths in US hospitals, 2002. Public Health Rep. 2007 Mar-Apr; 122(2): 160-6. Umscheid CA, Mitchell MD, Doshi JA, Agarwal R, Williams K, Brennan PJ. Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Infect Control Hosp Epidemiol. 2011; 32(2):101-14.

6. 6 National Standards  CMS Partnership for Patients Nine core areas of focus, four areas are HAIs: –SSI –CAUTI –CABSI –VAP  Joint Commission’s 2011 National Patient Safety Goals NPSG.07.05.01 –Use proven guidelines to prevent infections after surgery NPSG.07.04.01 –Use proven guidelines to prevent infection of the blood from central lines NPSG.07.06.01 –Use proven guidelines to prevent indwelling catheter-associated urinary tract infections

7. 7 SCIP Measures  SCIP-Inf-1: Prophylactic Antibiotic Received Within 1 Hour Prior to Surgical Incision  SCIP-Inf-2: Prophylactic Antibiotic Selection for Surgical Patients  SCIP-Inf-3: Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery Ends  SCIP-Inf-4: Cardiac Surgery Patients With Controlled 6 A.M. Postop Blood Glucose  SCIP-Inf-6: Surgery Patients with Appropriate Hair Removal  SCIP-Inf-10: Surgery Patients with Periop Temperature Management

8. 8 SSI prevention practices from studies included in review of HAI preventability  Appropriate use of perioperative antibiotics  Decreased use of preoperative shaving  Improvement in perioperative glucose control  Clinician education, reminders, and audit and feedback  Patient education Dellinger EP, Hausmann SM, Bratzler DW, et al. Hospitals collaborate to decrease surgical site infections. Am J Surg. 2005;190(1):9-15. Lutarewych M, Morgan SP, Hall MM. Improving outcomes of coronary artery bypass graft infections with multiple interventions: Putting science and data to the test. Infect Control Hosp Epidemiol. 2004;25(6):517-9. Rao N, Schilling D, Rice J, Ridenour M, Mook W, Santa E. Prevention of postoperative mediastinitis: A clinical process improvement model. J Healthc Qual. 2004;26(1):22-7. Umscheid CA, Mitchell MD, Doshi JA, Agarwal R, Williams K, Brennan PJ. Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Infect Control Hosp Epidemiol. 2011; 32(2):101-14.

9. 9 Building a team to define and address the problem  Key stakeholders  Multidisciplinary  Champions  Executive leadership (credibility, resources, influence)  Conflicts of interest Harris C, Turner T and Wilkinson F. Guideline Development Toolkit. (2008) The Centre for Clinical Effectiveness, Southern Health, Melbourne, Australia.

10. 10 Consumer Participation In Evaluation (PIE) Matrix

11. 11 Framing options to address the problem  Frame or “fit” problem within priorities of leadership to motivate support and solutions Lavis JN. Using research evidence to clarify a problem. Health Research Policy and Systems. 2009, 7(Suppl 1):S4 doi:10.1186/1478-4505-7-S1-S4

12. Monitor Knowledge Use Sustain Knowledge Use Evaluate Outcomes Adapt Knowledge to Local Context to Local Context Assess Barriers to Barriers to Knowledge Use Knowledge Use Select, Tailor, Select, Tailor, Implement Interventions Identify Problem Identify Problem Identify, Review, Identify, Review, Select Knowledge Select Knowledge Products/Tools Synthesis Knowledge Inquiry Tailoring Knowledge KNOWLEDGE CREATION