1. Interactive voice response systems: A potential method to track surgical site infections Alan J. Forster MD FRCPC MSc Scientific Director, Clinical Quality and Performance Management, The Ottawa Hospital Career Scientist, Ontario Ministry of Health and Long Term Care

3. Acknowledgments TOH OHRI CPSI Capital Health Vocantas Inc Carl van Walraven Natalie Oake Alison Jennings Nadea Saikaley

4. Surgical site infections Infection at site of surgery within 30 days of surgical date (1 year if foreign body) Common type of hospital acquired infection –3 rd most common HAI –Risk 2%-10% –30% of SSI involve deep structures Costly Timing: the majority of SSIs occur after discharge

5. Importance of day surgery in Canada growing +30% -20% +16% No. of cases in millions;Source: CIHI 2007

6. Interactive voice response systems (IVRS) Information technology – connects people to database using a telephone interface Consists of specific hardware and software Call scripts are programmed These are activated by various triggers Responses to prompts result in data fields being populated Subsequent prompts (or other actions) occur as a result of new data Commonly used in business

7. IVRS enables feed-back loops Reminders –Clinic appointments –Testing Monitoring –Condition –Compliance

8. Systematic review of published studies -Methodology MEDLINE search –Time period: 1950 to January 18, 2008 –Terms: » interactive + voice + response »calling + system »(telephony or telecommunications) + voice »automated + telephone Inclusion criteria –RCTs and CCTs that examined the effect of an IVRS intervention on clinical and/or process outcomes Two reviewers independently abstracted study data Outcomes were grouped into 1 of the following categories –Clinical endpoints (e.g. hospitalization, death) –Surrogate outcomes (e.g. HbA1c, total cholesterol) –Patient process adherence (e.g. immunization) –Patient-reported quality-of-life (e.g. Addiction Severity Index)

9. Literature validating patient response > 60 studies have compared the validity and reliability of data collected using an IVRS with standard data collection methods (e.g. in-person interviews, paper-and-pencil questionnaires) Examples: » Reported alcohol consumption / substance abuse »Depression screening tools Overall, IVRS yields valid and reliable data –Cost and time-effective –Participation rates are generally high –Participants may be more willing to disclose sensitive information to an IVRS

10. 38 included studies (29 RCTs and 9 CCTs) –Median sample size: 230 (Interquartile range 122-648) –IVRS aimed at changing behavior: N=23 E.g. immunization, physical activity –IVRS aimed at managing chronic disease: N=15 E.g. diabetes, heart failure Clinical endpoints – 3 studies –IVRS intervention associated with improved outcomes in 2 studies Surrogate outcomes – 7 studies –Overall, the IVRS interventions were associated with non-significant improvements in all outcomes Patient process adherence – 28 studies –Overall, the IVRS interventions were associated with improvements in outcomes (median effect 7.85% absolute improvement, 95% CI 2.8-19.5) Patient-reported quality-of-life – 8 studies –Overall, the IVRS interventions were not associated with improvements Systematic review of published studies -Results (preliminary findings)

11. Systematic review of published studies -Conclusions IVRSs are increasingly being used in healthcare settings Some IVRSs are part of an overall strategy while others are stand alone interventions Patient process adherence and quality-of-life outcomes are the most frequently reported Few studies examine clinical endpoints or surrogate outcomes IVRSs are a potential solution for improving the quality of ambulatory care

12. (Am J Manag Care. 2008;14(7):429-436) Objectives: To determine acceptability and feasibility of IVRS based follow up system To determine number of patients in whom intervention based on IVRS changes treatment To determine adverse event frequency and type following discharge

13. IVRS Hospital RN enters Pt data into IVRS Pt ID Phone # D/C date WWW Home phone Cell phone Other phone (work, family, friend, etc.) Questions 1.Right Pt? 2.New or worsening symptoms? 3.(Problems with surgery?) 4.Problems with medications? 5.Desire connection to Health Link? IF YES Nurse Post D/C Intervention

14. Methods Prospective cohort design Patients –Surgical: Consecutive women planned for gynecological day-surgery Exclusion: No phone, dementia, failure to provide informed consent

15. PATIENT FLOW Pt admitted to RAH Gyne Day Surgery Unit Gyne Surgery D/C from RAH Routine Care 30 days STUDY INTERVENTIONS Info entered into study DB & Pt assigned study ID Study ID, phone #, & D/C date entered into IVRS IVRS calls Pt Consent for study Post D/C Day 1 Analysis of call results Telephone survey Capital Health DB access Encounter Hx Lab data Health Link DB access Call records Analysis of outcomes Analysis of Pt experience

16. Study flow Potentially eligible patients N=317 Patients enrolled: N=270 (85%) Entered into IVRS N=266 (99%) 30 day follow up complete N= 249 (92%) Excluded patients: N=47 (15%) Missed opportunity Refused consent

17. Patient characteristics Surgery –Age: 38 years (31-48) –<10% had a chronic illness –4% had no functional limitations in terms of ADL’s –Discharged on day of discharge – 244 (98%)

18. Adverse events 33 patients (12% (95% CI: 8%-17%) Preventable but almost no ameliorable Major types: Therapeutic errors, adverse drug events, other

19. IVRS call flow 381 automated calls recorded 163 patients ‘answered’ calls 130 patients (52% of all patients) answered ‘yes’ when asked whether they were the correct patient 129/130 patients answered at least one question 104/130 patients answered all questions Answered ‘yes’ to at least one question=17

20. Patient perceptions n=96

21. Adverse events 40 patients (16% (95% CI: 12%-22%) Major types: Wound infection, pain, bleeding, UTIs, Anaesthesia complications 31 patients required corrective actions for their AE Timing of event start: median delay 9 days (IQR 3.0-15.5) –90% of problems started after day 1

22. Interventions No IVRS call resulted in the provision of HealthLink advice! Most AEs happened after call Therefore, IVRS did not result in the identification of any AEs

23. Summary Patients accept IVRS intervention and find it useful System design issues need to be addressed particularly, –Timing –Response Efficient method of providing follow up calls

24. Proposal: Ambulatory care SSI surveillance using an IVRS Automated calls days 5, 15 and 30 post discharge Simple questionnaire –Do you have any of the following … at your surgical site? –Have you seen an MD following your surgery? –Would you like to speak with a nurse? Notification to nurse working in surgical unit (PAU, SDCU)

25. If you do decide to implement, you need to consider implementation barriers. Consider technical and organizational factors.

26. Technical factors Patients do not dislike the program –It is relatively familiar technology and simple to use –Often patients think it is a person calling –Operate on KISS principle Software and hardware –Well established –System design is relatively straight forward –System integration is not difficult

27. Organizational factors Financial barriers –In-house expertise? Technical barriers –IS/IT Departmental protocols –Ongoing support Administrative barriers –Competing priorities

28. Summary Surgical site infections Description of IVRS technologies Literature review of IVRS technologies in healthcare Review study using IVRS technologies to monitor adverse events following day surgery Proposal: can an IVRS be used to monitor SSIs? - Yes