Transcript Evidence Based Medicine for Hug

Quality & Safety at Hadassah
A Progress Report
September 12, 2006
Mayer Brezis, MD MPH, Professor of Medicine
Center of Clinical Quality & Safety
Chairman, Quality & Safety Committee
Quality at Hadassah: some statistics
Total number of projects
Completed projects
Cross-institutional projects
Number of physicians involved
Presentations at annual
meeting of Society for
Quality in Medicine
2004 2005 2006
41
40
36
8
14
18
9
14
12
28
40
36
23
36*
33*
* Best poster presentation award
36 projects completed as MD or MPH
theses; 20 peer-reviewed publications
Outline of presentation
• Appropriateness of Coronary
Revascularization
• Quality of Elective Surgery for Inguinal
Hernia Repair
• Reduction of Neurosurgical Shunt
Infections
• Quality of Reconstruction Surgery
After Mastectomy
• Hand-washing by Medical Staff
• Progress on Previous Projects
• Evaluation of Specific Patient Care
Appropriateness of Coronary
Revascularization Procedures at
Hadassah Hospital: Adherence to
Clinical Practice Guidelines
Dr. Dalit Cayam-Rand, Dr. Ronny Alcalai, Prof. Amir Elami & Prof. Mayer Brezis
Heart Institute, Department of Cardiothoracic
Surgery & Center for Quality & Safety, Hadassah
Coronary Artery
Bypass Graft (CABG)
surgery
Percutaneous
Coronary
Intervention
Development of guidelines
•
Institutional guidelines were developed by
senior cardiologists and cardiac surgeons at
Hadassah, in collaboration with the Center
for Clinical Quality & Safety. The guidelines
were derived from those of the American
College of Cardiology and Heart Association,
adapted on basis of most recent literature.
• The guidelines were approved by staffs of
both the Heart Institute and Department of
Cardiothoracic Surgery at Hadassah.
• Six months after approval, implementation
of guidelines was examined.
Sample from guidelines
CABG is the first option for:
1. Left main coronary artery stenosis
(level of evidence A)
2. Obstruction of origin of
left anterior descending (LAD)
artery and of circumflex artery
(level of evidence A)
3. Triple vessel disease, with diabetes
or renal failure (level of evidence A)
4. Proximal LAD with high risk for
angiographic treatment (level of evidence B)
5. Triple vessel or proximal LAD and
failure of angiographic treatment (level of
evidence C)
Rate of adherence to guidelines
Rating
N
%
271
85%
(2) Both procedures appropriate
19
6%
(3) Deviation for medical reasons
6
2%
(4) Deviation for patient’s preference
4
1%
(5) Deviation with no notable reason
18
6%
(1) Complete adherence to guidelines
Overall rate of inappropriateness: 6%
Corrected rate (out of referrals): 8%
Rates of appropriateness
according to angiogram results
Angiogram result
N
Normal coronaries or insignificant
86
disease
Appropriate
86 (100%)
Single-vessel coronary disease
99
95 (96%)
Double-vessel coronary disease
71
70 (99%)
Triple-vessel disease (TVD)
62
49 (79%)
TVD & diabetes or renal failure
20
7 (35%)
Proximal LAD disease with high
risk for angiographic treatment
17
10 (59%)
“For patients with two or more
diseased coronary arteries, CABG
is associated with higher adjusted
rates of long-term survival than
stenting.” Hannan, E. et al.
N Engl J Med 2005 352: 2174-2183
“CABG is still the best treatment
for multivessel and left main disease”
Professor David P Taggart
Cardiovascular Surgery, Oxford
BMJ, April 2, 2005
Conclusion
Overall adherence to guidelines
satisfactory (over 90%)
Adherence is suboptimal among
specific subgroups of patients:
with proximal LAD, triple vessel disease & diabetes
or renal failure
Results discussed with staff
Are patients sufficiently
informed?
Evaluation of Quality of
Elective Surgery for Inguinal
Hernia Repair in Adults and in
Children at Hadassah
Dr. Tal Yemini, Dr. Mahmid Badriah, Dr.
Yoav Mintz, Prof. Raphael Udassin, Prof.
Avraham Rivkind and Prof. Mayer Brezis
Departments of General and Pediatric Surgery,
Ein Kerem and Mt Scopus & Center for Quality
& Safety, Hadassah Hebrew University
Medical Center
Goal & Methods
Evaluation of quality of care for
unilateral hernia repair by following
criteria:
Overall satisfaction
 Pain
 Return to activity
 Complications

Comparison to literature
Prospective phone survey of


114 adults (age 14-87)
102 children (age 2-6)
Satisfaction
Satisfaction was high to very
high in 94% of both adults and
children;
88% of adult patients and 95%
of parents would recommend
having such operation at Hadassah
Problems reported: waiting and
relation with staff
Pain & return to activity
Children
Adults
Analgesics
Return to
activity
1 day
3-4 days
5 days
10-15 days
Results concord with reports in literature
About 10% of adults had still more pain after surgery
than before and not returned to work after 4-6 weeks.
These results are consistent with the notion that patients
with minimally symptomatic hernia may not need surgical repair
JAMA 2006;295:285.
Rates of Complications
Rate
95%
confidence
interval
Range in
literature
Infection
Children
Adults
6%
12%
Children
Adults
10%
13%
2-13
7-20
0.7-14%
Hematoma
5-18
8-21
11-15%
Reported range varies by site of study & methodology
& motive (is it voluntary or mandatory?)
Conclusion
Performance of surgical repair at
Hadassah is consistent with standards
reported in literature
We could not find similar reports from
other Israeli hospitals
Importantly, measurement of rate of
infection and feedback to surgeons has
recently been shown to be an efficient
tool to improve performance and reduce
infection rates*
* Reduction in infection rates by surveillance with follow-up
and feedback. British J of Surgery 2006;93:630-638
Can We Reduce
Neurosurgical
Shunt
Infections?
Dr. Ido Paldor, Dr. Zvi Israel, Prof. Colin
Block and Prof. Mayer Brezis
Departments of Neurosurgery and Infectious
Diseases & Center for Quality & Safety,
Hadassah Hebrew University Medical Center
Background
Hydrocephalus (accumulation of
cerebrospinal fluid due drainage
obstruction) is a neurosurgical
condition treated by insertion of
a shunt draining fluid from the
ventricles.
Infection is a serious
complication of shunt insertion,
with a high mortality rate.
Shunts coated with antibiotics
may reduce rate of infection.
Results: rate of shunt infection
40
35
30
25
% of shunts
20
infected
15
10
5
0
Number of
shunts inserted
Intervention
2001
10
2002
17
2003
21
2004-5
24
Mortality dropped from 50% (in infected
cases) to none after intervention
Conclusion
Intervention reduced rate of infection
from average of 25% to less than 5%,
and abolished mortality from infection
This may derive from antibiotic-coated
shunts and also from surveillance itself,
shown to reduce surgical site infections*
* Reduced risk of surgical site infections through surveillance
in a network. Int J Qual Health Care 2006;18: 127-133
Quality of Reconstruction
Surgery after Mastectomy
Dr. Ravit Yanco, Dr. Matan Cohen, Dr.
Ehud Kleiner, Dr. Helen Green & Dr.
Avraham Neuman
Department of Plastic Surgery & Center for
Quality & Safety, Hadassah Hebrew University
Medical Center
Results and Conclusion
These results are similar to outcomes
reported in the U.S.* and will help make
better choice of implant
* Reconstructive breast implantation after mastectomy for
breast cancer: clinical outcomes in a nationwide prospective
cohort study. Arch Surg. 2005;140:1152-1159.
Hand-washing by
Medical Staff
Dr. Dror Cantrell,
Prof. Zvi Stern, Prof.
Colin Block & Prof.
Mayer Brezis
Department of Clinical
Microbiology & Center for
Quality & Safety,
Hadassah Hebrew
University Medical Center
Increase in physicians handwashing by alcohol gel
100
*
80
% of
physicians 60
washing
40
hands
between
patient 20
contacts
0
Medicine
Surgery
*
* p<0.001
Alcoholchlorhexidine
replaced the gel
during 1 week
Alcohol Gel Available in Ward
baseline
1st
month
2nd
month
3rd
month
Conclusion
A committee for Infection Prevention
at Hadassah is now designing a systemwide intervention including: alcohol gel,
education and feedback with periodic
monitoring of adherence.
Alcohol gel is more expensive that
water & soap but if effective, this may
have considerable impact on the
difficult and costly problem of crossinfections by bugs increasingly
resistant to multiple antibiotics.
Evaluation of performance by a
specific surgeon being considered
for tenure at Hadassah
Physician A performs high-risk, complex operations 2.5 more
frequently than other surgeons. Post-surgical length of stay
for physician A’s patients is shorter by 3-4 days compared to
other high complexity patients (p= 0.01). Patients managed by
physician A showed a first-month mortality rate of 1 out of
339 (0.28%) not different from the rate of the rest of the
urological team over the same period: 7 out of 2164 (0.32%).
The bottom line was that physician A performs at
least as well as, and probably even better than the
other surgeons of the Urology department.
Progress on Previous Projects
• Improved glucose control for
hospitalized patients with diabetes
• Improvement of palliative care
• Patient’s empowerment to improve
effectiveness and safety of oral
anticoagulation
• Perioperative prevention of clots
• Improved patient instructions at
discharge after hip or forearm
fractures
www.hadassah.org.il/departments/quality
Summary & Conclusion
• Diverse projects attempt to make
healthcare at Hadassah more patientcentered, more evidence-based and
more system-minded.
• While in some areas, noticeable
improvements have been achieved, it
is increasingly apparent that further
successes require a systematic mode
of monitoring and feedback.
Acknowledgments
Prof. Yoel Donchin, Ms. Nurit Porat, Prof.
Amir Elami, Dr. Ronny Alcalai, Dr. Mahmid
Badriah, Dr. Yoav Mintz, Prof. Raphael Udassin,
Prof. Avraham Rivkind, Dr. Zvi Israel, Prof.
Colin Block, Dr. Ravit Yanco, Dr. Matan Cohen,
Dr. Ehud Kleiner, Dr. Helen Green, Dr.
Avraham Neuman, Prof. Zvi Stern, Dr. Rony
Braunstein, Dr. Rami Oren, Ms. Lois Gordon, &
many other physicians, nurses, pharmacists &
students greatly contributed to projects
described in this report.