Doing Our Bestindianasgna.org/.../2019/03/Slides-Endoscopic-Safety.pdf · 2019. 3. 13. · •...

DoingOurBest:

CreatingaCultureofQualityinEndoscopy

AndrewE.Katz,M.D.LutheranHealthPhysicians

WhereWeAre

75millionEndoscopiesinUSAin201751.5millionGIEndoscopies

WhereAreWe?

AnnIntMed2005;142:756-764

WhyAreWeHere?•  Endoscopyisthoughttobesafe

•  Howsafe?Studiesinlargeseriesshow:

–  SeriousEvents1in200to1in10,000– Mortalitynoneto1in2000

–  ClinicalOutcomesDatabasefrom140,000EGDs:

•  CardiopulmonaryEvents1in170

•  Mortality1in10,000

–  Buttherearelimitationsonthecurrentstudies

LimitationsoftheMetrics?

•  Variabilityindatacollection–  SomeReportminorincidentssuchastransienthypoxemia

–  SomeReportonlyincidentspreventingcompletionofthe

procedure

•  SelfReportedData

•  NoStandardData

•  ImmediatePeri-ProcedureOnly

WhatCanGoWrong?

•  CardiopulmonaryEvents

– 60%0fadverseEvents

– RiskFactors•  ASA3orhigher

•  Age>80

•  PreexistingCardiopulmonaryDisease

WhatCanGoWrong?

•  CardiopulmonaryEvents:

– ProcedureRelatedRiskFactors

– Difficultyintubatingesophagus

– Prolongedprocedure

– PronePatient

WhatCanGoWrong?•  CardiopulmonaryEventsReported:

– MinorO2DesaturationorDecreaseinHeartRate

– Aspiration

– RespiratoryArrest

– MI,Stroke,Shock

WhatCanGoWrong?EGD

•  Bleeding

– MalloryWeissTearw/EGD<0.5%

– NominimumSafeLevelofPlateletesestablished

butrecommendatleast20,000fordiagnostic

EGDand50,000forbiopsies.

WhatCanGoWrongEGD

•  Perforation–  1in2500to1in11,000

–  IncreasedRiskEsophagealStricture,

EosinophillicEsophagitis,Zenker’sDiverticulum,

DuodenalDiverticulum,Cancer

– MortalityRate2-36%

– NeedtoIdentifyEarly

WhatCanGoWrong?EGD

•  Infections– ProcedureRelated

•  TransientBateremiaupto8%

•  Endocarditisrisksolownotabletobemeasured

•  AntibioticProphylaxonlyfor–  VaricealInjection–  PEG

–  Scope/InstrumentProcessing

WhatCanGoWrong?Colon

•  Cardiopulmonarymostcommonintraprocedure

–  0.9%overall,2/3ofallcomplictions

•  Transienthypoxemia230/100,000

•  ProlongedHypoxemia0.78/100,000

•  Hypotension480/100,000

ClinicalOutcomesResearchInitiative(CORI)2008

WhatCanGoWrong?Colon•  30DayPostProcedure

–  MedicarePtsCVHospitalizations(MI,Angina,arrhythmia,CHF)

•  1030/100,000PostColonoscopy•  885/100,000Controls

–  ProspectiveCORI30dayrisk1.4per1,000Colonoscopies

•  Angina

•  MI

•  Stroke•  TIA/RIND

ClinicalOutcomesResearchInitiative(CORI)2008


•  MinimizeRisksinHighRisk

– ASA3-5,Age>80,Comorbidities

•  Anesthesia/Cardiology/PulmE&M

•  DelayElectiveProceduresuntilEvaluated

•  ContinueAntiplateletAgentsPeri-procedure


•  Perforation

– ColonoscopeItself

– BarotraumafromInsufflation

– TherapeuticManuvers


•  Perforation

– PostProcedureAbdominalPainandDistension

– CXR/KUB/Upright

– CTmoresensitive

–  IfpatienthassxandPlainfilmsnegative,getCT.


•  Perforation

– 0.3%orless

•  277,434MedicaidPts8.2/10,000vs0.3/10,000matched

controls

•  >50,000MedicarePatients5-7/10,000

– NodifferencebetweenPolypectomyorDiagnostic


•  Bleedingearlyorlate–  2.1-3.7/1000forscreeningordiagnosticalone

–  8.7/1000withpolypectomy

– NoassociationbetweenASA/NSAIDusealoneand

bleeding

–  IncreasedRiskwithASA/NSAIDandPlavixbutneither

alone


•  Infection

–  TransientBacteremia4%

–  InfectionRare

–  PreprocedureAbxnotindicated

•  PostpolypectomySyndrome

–  ElectrocoagulationInjurywithoutperforation

•  Death(AllCauses)

–  2010review128Deaths/within30daysin371,099Colonoscopies(0.03%)

•  GasExplosion

WhatCanGoWrong?

•  SpecificProcedures–  PEG

•  4.9-10.3%

–  MinorandSerious

•  Seriousevents1.5%-9.4%

•  Aspiration,Bleeding,Ileus,Infection,Damagetounderlyng

organs,NecrotizingFasciitis,Death

•  PEGMortality0.53%

•  30dayOtherCauseofDeath14.7%

WhatCanGoWrong?

•  SpecificProcedures

– ForeignBodyRemoval(ScopevsFB)

•  Laceration<2%

•  Bleeding<1%

•  Perforation<0.8%

WhatCanGoWrong?

•  SpecificProcedures:Dilation0.1%-0.4%

– Perforation

– Bleeding

– Aspiration

– Bacteremia

EndoscopyisfundamentallySafeBut

AreWeDoingOurBestForOurPatients?

QualityImprovementinHealthcare

•  LessonslearnedinAviation,Automotive,and

NuclearPowerIndustries

•  EvidenceBasedChangesinPractice

– Goal:ProvideHighestQualityCare

•  Notignoringcostsandaccessibilityofcare

ToErrisHuman:BuildingaSaferHealthcare

SystemTheInstituteofMedicine

•  November,1999

ToErrisHuman:IOM1999

•  44,000->98,000deathsperyearinHospitalsfrompreventablemedicalerrors

•  Top10CausesofDeathinUSA

•  Costoferrors:$17-$29billionperyear:increasedcare,lostincome,losthousehold

productivity

SystemErrorsnotHumanErrors

•  Humanshavelimitations

– Multitasking

– Concentration

– ProlongedAttention

SystemsFailure

EachSourceofErrorisasliceofSwisscheese

SystemsErrors->SystemsResponse

•  IndividualsDoMakeMistakes

– ActiveFailures

– HittingaholeintheSwissCheese

•  MostErrorsaretheresultofSystemsFailures

– RobustSystemsErrorPreventionpreventsmost

activeerrorsandotherproblemsfromcausingharm

Errors

•  Diagnostic

– Error/DelayinDx

– Failuretoemployindicatedtests

– UseofOutmodedtest/therapy

– Failuretorespondtoresults

Errors

•  Treatment

– Errorinperformance/administration

– Errorindose/method

– AvoidableDelay

–  InappropriateCare

Errors

•  Prevention–  FailuretoProvideProphylacticTreatment

–  Inadequatemonitoringorfollow-uptreatment

•  Other

–  Failureofcommunication

–  EquipmentFailure

– OtherSystemFailure(s)

IoM:CrossingtheQualityChasm

•  6DimensionsofHealthCare

–  Safety

–  Efficacy

– Patient-CenteredCare

–  Timeliness

–  Efficiency

–  Equality

TQM:TotalQualityManagement

•  BeganinJapaneseManufacturing

•  USNavyAdopted


•  Standardization

– Training

– Equipment

– Processes


•  1950sW.EdwardDemingPDCAcycle

– Plan(toimprovetheprocess)

– Do(whatyouplan)

– Check(Monitorwhatwasdone)

– Act(Actionplaninresponsetooutcome)


•  QualityAssuranceisaContinuousProcessnot

astaticgoal


•  DonaldBerwick,M.D.

– Pediatrician

– AppliedTQMPilotStudy21Hospitals

•  MajorImprovementsinOutcomesinHealthcare

ApplyingthesePrinciples

•  BasisofTQM/6SigmainHealthcare

QAinHealthcare

•  Outcomesin3levels

– StructuralLevel

– ProcessLevel

– ClinicalOutcome

Level1:StructuralIssues

•  PhysicalCharacteristics– Buildings/Environment

–  Equipment

•  StaffCharacteristics–  Training

–  SkillsMix

–  TeamCulture

Level2:ProcessesofCare

•  InteractionBETWEENProvidersandPatients

–  InterpersonalInteraction“BedsideManner”

– ActualProvidedService/Procedure

Level3:ClinicalOutcomes

•  PatientHealthStatus

•  PatientSatisfaction

Note:VariationsinClinicalOutcomesdonot

alwaysmeandifferentQualityofDeliveredCare

4ReasonsforVariabilityinMeasuredQuality

•  DifferencesinSocio-Demographics,Severity

ofDisease,Co-Morbidities

•  MeasurementDifferences

•  RandomVariation

•  RealVariationinQuality

AssuringQualityinGastrointestinalEndoscopy

•  CredentialingandPrivileging

– MD

– Nursing

– Techs

– Others


•  DetermineCompetency

–  ThresholdNumbersofProcedures

–  Observationofcases

•  RenewalofPrivileges

–  PerformanceMeasures

–  CME

–  ParticipationinQualityImprovementProjects

–  Observationofcases


•  QualityandassuranceandImprovement

–  Whatshouldbemeasures,howoften,howlong

–  Benchmarksshouldbeset,compliancemeasured

–  Feedbackgivenforbenchmarksmadeandmissed

–  PolicyforRepeatedFailuretomeetminimalstandardsneedstobeset

•  SentinelEvents

–  Deviationfromoptimalcare

–  Complicationsfromprocedure

WhyDoThis

•  MoreEndoscopicProcedures

•  MoreComplexPatients

•  Sicker/OlderPatients

•  PatientsandPayers

WhatCanWeDo?

•  ImprovingQualityandSafetyinthe

EndoscopyUnit

•  ASGEEndoscopyUnitRecognitionProgram

(EURP)

WhatDoesEURPDo?

•  StandardBenchmarks

•  UniformStandards

•  ComparisonGroup

•  Feedback

EURP

•  PreProcedureAssessmentofProceduralRisks

–  ASAorMallampatiscore

•  BowelPrepQualityAssessment

•  CecalIntubation/AverageWithdrawlTime

•  AdenomaDetectionRate

•  AdverseEventTracking•  PatientSatisfaction

EURP:TimeOut/SafeProcedureReview

•  ABarriertoErrorsintheEndoLab

– CorrectPatient

– CorrectProcedureandindications•  CorrectStaffingandEquipment

•  Identification/preventioncomplications,errorsand

delaysduringtheprocedure

BostonBowelPrepScaleBBPS

•  WithdrawalPhaseofColonoscopy

– Washing,Suctioningcompleted

•  All3SegmentsEvaluated

–  CecumandRightColon

–  TransverseColonincludingHepaticandSplenicFlexures

–  LeftColonincludingDescending,Sigmoid,andRectum


•  EachSegmentScored0-3scale

–  0

•  Unabletobeseen

–  1

•  Portionofmucosaseen,butsomenotvisualizedsecondarytostaining,opaqueliquid,orsolidstool

–  2

•  Mucosawellseenbutminoramountorresidualstaining,smallamountsofresidualopaqueliquidorsolidstool

–  3

•  EntireSegmentseenwithoutresidualopaqueliquid,solidstool,orstaining

•  Scored0-9withadditionof3segmenttotals

•  IfPostSurgicalColonSegmentisrecordedas“NA”andscorereportedassum*

•  IfTechnicalIssues/PatientInstabilityprecludesevaluationrecordas“NA”

•  IfProcedurehaltedsecondarytoinadequitedistalprep,recordallproximalsegmentsas“0”


KimE,ParkY,KimY,ParkW,KwonS,ParkK,etal.AKoreanexperienceoftheuseofBostonbowelpreparationscale:Avalidandreliableinstrumentforcolonoscopy-orientedresearch.SaudiJGastroenterol2014;20:219-24.


•  ImprovesClinicalOutcomes

– LimitsVariabilityAssessingBowelPrepbetween

Providers

– DistinguishesDegreeofPrepAdequacy

– AccountsfordifferencesinDifferentColonic

Sections


•  TotalBBPSCorrelateswith

– PolypDetectionRates

–  InsertionandWithdrawalTimes

– NeedforEarlyProcedureRecall

EURPRequirements

•  Atleast50%ofEndoscopistsbeASGEmembers.DiscountedFeesfor

100%

•  AtLeast1Physicianand1NurseManagercompleteASGEQualityCourse

•  AttestationforSpecificUnitPolicies

–  EndoscopicPrivilegeGuidelines–  EndoscopeProcessingGuidelines

–  Preventionoftransmissionofinfectiousagents

–  EndoscopyStaffCompetenciesinendoscopereprocessionandsterile

medicationadministration

EURP

•  FormalApplicationProcess:

– 1yearofdataforaboveQualityMetrics

– AnySuboptimalPerformanceIdentifiedhasan

improvementplaninplace

– CompletionandSubmissionofaprevious

ImprovementProject

Hillel’sThreeQuestionsforEndoscopy

•  1)IfIamnotforme,whowill?

– Answer:Weareateam

•  2)IfIamonlyformyself,whatamI?

– Answer:Youshouldnotbe.YourTeamneedsto

worktogethertoachieveexcellentpatientcare

•  3)Ifnotnow,when?

– Answer:Notimelikethepresent!

Doing Our Bestindianasgna.org/.../2019/03/Slides-Endoscopic-Safety.pdf · 2019. 3. 13. · •...

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