IOM Workshop on Standards for Clinical Guidelines

Monday, January 11, 2010

Elizabeth Mort, MD, MPHMassachusetts General HospitalPartners HealthCare, Inc.

2

Integrated, academic health system founded in 1994 by Brigham and Women’s Hospital and Massachusetts General Hospital

Four-part mission is patient care, teaching, research, and community service

1.7 million patients receive care from Partners institutions and physicians

170,000 hospital inpatient discharges annually

4.3 million outpatient and physician visits annually

We are a large consumer of clinical guidelines

Partners HealthCare, Inc.

3

Partners HealthCare Hospitals

Martha’s Vineyard Hospital

Nantucket Cottage Hospital

Rehab Hospital of the Cape and Islands

Faulkner Hospital

Newton-Wellesley Hospital

McLean Hospital

Massachusetts General Hospital

Spaulding Rehabilitation

Hospital

Shaughnessy-Kaplan

Rehabilitation Hospital

North Shore Medical Center -

Union

North Shore Medical Center -

Salem

Non-Acute Hospital

Acute Care HospitalH

Brigham and Women’s Hospital

Partners HealthCare

4

Role of guidelines at Partners HealthCare, Inc

Goal is to assure that all patients get the highest quality care, reliably delivered anywhere in the system.

Identify priority areas for system-wide improvement.

Review clinical guidelines using clinical experts and develop system-wide approaches.

Implement guidelines using high reliability design, leveraging system resources such as electronic medical record, registries, clinical decision support rules, etc.

Measure compliance transparently and study failures/variance.

Refine as needed

http://qualityandsafety.partners.org/

6

Recommendations for guideline standards

1. Concur with many of the presenters today that describing the level of the evidence and the strength of the recommendation is critical. Agree with developing a standard taxonomy to simplify.

2. Describe the exact nature of and the probability of obtaining the benefit and risks. (Allows prioritization of action at all levels, from the system to the individual patient.)

3. Highlight areas of controversy.

4. Develop an organized, transparent, accountable, and safe approach to provide consensus opinion and expert opinion on the management of populations or situations that are not explicitly addressed in the clinical practice guidelines.

5. Provide guidance to facilitate implementation if available and suggest performance measures if appropriate.

7

8

Additional FAQs – Care of the elderly, pts with renal failure, who have CHF, what about CDEs, etc.

9

10

11

12

Patient arrives atED triage

Is there apre-hospital ECG

indicatingSTEMI?

ED initiatestreatment and

consent forcath lab

yes

ED does ECG andgives it to ED

physician in 10mins

no

Is STEMIconfirmed?

Continue EDwork-up and cancelcath lab, as needed

no

ED transportspatient to cath lab

ED calls operatorto page cath lab

staff andinterventionalist

yes

EMS does ECG

EMS notifies ED ofSTEMI, starts IV,and draws blood

ED calls operatorto page cath lab

staff andinterventionalist

Are pagesconfirmed?

Cath lab staff andinterventionalistarrive and scrubwithin 30 mins

yes

Are pagesconfirmed?

Cath lab staff andinterventionalistarrive and scrubwithin 30 mins

yes

no*

*if no response within 10 mins,go to next one on on-call list

Patient arrives inED without

pre-hospital ECG

Patient hassymptoms and

calls EMS

Startprocedure

Is STEMIsuspected?

no*

yes

PATH #2

PATH #1

Admit patientto CCU

ED communicateswith cath lab to

determinereadiness to

receive patient

Is PCIindicated?

yes

no

no

Final checklist andwritten consent

completed

Include guidance on implementation: STEMI

Bradley, E. et. al; Reducing door-to-balloon times to meet quality Bradley, E. et. al; Reducing door-to-balloon times to meet quality guidelines: How do successful hospitals do it? guidelines: How do successful hospitals do it? CirculationCirculation 2004 2004

13

Time for staff to arrive: 35 min

Triage Time: 10 min

Lab arrival to reperfusion: 30 min.

Step

1 Patient arrives in ED, ECG is completed, and ED physician diagnoses STEMI

2 ED calls operator to page on-call cath lab staff and interventionalist

3 ED stabilizes patient; initiates MI protocol; communicates w ith cath lab

4 Cath lab staff and interventionalist go to and arrive at cath lab

5 ED transports patient to cath lab

6 Final checklist for PCI and w ritten consent

7 Catheterization and PCI

Figure 3. Path #2 -- Steps and timeline for acute reperfusion: patients who arrive in ED without pre-hospital ECG

65 70 75 8045 50 55 60Minutes

0 5 10 15 20 25 30 35 40

Patient arrives in cath lab

Patient reperfusion

Pt arrives in ED

DTB DTB cancan be be < 80 < 80

minutesminutes

DTB DTB cancan be be < 80 < 80

minutesminutes

Include guidance on implementation: STEMI

Bradley, E. et. al; Reducing door-to-balloon times to meet quality Bradley, E. et. al; Reducing door-to-balloon times to meet quality guidelines: How do successful hospitals do it? guidelines: How do successful hospitals do it? CirculationCirculation 2004 2004

14

Recommendations for guideline standards

1. Concur with many of the presenters today that describing the level of the evidence and the strength of the recommendation is critical. Agree with developing a standard taxonomy to simplify.

2. Describe the exact nature of and the probability of obtaining the benefit and risks. (Allows prioritization of action at all levels, from the system to the individual patient.)

3. Highlight areas of controversy.

4. Develop an organized, transparent, accountable, and safe approach to provide consensus opinion and expert opinion on the management of populations or situations that are not explicitly addressed in the clinical practice guidelines.

5. Provide guidance to facilitate implementation if available and suggest performance measures if appropriate.