MHP – Quality Metrics

Avery B. Nathens MD PhD, Surgeon-in Chief

Sunnybrook Health Sciences Centre

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Objectives

• Develop key quality metrics that are easily measured

and comparable

• Identify set targets for measureable patient outcomes

• Discuss options for formal provincial reporting

April 30, 2018

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Dimensions of Quality

Accessible

• Right care at the right time

Effective

• Evidence based practices

Safe

• Avoid harm

Patient centred

• Needs and preferences of the patient

Equitable

• Same level of care for every patient

Efficient

• Maximize resource use, minimize waste

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Structure Process

Outcome

• Was medicine

properly

practiced?

• Staff, physical

resources, policies

• Modifiable

Donabedian approach to quality

assessment

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What is a good quality indicator?

• Important

– Must apply to a large number of patients OR

– Involve a high risk condition

• Scientifically acceptable

– Reliable – same result on repeated measures

– Valid – does it measure what its supposed to measure

• Feasibility

– Data must be readily available (opportunity costs)

• Usability

– Must be understood by intended audience to ensure PI can

happen

• Modifiable

April 30, 2018

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Provincial reporting:

challenges

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MHP Policy Effective care

• Hospitals should have a protocol to guide the

management of the severely bleeding patient

– Structural measure

• Hospitals should have a multidisciplinary QA committee

to review MHP activation

– Structural measure

April 30, 2018

…. ….that reports to the hospital Quality of Care

Committee [MAC]

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Kaizen

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Benefits of standardization

• Clarifies the process

• Documents the best way to achieve a goal

• Reduces variation

• Facilitates training

• Provides the baseline for improvement

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Act

Plan

Do

Check

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TXA administration

Effective care

• The proportion of patients receiving 2 g of tranexamic

acid within 1 hour of injury/onset of hemorrhage

– Process measure

– Modifiable

• Should it be time of onset of hemorrhage/injury or

recognition of hemorrhage – not usable in current form

• Is it 2 gm or first dose of TXA?

• Suggested: The proportion of patients receiving 1 g of

tranexamic acid within 30 min of activation of MHP

• Amenable to provincial reporting

April 30, 2018

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Timely transfusion Accessibility

• The proportion of patients issued red cells either before

or within 10 minutes of protocol activation

• Process measure

– Is “issuing blood” the relevant measure?

• Blood might be issued and take 30 min to get to the patient

– Should it be time to bedside? Time to transfusion?

– Consider: The proportion of patients in whom transfusion is

initiated within 15 min of protocol activation

– Modifiable, measurable, relatively independent of case mix –

acceptable for provincial reporting

April 30, 2018

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Hemorrhage control

Access

• The proportion of patients (of patients requiring transfer

for definitive care) with initiation of call for transfer within

15 minutes of protocol activation

– Process measure

• Modifiable? – very tight window, context dependent

• Activation might precede identification of source of

hemorrhage

– Might be faster to treat locally then transfer patient

• Acceptable for internal QI, not for provincial reporting

• Suggest extend window to an hour

April 30, 2018

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Timely access to hemorrhage

control

• Additional consideration

• The proportion of patients with initiation of hemorrhage

control (where possible) within 60/90(?) min of protocol

activation

– Time to operative intervention, time to angioembolization,

endoscopic control, etc

– Modifiable, independent of case mix

• Acceptable for provincial reporting

April 30, 2018

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Is one hour reasonable?

• PROPPR Study – 28 min to operating room

• Haas and Nathens, J Am College of Surgeons, 2009

– Time to OR among patients with penetrating truncal injury

presenting with shock – 1 hour in trauma centres, 50 min

in non-trauma centres

April 30, 2018

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Pelvic angioembolization

TQIP experience

• Time to angiography from ED arrival among patients who

had this as their FIRST intervention

• Median 3.1 hours, most (75%) between 2-4 hrs; 1%

within 30 minutes

• Non-teaching hospital – 33 minutes quicker

• Higher volume centers (>10 per year) - 20 min shorter

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Time to angiography & mortality

Hemorrhagic shock

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Management of hypothermia Safe, effective care

• The proportion of patients achieving a temperature

>35⁰C at termination of the protocol

– Outcome measure

– Modifiability a challenge

– Risk adjustment would be necessary for provincial

reporting • GI bleed vs obstetrical hemorrhage, vs traumatic hemorrhage

• Dependent on exposure, extent/volume of resuscitation

• Acceptable for internal QI, not for provincial reporting

April 30, 2018

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Transition to group specific

blood - efficiency

• The proportion of patients transitioned to group specific

blood within 90 minutes of arrival/onset of hemorrhage

– Process measure

• Needs more precision to ensure reliability and

usability….within 90 minutes of MHP activation

• Reflects ability of the provider(s) to obtain blood sample

& timely submission to lab

• Independent of case mix

• Case mix independence, modifiability suggest an

appropriate indicator for provincial reporting

April 30, 2018

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Hemoglobin targets

• The proportion of patients with hemoglobin levels

maintained between 60-110 g/L during protocol activation

– Outcome measure

• Ability to achieve this target highly dependent on:

– Rate of bleeding (case mix)

– Ease with which hemorrhage control can be achieved (case

mix +/-)

– Turnaround time of labs (modifiable)

– Use of lab data (modifiable)

• Given case mix issues, not ideal for provincial reporting but

might have value for internal QI

April 30, 2018

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Avoiding wastage

Efficient care

• The proportion of activations without any blood product

wastage (including plasma that is thawed and not used

within the 5 day limit on another patient)

– Outcome measure

• Some modifiability on the provider’s part but potentially case

mix dependent - early death, early hemorrhage control

• Incentivizes administration of product when it might not be

necessary

• As written, brings in other case mix issues (plasma thawed

to be used on another patient)

• Might be acceptable for internal QI only

April 30, 2018

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Appropriateness of MHP activation Effectiveness, Efficiency

• The proportion of patients with appropriate activation

(non-survivors with hemorrhagic death transfused <6

units and patients transfused >6 RBC units)

• Process measure

• Needs element of time….within 4 hours

• True positive: activation among those who received>6

units in 4 hours or activation among those who received

transfusion yet died with hemorrhagic death within 4

hours

• False positive: activation among survivors who received

<6 units in 4 hrs

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Appropriateness

• Appropriateness becomes the positive predictive value:

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• PPV is influenced by case mix (prevalence)

• Not ideal for province wide reporting; good for internal

use and to track over time within specified populations

– E.g. trauma vs obstetric vs surgical

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Appropriateness

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Appropriateness

• What happens if we never activate MHP and we should?

• Balancing measure would be “Negative predictive value”

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• TN = very large, undifferentiated population

• TN=any transfused patient? Any transfused patient

meeting specific criteria?

• Province wide reporting would be challenging

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Appropriateness

• As part of the MHP quality assurance process, reviews

should be undertaken for every patient in whom MHP is

activated and for every patient who receives >6 units of

pRBC’s within 4 hours in whom MHP is not activated

• Reviews should address

– Appropriateness of activation (or lack of activation)

– Timeliness of activation and termination

– Administration of products and adjuncts (Ca, TXA)

– Avoidance of hypothermia

– Timeliness of hemorrhage control/transfer

April 30, 2018

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Do quality indicators improve

care

• Providers need to have confidence in the data, its validity

and there must be a perceived component of

modifiability

• Most provincial reports get little air time

– No confidence

– Data reviewed in wrong forum

• Even if the data are correct and there is opportunity for

improvement, most don’t know how to affect change

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NATIONAL SURGICAL QUALITY

IMPROVEMENT PROGRAM (NSQIP)

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NSQIP Experience

• VA NSQIP

– Mortality: 3.16% to 1.7%

– Morbidity: 45% lower

• ACS NSQIP (2005-2008)

– Morbidity: 82% of centers improve

– Mortality: ~66% of centers improve

– Improvements identified in all groups

• High, low, and average performers

• Low performers improved the most

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Quality Collaboratives

• Accelerate improvements

• Peers hold others

accountable for change

• Goal setting, sharing of

ideas, resources

• Sharing of successful

change strategies

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Summary

• Several QI indicators acceptable for provincial reporting

– Current MHP policy

– TXA administration

– Timely transfusion

– Timely access to hemorrhage control

– Transition to group specific blood

• Others built into internal QI process with mandate for

review

• Empower providers to affect change through collaboratives

April 30, 2018

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Excellence is a journey, not a

destination