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mPOWEr UW Grand Rounds

mPOWEr
by

Heather Evans

on 13 January 2016

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Transcript of mPOWEr UW Grand Rounds

Surgical site infections
are a big problem
>300,000 seen annually
7-10 extra days in the hospital
2-11 times risk of death
Est. annual cost $3-10 billion
# of complications
Creating a mobile Post-Operative Wound Evaluator

Department of Surgery Grand Rounds
University of Washington
December 5, 2014

@heatherevansmd
Heather L. Evans, MD, MS
Follow-up visit?
Kazaure et al. Arch Surg 2012
of all SSIs occurred
AFTER
hospital discharge and Post-discharge SSIs complicated more than one in 12 elective surgical procedures overall
Daneman et al. J Hosp Infect 2010
58%
More than one in four post-discharge SSIs were diagnosed in the ER or at readmission.
Many of the return emergency department visits occurred at a different hospital (3575/11253, 32%).
26%
RCT of evidence-based bundle for preventing SSI
Rates of superficial/deep SSI are 45%

vs.
24% (control)
RCT of silver nylon in preventing SSI following colorectal surgery
33% (control)
vs. 13% SSI
RCT of ertapenem versus cefotetan prophylaxis in elective colorectal surgery
26.2% (cefotetan)

vs. 17.1% (ertapenem) SSI
RCT of wound protector in emergent and elective laparotomy
184 patients experienced surgical site infection within 30 days of surgery
91/369 (
24.7%
) in device group vs. 93/366 (
25.4%
)

control group
Anderson et al Infect Control Hosp Epi 2008
Zimlichman et al JAMA Intern Med 2013
Gibson et al. Am J Surgery 2013
Readmission occurred in approximately 54% of patients who were diagnosed after discharge, and one third of those patients developed superficial SSIs.
48%
Kazaure et al. Arch Surg 2012
$20K per infection
2012-2013
AHRQ/UW K12 CER Career Development Award

2013-2014
UW
Dept of Surgery Research Reinvestment Fund
2014-2015

UW C4C Commercialization Gap Fund
2014-2015
UW ITHS Small Pilot Grant
2014-2016 Surgical Infection Society Foundation Grant
mPOWEr team
Bill Lober
Andrea Hartzler
Patrick Sanger
Sarah Han
Gayle Wiley
Cheryl Armstrong
Biomedical Health Informatics, Global Health, School of Nursing
Technical lead
User-centered design
MD/PhD student
Patient advisor
Project coordinator
Nursing advisor
UW Information School
UW School of Medicine, BHI
UW Department of Medicine
Dept of Surgery (SORCE)
Thanks
Dave Flum
Ron Maier
Carlos Pellegrini
Gayle Dykstra
Sean Sullivan
HMC Division
Current system for
post-discharge SSI surveillance is ineffective
Worried about poor
outcomes, delay in care
want
earlier follow-up
need better
patient education
want wound
photos from patients
at home
preferred notification of
problems only
92% would
adopt the system
in their practice despite concern over potential
increase in workload
Barriers to ideal care
both before and after discharge
Contributed to significant
anxiety, delayed care
want
easier way to contact providers
for follow-up
need more
information
want to
send photos
to providers
comfortable
with essential features
preferred
regular use
of app
trusted that follow-up would occur
after submitting data via mPOWEr
“No standardized or reliable method for post-discharge surveillance has been established”
Joint SHEA/IDSA Practice Recommendations
October 2008
Anthony et al. Arch Surg 2011
Kreiger et al. Dis Colon Rectum 2011
Itani et al. NEJM 2006
Pinkney et al. BMJ 2013
Primary outcome measures (@d/c, 3, 7-14 & 30 days):
1) discharge perceptions/practices
readiness for discharge
quality of discharge teaching
ability to cope after discharge
patient perceptions about their wound
2) utilization of health care services
3) patient outcomes
empowerment
satisfaction
quality of life
willingness to use mPOWEr
The Problem
The Need
The Solution
Case series of elective colorectal surgery from a single colorectal surgeon at academic institution
SSI rate 45/176 (
25%
) cases over 2 years
higher rate than usual institutional surveillance (9%)
22 (45%) SSI diagnosed after discharge
Smith et al. Ann Surg 2004
If you actually look for it...
days after hospital discharge
Are we providing the ideal post-operative care?
Takeaways from Needs Assessment
Pilot study: Understanding the post discharge experience of surgical patients
Aim 1.
To characterize the post-discharge experience of surgical patients

Aim 2.
To assess the receptiveness of patients to mHealth for post-discharge self-management.

Aim 3.
To test the feasibility of collecting surgical site data using standardized questions in a serial manner
RQ1:
What is the relationship between
readiness for discharge
and (1) post-discharge
utilization
of healthcare services and
(2)
empowerment, satisfaction and QoL
after discharge?
RQ2:
Is there an opportunity to
engage patients
in post-discharge communication through
mobile health apps
?
RQ3:
Can patients accurately report the
signs and symptoms of SSI
using a
computerized questionnaire?
National rate of SSI following elective colon surgery, according to the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP)
9%
Kazaure et al. Arch Surg 2012
Estimated cost savings:
$4,000-5,000
for every readmission prevented!
Lawson et al. Ann Surg 2013
Patients Said
We need a way to get post-discharge data from patients!
“First I called the nurse's hotline or whatever. And I talked to them, and it was
hard to get a hold of anyone
who even knew what was going on with my case or anything.”
NSQIP participant data files from 2005-2010
30-day complications for 21 general surgery procedure groups (inpatient)
Of 551,510 patients, 16.7% experienced a complication
41.5% occurred PD
surgical site infections & thromboembolic events most common
Most
surgical site infections occur after hospital discharge
For the top 7 procedure groups, 60-75% of complications involved the surgical site
Patient + Provider Needs Assessment
Participants
| 13 patients with post-discharge wound compli-cations s/p colorectal or ventral hernia at HMC or UWMC
Data collection
| 1-on-1 semi structured interviews on:
patient's experience of complications
desirable features/qualities of mPOWEr
Surveys on tech experience, mPOWEr usage, demographics
Data analysis
| iterative coding of transcribed interviews using grounded theory + descriptive stats in Excel
Participants
| 24 surgical providers (surgeons, ARNPs, RNs) at UWMC/HMC
Data collection
| anonymous, web-based survey with 28 multiple choice/free response questions covering:
provider/practice characteristics
current post-discharge SSI surveillance workflow
mPOWEr design and effect on workflow
expected use of mpower
Data analysis
| descriptive stats in Excel + basic thematic analysis
“That's pretty much what the triage nurse tells you anyway. 'You have to come in.' But if you have a picture of it, and it's nothing, then that would make it so that you wouldn't have to go in necessarily… It would be more advantageous and
you wouldn't have to sit there for five hours (laughs) in the ER
.”
“It took a long time to heal, and it oozed a lot… I thought it was normal… I didn't know that other people didn't have it, didn't have a clue.
I didn't know till today I had an infection
.” (P2)
“I have a smart phone so I used that to take the picture. I thought that was very good to be able to send them an actual picture of what was happening so that way, you know, a little more hands on than ‘okay - this is… ‘ - trying to describe it over the phone. ...
The nurse commented about how good that was too to have a picture to look at
.”
Design: prospective observational study with repeated measures
Subjects: Patients with elective or emergent
1) bowel surgery via laparotomy
2) open ventral hernia repair
Coming to HMC and UWMC in early 2014!
Anderson et al. Infect Control Hosp Epidemiol 2008
http://eutils.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&id=18840089&retmode=ref&cmd=prlinks
http://eutils.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&id=23579579&retmode=ref&cmd=prlinks
http://eutils.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&id=23165614&retmode=ref&cmd=prlinks
http://content.wkhealth.com/linkback/openurl?sid=WKPTLP:landingpage&an=00000658-200405000-00003
http://eutils.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&id=18840089&retmode=ref&cmd=prlinks
http://archinte.jamanetwork.com/article.aspx?articleid=1733452
http://www.sciencedirect.com/science/article/pii/S0195670110000915
http://linkinghub.elsevier.com/retrieve/pii/S0002961013005126
Sanger et al. AMIA Annu Symp Proc. 2013
Sanger et al. AMIA Annu Symp Proc. 2013
Sanger et al. AMIA Annu Symp Proc. 2013
Sanger et al. AMIA Annu Symp Proc. 2013
Visit us at https://sites.google.com/a/uw.edu/mpower/home
SSI diagnosed after discharge
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