Prof. Dr. med. Roland Bingisser Head of Clinical Emergency Medicine University Hospital Basel. making?

Transcription

1 Pathway decision making Prof. Dr. med. Roland Bingisser Head of Clinical Emergency Medicine University Hospital Basel What s published in decision making? Huge body of evidence: Adherence to guideline- or protocol-based care was proven to increase quality of care Big body of evidence: Decision support, usually in the form of computerized reminders, was a component of most adherence studies Existing body of evidence: Decision support functions were usually embedded in electronic health records or computerized provider order-entry systems. Small body of evidence: Pathway decision making in Emergency Medicine

2 What s new in pathways?? Standardized diagnostic and therapeutic pathways are beginning to have an impact Emergency decision pathways are beeing established worldwide Basel: > 100 Emergency Pathways in the UHB Any Change in decision pathways are beeing communicated through Emergency Standards All cases are beeing evaluated according to the management by this Tool Pathways or Standards? Standards: 3876 Medline Hits from nursing to administration, everything.. Guidelines: 3458 Medline Hits Not readable, GOLD: 222 pages! Sponsoring issues.. Policy: 2564 Medline-Hits Management-centered Algorithms: 1300 Medline Hits cardiology, some lung embolisms, then not many more Pathway: 886 Medline Hits (Pathway & Decision & Emergency: 28) Synkope, chest pain, afib, C-spine rule

3 Emergency medicine: Single tests vs. pathways Diagnostics mainly based on single tests Sometimes on a test series Rarely on entire pathways What s the evidence for a therapy? Mostly based on single measures E.g. Thrombolysis for Stroke Integrated Pathways better: Decision & Therapy Stroke: Chain of Surival / CT / Pressure control / Rehab How to do research on Pathways Pathways? Before vs. after implementation Randomized (cave: spill-over effects) Surveillance of a defined quality goal Simple performance measurement after implementation (safety / event-free survival) Long-term performance of a simple algorithm for early discharge after ruling out acute coronary syndrome. Chest :1364

4 The problem of single tests: BNP BNP: When is it really useful??? Pre-Test probability increases: Primary care 20 up to 60% Emergency 50 up to 85% + Likelihood Ratio of 80% sufficient for a Diagnosis? Post-Test probability of 20% sufficient for Exclusion? Are Specialists better than Pathways? That s what they claim to be Daytime only please Nighttime: Pathways are ok Specialists are better than standards: Stroke Team vs. Stroke Unit Stroke Team communicates standardized pathway Stroke Unit independent Benefit only with large vessel problems : mortality in a normal Emergency Department : OR specialists during their morning (1.3-18) Rounds talking to the Night Shift in Lacunar Strokes: the Emergency Department Hospitalisation in Stroke Unit longer (18 vs. 13 d) use of ressources higher Stroke 2002;33:449

5 Specialists and perception gap Example: Intensive care physicians Questionnaire: 92% use lung protective strategies Audit: 4% really use the guidelines! (Brunkhorst 06) Example: Multidisciplinary Management of frequent attenders (Med J Aust 2006; 184:602) Appear more frequent after Intervention (777x / 610 x) Are more often hospitalized Emergency standards: : Common Sense? Do we lose individualized Medicine? Details : destructive, sudden vs. strong thoracic pain Does the whollistic Medicine get lost? Dyspnoea -> COPD -> inhalation -> dismissal > CAVE: Pat. suffers from Diabetes, Depression Does the specialized Medicine get lost? 20 year old patient (f), 15 tbl. Dormicum. Dissmissed instead of Psy Consult.. 80 year old patient (m), short speech problems. TIA pathway Will the Manager overrule Emergency Physicians? Pathways are beeing examined very exactly by their costs..

6 The curse of Pathways Physician delegates nurses start diagnostics and treatment Take blood according to standardized pathways Monitor according to standardized pathways Pain therapy according to standardized pathways Physician gets transparent / controllable nurses in control of timing Delivery room: APGAR after 1 / 5 Emergency: suspicion of meningitis: Rocephin after 30 given? Evidence against Standards Can increase costs Urolith-CT and flank pain Stroke-Pathways: No change in outcome! Cochrane DB Syst Rev CD 2924 Pat. Satisfaction p < 0.02 QoL p < BMC Health Serv Res 6:16 Pre Post Tod 21% 23% MRS < 4 66% 67%

7 Blessings of Pathway decision making The (mostly implicit) goals can be achieved Reduction of hospitalisation Reduction of costs Increase of the satisfaction of patients and staff Outcome improvement Examples published since 2006 Faster delivery of drugs to ACS patients cuts mortality. (BMJ 2006; 333:11) Evidence-based pathway for afib reduces length of stay (Mil Med 2006; 171:567) 43h vs. 82h Increased use of OACoagulation Organisational Standards also help: > Delayto see a patient in the ED? Computerized: 57% / 10min. Telephone: 63% / 10min. Loudspeaker: 67 % / 10min.

8 Impact on unnecessary interventions Impact of the cardiac troponin testing algorithm on excessive and inappropriate troponin test requests. Am J Clin Pathol :195-9 The ctni testing algorithm reduced unnecessary orders for ctni tests with no reduction in meeting patients'critical needs Validation of a rule for termination of resuscitation in outof-hospital cardiac arrest. N Engl J Med : Implementation of this rule would result in a decrease in the rate of transportation from 100 percent of patients to 37.4 percent. A new algorithm for the initial evaluation and management of supraventricular tachycardia Am J Emerg Med :402-6 Adenosine use was limited to 54% of the cases. No patient developed hemodynamic instability after algorithm-dictated interventions were carried out. How can Pathways be implemented? Detailled agreements with all involved specialties Include as much evidence as possible Indicate, where evidence is missing Readable everywhere (A3 Architecture) Computer based

9 Problems? Acceptance Talk to Specialits first Start your own Outcome-Studies Not everything is accessible by Algorithms.. Goal: 60% Decisions by Pathways (?) Links to Computerized Physician Order Entry Systems (CPOE) absolutely necessary Pros and cons of Pathway Decision Making Mostly implicit goals canbeachieved Minimization of Hospitalization Minimization of Cost Improving Patient Care and Satisfaction Quality in relevant outcome measurable Physician delegates power Nursing gets more independent Blood Testing Algorithms Monitoring Pain Therapy Physician is transparent Nurse in control of timing Manager in control of costs..