Using the validated and integrative Theoretical Domains .... Following engagement and formal buy-in from site leadership
F A L L
2 0 1 6
E M E R G E N C Y
S C N
GI BLEED Reassessing the Clinical Management of GI Bleeds We have had a busy summer for advancing research and engaging physicians across Alberta to plan for quality improvement in the management of non-variceal upper GI bleeds. Dr. Marilynne Hebert has completed her qualitative research into the management of GI Bleeds through focus groups with thirty-nine ED physicians, gastroenterologists, and nurse managers at all seven participating hospitals. Dr. Hebert has written a policy brief that is currently informing our ongoing activities, and a manuscript is ready for publication. Dr. Gil Kaplan’s surveillance cohort, which will look at clinical outcomes and comprehensive administrative data for GI bleed patients provincially, has finalized a research agreement with AHS to obtain the broadest set of data on GI bleeds in Alberta ever assembled, fueling our analysis if management in Alberta and the impact of our efforts to improve care. Engagement of target sites has proceeded in partnership with Quality and Healthcare Improvement, and has led to the formation of local working groups at every site. Local chart reviews are underway across the province and sites are gearing up for their first Alberta Improvement Way workshops this summer. We are also reaching out to engage patients and have just recorded a podcast, Choosing Wisely in the Management of GI Bleeds, to advance awareness and promote a shared decision making model. (Listen to the podcast here). We have a busy year ahead of us, but we are well on our way to making a difference in our health system and the lives of Albertans. -Dr. Eddy Lang Department Head, Emergency Medicine, University of Calgary
Team Mission To improve the management of patients presenting to the emergency department with upper gastrointestinal bleeding, reduce patient exposure to unnecessary procedures and risks, and improve overall patient outcomes.
EMERGENCY SCN: GI BLEED
FALL 2016
A Qualitative Look at Clinical Practice
Hospitals across Alberta demonstrate a great degree of practice variation in emergency treatment of upper GI bleeds. Dr. Marilynne Hebert and Shoghi Nikoo, leading the qualitative arm of the PRIHS2 project, aim to clarify why this variation exists. This knowledge will be used to inform interventions to reduce RBC overtransfusion, overuse of IV PPI, and maximize efficiency of endoscopy. They are exploring factors that influence the management of patients with non-variceal upper GI bleeds presenting to the emergency department by investigating emergency physicians, gastroenterologists, and nurses’ experiences with these patients. Using the validated and integrative Theoretical Domains Framework, they are exploring what barriers to guideline implementation are driving the variance in referral for endoscopy, pre-endoscopic IV PPI use, and blood transfusion in hemodynamically stable patients. Their team has conducted 14 focus groups and interviews with over 40 emergency physicians, gastroenterologists, and nurses from across the province. Interviews and focus groups focused on the practical, environmental, personal, contextual, social, and emotional determinants of behaviour, with a focus on determinants amenable to intervention. Data were analyzed according to the domains outlined in the validated Theoretical Domains Framework, which describes 14 domains that impact professional behaviour in health care. The framework was formulated to provide an approach to policy intervention in areas of practice variation founded in locally important factors that influence behaviour. The final goal is to understand what drives current behaviour and what interventions may guide those behaviours into greater concordance with evidence-based clinical practice guidelines. Data analysis is still underway; however, preliminary results suggest that the biggest factors impacting physicians’ behaviour is a drive to reduce patient mortality and morbidity, and to provide symptomatic relief. In general, emergency physicians and gastroenterologists are aware of the guidelines regarding RBC transfusion, and recognize the value of responsible resource management. The guidelines around the use of IV PPI were less clear for many of our participants; use of IV PPI and timing of endoscopy appear to be largely influenced by local convention. One of the biggest factors impacting behaviour appears to be beliefs about consultant or team expectations – ED physicians, for example, often reported prescribing IV PPI because they expected their GI consultants to have wanted them to started it; some gastroenterologists, conversely, reported frustration about IV PPI or blood transfusion being started before they were consulted. These impacts were highest at larger centres, where communication between ED physicians and gastroenterologists were more formal. Ongoing analysis will continue to investigate the cultural and contextual factors that drive practice, and on cases that don’t fit the populations used to form current practice guidelines. -Shoghi Nikoo MD/MA Student, University of Calgary
2
EMERGENCY SCN: GI BLEED
FALL 2016
Current Research at FMC One of the many recent research projects undertaken by the Division of Gastroenterology Research at the Foothills Medical Center (FMC) and led by principle investigator, Dr. Kerri Novak, involves the introduction of the Glasgow Blatchford Score (GBS) to Alberta Health Services (AHS) emergency departments (ED). Thousands of Canadian patients visit AHS EDs every year for non-variceal upper gastrointestinal bleeding (NVUGIB). The correct course of action for these patients is not always clear. Most patients receive emergent endoscopy evaluation, proven to be preventative at reducing re-bleeding, and other complications including, in some instances, mortality. However, this may be neither necessary nor beneficial for a substantial number of patients. A safer and more cost-effective course of action may be “safe discharge” from the ED, with appropriate outpatient follow up. The questions begging to be asked are: what constitutes “safe discharge” and what can assist ED physicians in risk stratifying patients for the most appropriate treatment? The GBS proposes a unique tool to help physicians risk stratify patients based on severity of their NVUGIB, by ranking patients 023 based on blood urea, hemoglobin, systolic blood pressure and other markers. It is proposed that introducing the GBS to AHS EDs will help physicians prioritize patients with NVUGIB for endoscopy and reduce patient length of stay in the ER by utilizing appropriate outpatient care. Additional and related research being conducted at the FMC involves the study of trans-abdominal ultrasound (TAUS), a safe and effective clinical tool for early diagnosis of CD using imaging of the luminal gastrointestinal tract in correlation with ileocolonoscopy. TAUS can prevent the unnecessary exposure of patients with Crohn’s Disease to the risks of cumulative ionizing radiation related to recurrent CT and CT Enterography. One of the most important goals at the FMC is to promote patient involvement in their treatment program. Patients will be educated about their current conditions, involved in treatment decisions and educated as to what they can do to help improve their quality of life. Patient feedback will be collected and evaluation of patient satisfaction will be based on the patient’s perspective of all aspects of the treatment program. -Aviva Doctor Honors Biomedical Student, York University
3
EMERGENCY SCN: GI BLEED
FALL 2016
Quality Improvement and Change Management The Emergency Strategic Clinical Network holds a Partnership for Research and Innovation in the Health System (PRIHS) grant to improve the management of patients presenting to emergency with upper gastrointestinal bleeding (UGIB). This quality improvement initiative aims to bring about sustainable change, and our team has partnered with Quality and Healthcare Improvement to run an Alberta Improvement Way (AIW) Collaborative at seven hospitals to improve patient disposition, collaboration with gastroenterology, and to implement the ESCN Clinical Content for UGIB. The goal of this initiative is to reduce unnecessary hospital admissions, transfusions, intravenous protonpump inhibitor use, and improve overall patient care. Following engagement and formal buy-in from site leadership, Core Working Groups are formed at the site level. These working groups are cross-functional and members are representative of key stakeholders such as physicians, nurses, managers and technicians. The working group is led by a Site Core Team Lead, who champions the initiative and ensures initiative activities are on track. The sites commit to working over a period of 12 months, alternating between half-day ‘Learning Sessions’, in which the Core Working Group comes together to learn about the project topic and to plan changes, and ‘PDSA Cycles’, during which the groups test the planned changes in their clinical setting. There will be three Learning Sessions; in the first session, local issues will be identified and a functional GI clinical pathway will be developed within the local context. This pathway will then be tested and changes implemented in a series of PDSA cycles. Subsequent Learning Sessions will provide an opportunity for teams to report successes and opportunities for refinement, as well as share learnings with partner sites with similar demographics. Throughout the initiative, teams will be supported by QHI Process Improvement Consultants. The iniaitiative will conclude with an evaluation and wrap-up session to celebrate successes and plan for sustainability.
4
EMERGENCY SCN: GI BLEED
FALL 2016
Researcher Profile Dr. Kerri Novak Dr. Kerri Novak is a Clinical Assistant Professor of Medicine at the University of Calgary, a practicing gastroenterologist, and the Deputy Section Head and Medical Lead for Gastroenterology. Her previous roles include Acting Facility Medical Director at Foothills Medical Centre, Medical Lead for Central Triage and Access, Co-Lead of the Provincial Closed Loop Referral Pathway, and the Medical Lead of Quality Assurance within the Division of Gastroenterology.
Kerri completed her medical degree at the University of British Columbia, and her internship at the University of Calgary. Her research interests include imaging in inflammatory bowel disease, particularly the use of ultrasound for the evaluation of Crohn’s disease. Kerri is part of the Foothills Upper GI Bleed Working Group, which is working to implement an evidence-based pathway for the assessment and disposition of nonvariceal upper GI bleeds. She is also the Principal Investigator of a Chief Medical Office (CMO) Quality Improvement grant to evaluate the impact of a care pathway at Foothills, and Co-Principal Investigator of the provincial PRIHS grant Reassessment of Clinical Practices for Patients Presenting to the Emergency Department with Upper Gastrointestinal Bleeding.
Dr. Novak’s recent podcast with Dr. Eddy Lang, Choosing Wisely in the Management of GI Bleeds, can be found at http://goo.gl/aVcJjn
