CERTAIN – Checklist for Early Recognition and Treatment of Acute Illness

Dr Ognjen Gajic Professor of Medicine Mayo Clinic Rochester MN USA Multidisciplinary Epidemiology and Translational Research in Intensive Care (M.E.T.R.I.C.)

@ [email protected]

Disclosure

• Research support from NIH, CMS and Mayo Clinic • Provisional patent application for critical care related software tools has been submitted by Mayo Clinic • No financial relationships with any commercial companies and no other relevant disclosures

Learning Objectives • Discuss the need for precompiled responses to acute clinical illness (“the checklist manifesto”) • Explore how novel informatics technologies can assist dissemination of knowledge to the point of care • Introduce CERTAIN – Checklist for Early Recognition and Treatment of Acute Illness • Discuss the challenges and opportunities within international implementation study of point of care checklists

Definition of a Problem: Hospital Ward

45-year old with pneumonia

In the ICU

Few days later

Finally…

Chaos Theory of Critical Illness Good Outcome

Bad Outcome

Window for Early Treatment & Prevention Daily Rounds

911

Emergency Room

Operating room

Recovery room

Hospital ward

Rapid response team

ICU

Golden hours

“The most sophisticated intensive care becomes unnecessarily expensive terminal care…” Peter Safar

Safar P. Critical care medicine – Quo Vadis? Crit Care Med 1974; 2:1–5

Challenges during golden hour

Runciman et al. Qual Saf Health Care 2005

Challenges during golden hour

Runciman et al. Qual Saf Health Care 2005

“The fundamental problem with the quality of medicine is that we’ve failed to view delivery of health care as a science”

• The tasks of medical science fall into three buckets. – understanding disease biology – finding effective therapies – insuring those therapies are delivered effectively

• That third bucket has been almost totally ignored. It’s viewed as the art of medicine. – “That’s a mistake, a huge mistake”

Peter Pronovost http://www.letstalkhealthcare.org/health-care-costs/how-a-checklist-can-improve-health-care/

Science of Healthcare Delivery Core Components (tools) • Epidemiology The application of epidemiologic principles to understand the frequency, outcomes and risk factors associated with various healthcare delivery systems and approaches

• Clinical Informatics The application of clinical informatics to assist in the management and processing of data, information and knowledge to support the practice and delivery of clinical care

• Systems Engineering The application of systems engineering principles to design and implement novel health care systems which can more effectively deliver the highest quality care

Probability of Performing Perfectly

Botwinick L, Bisognano M, Haraden C. Leadership Guide to Patient Safety. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2006. Available on www.IHI.org

The Checklist

©2010 MFMER | slide-18

Operating room crises checklists: results

Arriaga, A. F., A. M. Bader, et al. (2013). "Simulation-Based Trial of SurgicalCrisis Checklists." New England Journal of Medicine 368(3): 246-253.

Operating room crises checklists: provider satisfaction

Runciman et al. Qual Saf Health Care 2005

Checklists in ICU practice

Pronovost et al. Journal of Critical Care, 2003 Pronovost et al.NEJM, 2006

Mind the gap

• Focus on specific condition/specialty/setting • CPR (too late) • Heart attack/stroke • Trauma • ~90% of acute critical illness not covered by a structured approach • Focus on training and remembering • Expensive!

Conventional clinical practice

Courtesy Dr Kilickaya

Conventional clinical practice Has no idea

Courtesy Dr Kilickaya

Conventional clinical practice Has an idea

It is Wrong

Courtesy Dr Kilickaya

Conventional clinical practice C c

Knows what to do

Not organized

He delays

Courtesy Dr Kilickaya

CERTAIN practice C c

Idea ?

CERTAIN

Courtesy Dr Kilickaya

Knows ?

Conceptual framework

Kilickaya et al. Yearbook of Intensive Care and Emergency Medicine 2014, in press

Patient knowledge

Medical knowledge

Methodology

Simulation

CERTAIN description

ELITE

ROUNDS

Stabilization Module

Optimization Module

Admission

Rounding

Resuscitation http://www.icertain.org/

Interface

Assessment

Decision support

Keeping track of interventions

Checklist with timer for critical procedures

Hypothesis

The care assisted by decision support tool (CERTAIN) will improve the process and outcome of acute critical illness

Aim

• Designing point of care decision support (CERTAIN) to facilitate global adoption of systematic and disciplined evaluation and treatment of acutely ill patients • To Implement CERTAIN into clinical practice of ICUs with variable resources, across the globe and evaluate the impact of this tool on the processes and patient outcomes

Study Sites Bosnia Serbia Turkey

Mexico Panama Dominican Republic Brazil

Kenya Rwanda Uganda

Mongolia China India

Step-wedge cluster implementation

Online data collection

Cloud computing

Remote education of bedside providers • Transcontinental “screen share” feature (CERTAIN) AND

• Cheap audio (+/- video) communication (Skype, Google+…)

Online training – Mission statement explaining the rationale and importance of early resuscitation. – “Knobology” video: visual guide through software functionality – Access: opportunity of exploration of CERTAIN software by themselves – PowerPoint Presentation of Workflow and CERTAIN methodology – Video of a case management using CERTAIN workflow

Video-assisted coaching and certification – Refreshing key aspects of online training – “Knobology” quiz (computer-assisted checklist use) – Video assisted team training Training

Participant 1

Participant 2

Participant 3

Test Case 1A

Team Leader

Prompter

Team Member

Test Case 2A

Team Member

Team Leader

Prompter

Test Case 3A

Prompter

Team Member

Team Leader

– Certification (scoring) Certification

Participant 1

Participant 2

Participant 3

Test Case 1B

Team Leader

Prompter

Team Member

Test Case 2B

Team Member

Team Leader

Prompter

Test Case 3B

Prompter

Team Member

Team Leader

– Survey

Refining, customizing and updating decision support content • Systematic review of practice guidelines – checklist drafts by investigators from various backgrounds (anesthesiology, emergency and internal medicine)

• International survey of acute care providers • Iterative review through a structured feedback by expert users from various international settings and backgrounds (“bug reports”)

Users’ feedback with screen capture

PDSA cycles Tool Refinement and Validation

Concept Introduction

Patient Betterment

Data gathering and Quality improvement

Identification of local champions

Education and Training

Outcome assessment Better care

Adherence to basic critical care processes

Better health

Hospital and 28 days mortality

Lower cost

Hospital length of stay

CERTAIN Executive Committee

Advisory board A Gawande, J Farmer, Y Donchin, K Hillman

US Critical Illness and Injury Trials Group

M Vukoja – Principal Investigator R Kashyap – Co-PI (Project Manager) L Bucher –Co-PI (AACN) N Adhikari – Co-PI (ATS) M Schultz – Co-PI (ESICM) O Gajic – Co-PI (USCIITG) M Gong – Co-PI Implementation D Talmor – Co-PI Outcome O Kilickaya – Co-PI Technical

AACN ATS International Committee

Technical development O Kilickaya, Lei Fan, V Herasevich, B Pickering

Education and Implementation R Kashyap, M Kojicic, K Harder, M Gong

ESICM Global Working Group Refining, customizing and updating decision support B Bonneton, M Schultz, N Adhikari, L Bucher, M Dunser, R Fowler, G Diverti, P Park, P Hou, S Senkal, S Gavrilovic, O Kilickaya, O Gajic, all site investigators

Study Center I Outcome assessment M Kojicic, A Ahmed, Raja Reddy, D Talmor

Ancillary Projects Simulation R Sevilla-Berios Cost effectiveness H Omanic Commercialization Al Berning

Study Center II Study Center III Study Center IV Study Centers …N

ATS travel award

http://www.icertain.org/

Acknowledgements Neill Adhikari Adil Ahmed Al Berning Ronaldo Sevilla Berrios Benjamin Bonneton Linda Bucher Enrique Ortiz Diaz Gavin Divertie Yoel Donchin Yue Dong Martin Duenser Cristopher Farmer Emir Festic Rob Fowler Pablo Moreno Franko Ognjen Gajic Srdjan Gavrilovic Atul Gawande Michelle Gong Kathleen Harder

Vitaly Herasevich Peter Hou Rahul Kashyap Oguz Kilickaya Andrea Konvalinova Fan Lei Guangxi Li John Litell Jack O'Horo Hajrunisa Omanic Sonal Pannu Pauline Park Brian Pickering Beth Rivello Marcus Schultz Serkan Senkal Sanjay Subramanian Danny Talmor Venu Velagapudi Marija Vukoja

AWARE & CERTAIN

http://www.icertain.org/

[email protected] [email protected] [email protected]

…to prevent DEATH (Diagnostic Errors and Therapeutic Harm)