Project: Appopriate Preoperative Diagnostic Testing: A Choosing Wisely Manitoba Initiative


Project: Appopriate Preoperative Diagnostic Testing: A Choosing Wisely Manitoba Initiative

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Project: Appopriate Preoperative Diagnostic Testing: A Choosing Wisely Manitoba Initiative

Team: Health Systems Performance

Date: This is not a timed event.

Description


Choosing Wisely Canada is a national campaign aimed to help engage clinicians and patients in conversations about unnecessary tests and treatments, and make smart and effective care choices. Inappropriate preoperative diagnostic testing has been identified as a priority. Routine preoperative tests for low risk surgeries results in unnecessary delays, potential distress for patients and significant cost for the health care system https://choosingwiselycanada.org/internal-medicine/.

In 2014 the Centre for Healthcare Innovation and our partner Diagnostic Services Manitoba, with funding from the Manitoba Patient Access Network, set out to identify and remove barriers to the sustainable adoption of previously developed pre-operative testing guidelines, in order to reduce unnecessary preoperative diagnostic testing.

An examination of the barriers and facilitators to guideline adoption and implementation of the guidelines, including further analysis of 3 audits completed previously, meetings with administrators and stakeholders from primary care, surgery, anesthesia, preadmission clinics and eHealth, focus groups with family physicians, and a review of the literature all informed the development of a revised guideline and implementation strategy.

The implementation of a revised Cataract Surgery History and Physical (H&P) Form, emphasized that tests are not usually required for cataract surgery and eliminated cueing for unnecessary pre-operative tests. At the same time a Red-Green project eliminated pre-operative History and Physicals for ~60% of cataract surgery patients. Pre and post-implementation audits showed a 77.5% reduction in patients undergoing pre-operative testing from pre to post-implementation of these 2 projects.  

Building on what we learned through the cataract project, on July 11, 2016, five revised documents were implemented to help reduce cues that prompt unnecessary testing for all other types of surgery. The revised documents were the result of collaborations with key partners – including representatives from WRHA Surgery Program, Department of Surgery, Preoperative Assessment Clinic (PAC), Anesthesia, Primary Care, Family Medicine, DSM and the George and Fay Yee Centre for Healthcare Innovation. The revised documents were implemented in eight surgical sites across Winnipeg.

Five Documents:

1) Routine Preoperative Lab Test Guidelines

2) WRHA Preoperative History & Physical Form

3) WRHA Surgery Preoperative Assessment Patient Questionnaire

4) New - Patient Quick Reference Cover Letter

5) New - Preoperative Care Cover Letter

Post implementation focus groups with Primary Care Physicians (PCP), surgical office assistants and anesthesiologists revealed that that 80 - 90% of respondents are using the revised guidelines with all appropriate patients and agree that the revised guideline are better than the previous guideline.  Implementation was lower for the patient and physician cover letters.

Next Steps

Audits of surgical sites across the region will be ongoing through 2017 and early 2018. The audits will be used to give feedback to surgeons about their ordering behaviour and to assess whether the project met its goals. A sample of 10 surgeries for each surgeon will be audited from across the region using a simple data collection form to identify unnecessary tests. The results of the audit in two pilot sites (Victoria General Hospital and St. Boniface Hospital) will be analyzed in the fall of 2017 and audits of the remaining sites will be carried out and analyzed in the late fall 2017. Check back here for the data analysis results and follow up steps.

Documents and Photos