Robin McLeod Is Moving Best Practices Model to All Divisions of the Department of Surgery

Robin McLeod

Robin McLeod has a passion for using the best evidence to provide the best patient care. This passion led her, in 2006, to initiate Best Practice in General Surgery-a quality improvement initiative in which the objective was to ensure that general surgery patients receive care based on the best available evidence. This program is leading toward standardized care across the U of T affiliated hospitals. In 2012, the BPIGS group developed an Enhanced Recovery after Surgery (ERAS) guideline for patients having colorectal surgery. They received a grant from the Council of Academic Hospitals which supported the implementation of the U of T iERAS program across 15 academic hospitals in Ontario. The iERAS program saved 1 hospital day for colorectal surgical cases. Since there are 5,000- 10,000 cases per year in Ontario, there is a potential gain of another 5,000 - 10,000 available beds in addition to the cost savings.

Robin reports that the iERAS program changed the way patients were cared for and led to a decrease in the length of stay and lower complication rates and cost. But perhaps the most important impact was how the perioperative teams including nurses, surgeons and anaesthesiologists began to communicate and collaborate. Working as a team made positive changes. One of the iERAS champions commented: “There was a noticeable difference…I think it was after the second data review… and people decided together that we could improve things. People stopped pointing fingers. It all came together and we decided to look at this as a team”. These learnings from the program have strengthened Robin’s belief that some resources may be required to improve care, but more importantly, a lot can be accomplished by working collaboratively to implement changes.

With that in mind and with the support of Chairman Jim Rutka, Best Practice in General Surgery has been transformed into Best Practice in Surgery (BPS). The mission is the same-ensure all patients receive optimal care based on best evidence. This has been a good fit with the adoption of NSQIP by many of the hospitals across the province. (NSQIP is the National Surgical Quality Improvement Program sponsored by the American College of Surgeons. The program supports data collection and allows hospitals to compare their outcomes with other institutions). While NSQIP allows hospitals to assess their performance against others and identify where there are gaps in clinical care, they often do not know how to fix those gaps; the guidelines developed by BPS are helpful. A good example is The Ottawa Hospital which adopted NSQIP before becoming a partner in the iERAS program. They found that implementing NSQIP alone did not improve outcomes but once the hospital implemented iERAS, they noted a significant decrease in hospital stay and complications.

The Best Practice in Surgery committee is comprised of members from all hospitals and divisions in the Department as well as representatives from Anaesthesia, Otolaryngology, Opthamology and Gynaecology. There are a number of projects on going. For example, they are developing a Surgical Wound Management guideline in conjunction with the Toronto Central CCAC and a Surgical Site Infection guideline with the Antimicrobial Stewardship Committee. Hospitals save $5,000 for every wound infection prevented, whereas keeping the patient warm and using antibiotics correctly costs far less.

Adina Feinberg, a general surgery resident, and Hance Clarke, an anaesthesiologist at the Western, are leading a group developing a guideline on a very relevant topicopioid use by patients post-discharge. Prior to undertaking this work, Adina did a systematic review, and found that 50-70% of opioids prescribed for post discharge use are not used and rarely are patients given directions on how to get rid of the excess pills.

Erin Kennedy is leading work on the patient experience. She has led 3 workshops to learn about the patients’ surgical experience and how we could optimize it. The workshops have been attended by 25 surgical patients as well as surgeons from all disciplines, residents and nurses. Not surprising, communication was top of their list of priorities. While Erin’s team has developed a longterm plan to address the identified priorities, they quickly distributed their “5 Easy Things to Improve Patient Experience”. One of those has already led to change-all the patients agreed that it was scary when they were wheeled into the operating room and looked around and saw all personnel on their cellphones!

Thoracic surgeon Najib Safieddine has developed a quality improvement curriculum for all first year residents who attend a series of lectures, and work throughout the year in small groups to develop a quality initiative. This year’s projects addressed a wide range of topics - from improving resident education to standardizing specific clinical surgical issues to processes to improve and measure patient and family in-hospital experience.

With the emphasis on quality and safety in all health systems today, Jim Rutka has strongly supported Best Practice in Surgery, recognizing that physicians are central to ensuring the best clinical care and patient experience. Best Practice in Surgery offers an opportunity for the Department to be a leader in quality as we are in education and research.

Emily Pearsall, MSc, Manager, Best Practice in Surgery Department of Surgery, University of Toronto

[There is an excellent article about “Why You Should Chew Gum After Surgery” by Erin and Robin in the Toronto Star, describing this program.

It’s in doctorsnotes@thestar.ca, a weekly column by members of the U of T Faculty of Medicine. This is a great way to communicate with the public. Ed.]