In our continuing effort to provide information about all the benefits of membership in the American College of Surgeons (ACS), this month’s column spotlights two resources that may contribute to your daily practice and the delivery of optimal patient care: Evidence-Based Decisions in Surgery (EBDS) and the College’s patient education programs.
Since its inception more than 100 years ago, the ACS has been dedicated to helping surgeons obtain the knowledge needed to provide the highest quality care to their patients. High-quality surgical practice is both a science and an art. The art emerges through dedication to ethical practice, empathy and respect for the patient and his or her preferences, and the delivery of compassionate care. The science of surgery requires a lifelong commitment to learning.
An increasing emphasis is being placed on the use of evidence-based practices in the delivery of health care. Clinical practice guidelines offer high-quality evidence that surgeons can apply in daily practice. Guidelines often are developed by government agencies, professional medical organizations, and research groups to facilitate the implementation of evidence-based practice by individual practitioners, practice groups, and health care institutions. The ACS, for example, has developed practice guidelines for use in surgical practice—the EBDS program.
What are clinical practice guidelines?
The core objective of evidence-based practice is to standardize the application of scientific knowledge at the point of care. Standardization is a process that is intended to decrease the inappropriate variation that negatively affects quality, safety, and cost-effective surgical care; decreasing this variation should be synergistic with promoting, not stifling, innovation. One important function of clinical practice guidelines is to add ease to the process of reducing variation in practice.
Clinical practice guidelines are developed by government agencies, such as the U.S. Preventive Services Task Force and the National Institute for Health Care and Excellence, UK. Most practice guidelines are developed by professional medical organizations, including the American Heart Association, the National Comprehensive Cancer Network, the Society of American Gastrointestinal and Endoscopic Surgeons, the Society for Surgery of the Alimentary Tract, and the Eastern Association for the Surgery of Trauma. Independent research groups, including the Surviving Sepsis Campaign, also produce practice guidelines.
Producing clinical practice guidelines begins with identification of the clinical problem(s) to be addressed, followed by assembling the evidence. In this stage, the focus is on available prospective randomized trials, meta-analyses of multiple trials, and strong observational studies. When the evidence available in the literature is insufficient, expert opinion is gathered from the proceedings of meetings designed to gather, evaluate, and publish expert opinion. The evidence is then graded using systems such as those developed through the U.S. Preventive Services Task Force, the Centre for Evidence-Based Medicine (University of Oxford), and the American College of Physicians Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system.
After the evidence is assembled and graded, a list of recommendations is produced. Accompanying each recommendation is a statement on the grade of evidence that supports the recommendation and a statement regarding the strength of the suggestion; the latter statement is formed from the judgments of the clinical importance of the recommendation made by the guidelines production group assembled by the sponsoring organization.
When the list of recommendations is complete, they are supplemented by a review of the supporting evidence from the medical literature, and all of this information, along with an extensive bibliography, is published. Guidelines may be published in a peer-reviewed journal, housed on an organization’s website, or both. Usually, the full guidelines are available at no charge from the sponsoring organization’s website.
Despite the care and effort invested in producing guidelines, there are sometimes problems with the evidence used, including a shortage of acceptable randomized controlled trials, especially for surgical conditions. Available randomized trials test hypotheses in carefully selected groups of patients, which raise the possibility that selection bias may reduce the generalizability of the findings. The outcomes observed in prospective randomized trials demonstrate the ability to achieve a result (efficacy). In daily surgical practice, it would be preferable to be confident that the desired outcome would be produced repeatedly in different patients (effectiveness). Although guidelines supported by evidence from high-quality observational studies (cohort or case control designs) may be as useful as guidelines supported by randomized trials, these studies are scarce. That said, results of prospective cohort studies involving large numbers of patients from multiple institutions may offer insight into outcomes that can be expected in “real world” experience. The final problem worth mentioning in this context is that research studies performed to validate the effectiveness of guidelines are published infrequently.
Barriers to the use of clinical practice guidelines
Available data indicate that strong, widely accepted guidelines are used in only 50 percent of patient care encounters, for myriad reasons. For example, there may be significant variation in the clinical picture an individual patient presents. Application of the guideline may be futile or inappropriate because the patient’s problem varies significantly from the problem described in the guidelines. Implementation of guidelines may be hindered by lack of agreement (buy-in) among all members of the surgical staff. Of equal importance is failure of the health care institutions to provide resources to ensure adequate compliance with the guidelines and that the data are gathered to confirm the guidelines are having the desired result. A barrier particularly pertinent for surgeons is the simple fact that guideline documents are lengthy (sometimes exceeding 250 pages) and the portions that are pertinent to surgical practice may be difficult to locate.
EBDS: A first step
The EBDS provides sets of recommendations based on existing practice guidelines supplemented with input from experts in the area of practice addressed by the module. The modules are developed at the ACS and are peer-reviewed by six to 10 members of the ACS Board of Governors and the ACS Advisory Councils. Each module summarizes guideline recommendations pertinent to surgical practice along with the grade of evidence supporting the recommendation. Advice is provided relevant to the resources needed to implement the guideline in practice; a listing of the types of data needed to document guideline compliance and effectiveness also is provided. Patient education links and lists of supplementary recommendations from module reviewers are presented in separate sections. The modules conclude with a list of references that may help the user better understand the guideline and the problem addressed in the module.
After signing in, the user can select a topic. The user is then taken to the opening page for the topic. The next page contains a review of the guideline recommendations and describes the supporting evidence. Illustrative examples are shown. Some modules include a clinical decision pathway. (See sample screens in Figure 1, below.)
The modules are housed in a mobile-optimized website. The modules are designed to assist with and improve communication between the surgeon and other health care professionals. Modules also have been useful in facilitating conversations with patients and patients’ families. Finally, the information may be used to support clinical decisions. Currently, 39 modules that have been chosen because of their relevance to the diagnoses related to the 20 most common operations general surgeons perform. The modules are revised based on annual reviews and are updated whenever guideline revisions or modifications are published.
The EBDS is a resource of great potential value in surgical practice. Our objective is to make evidence-based practice easier for surgeons by providing accessible and easy-to-use guidance that can be employed at the point of care.
Figure 1. EBDS website sample screens
Patient Education Program
The ACS Surgical Patient Education Program encompasses a range of patient education interventions and resources. These programs are aimed at improving the quality of patient care and promoting patient safety through educational efforts that recognize patients as integral members of the surgical team. The goals of the program support excellence in surgical care and address a range of national mandates, including reduction in complications, prevention of readmissions, improved satisfaction scores, and decreased health care costs.
Patient home skills kits
The surgical prep home skills program provides the surgical team with simulation-based patient training designed to preoperatively teach patients and families the necessary skills for at-home care and to recognize complications. With fast-track options and early discharge, more patients recover at home, making a surgical home prep program an essential component of their care. Each kit contains an instructional booklet, DVD with step-by-step instructions, equipment and a practice model, a checklist to guide and validate skill acquisition, website references, and a self-evaluation.
With more than 50,000 kits distributed, patients have rated this service—developed in collaboration with multiple associations—as more helpful than any other resource in preparing them for discharge to home. The use of the kit resulted in higher patient confidence scores (which was associated with fewer complications), increased satisfaction, and fewer readmissions. Adult ostomy (Spanish and English-language versions), pediatric ostomy, feeding tubes, and central line kits are available online. A wound and drain skills program, as well as a tracheostomy program, are currently in development.
The Informed Surgical Prep brochure and e-learning materials prepare patients for their operation. The electronic materials also can be used to address meaningful use criteria. In addition to medications and surgery, the new Quit Smoking before Surgery brochure graphically illustrates the potential surgical complications of smokers versus nonsmokers in the areas of cardiovascular and wound health, as well as cancer recurrence. Preoperative smoking cessation counseling is a reimbursable item, and the brochure with the Quit Smoking Action Plan helps surgeons meet that coding requirement. A 1.0 continuing medical education program on the codes and implementation also is available. The eight-page color procedure brochures meet the ACS guidelines for informed consent and current Joint Commission patient safety requirements. Procedure options with images, discharge instructions, procedure-specific risks, and potential complications using the risk calculator are included. They are available free on the ACS website with a print and electronic purchase option. New to the series are colectomy and colonoscopy, along with six different prep options.
The Surgical Cancer Series continues to offer the Lung Cancer Program developed in collaboration with the American Association for Thoracic Surgery, Society of Thoracic Surgeons, Association of PeriOperative Registered Nurses, and Commission on Cancer. The program covers the entire perioperative period, including preoperative exercise and smoking-cessation plans, tests and cancer staging with images, hospital safety and guidance for active recovery, discharge instructions, and a survivorship plan. The DVD and 20-page booklet are available on the ACS website.
The ACS Patients as Partners website contains materials that can be viewed at no charge with minimal fees for print and digital access. A new option is a digital access version of ACS patient education brochures and videos, with the ability to efficiently deliver and send evaluations to patients. The materials can be printed in the office, viewed on the surgeon’s practice website from a mobile device, or sent via e-mail or to the patient’s portal. New government, cancer, medication, and lab resources are also available as part of this package.
The ACS has teamed up with Dialog Medical iMedConsent to offer more than 2,000 informed consent documents, featuring pre- and postoperative instructions. Documents can be individualized and are compatible with all electronic medical records.
Contact Sapna Dalal, MHSA, at email@example.com or Lewis Flint, MD, FACS, at firstname.lastname@example.org with any questions, comments, or recommendations regarding the EBDS program, and Kathleen Heneghan, MSN, RN, CPN, at email@example.com with any questions about the Patient Education Program.