Cohan Protocol 5

Cohan Protocol 5

by JESSICA COHAN -

My protocol is in a bit of flux right now, so I apologize for switching implementation plans in the middle of class.  However, though a series of conversations I have decided to focus on the implementation of a surgeon’s “toolbox” that we anticipate will facilitate accurate and meaningful discussions about risk during the patient’s surgical appointment.

A. Describe one tool that you will employ in your intervention strategy using the following domains....

Tool—type:  A surgeon’s “Toolbox” for use in elderly patients considering major surgery.  It includes:

  1. NSQIP surgical risk calculator: provides individualized risk information to patients compared with the “average” patient.
  2. E-prognosis calculator: provides estimated mortality risk over 1, 5, and 10 years for your patient without surgery.  Will function as a baseline.
  3. A brief tool to facilitate the discussion about surgical risks using a “best case/worst case” framework that we anticipate will enhance patient understanding of the expected postoperative course.

Target Population:  Surgeons

Target Behavior:  Use the toolbox in clinic with every patient ≥65 years old who is considering major surgery.  In clinic, surgeons will calculate the patient’s individualized surgical risk  and use the information as a guide to have a conversation regarding “best and worst case scenarios” after surgery. This will be bolstered with a calculation of the patient’s baseline 1, 5, and 10-year mortality risk without surgery.  The reports will be given to the patient to take home after the visit in case they want to share it with family/friends for decision making.

PRECEDE Category:  Enabling.  This tool will enable surgeons to move away from using “laundry lists” of surgical complications and tailor the conversation to the individual patient in language they can understand. 

Platform:  Online.  Working to integrate into APeX in the clinic patient navigator.

B. For a multi-tool intervention strategy, use the PER worksheet attached to describe how you will address each of the PRECEDE framework components

Target Behavior

Use “toolbox” in every patient ≥65 years old who is considering major surgery

Target Audience

Surgeons

Other Key Individuals

Residents, nurse practitioners, patients, and families.

PREDISPOSING

ENABLING

REINFORCING

KNOW

BE ABLE TO DO (skills)

REMINDED

The calculator exists

Have difficult discussions with patients that involve uncertainty

Links embedded into patient navigator.

What information patients need to make “informed” decision.

Provide a “best estimate” of the expected postoperative course

Reminder when submitting orders for an operation (usually done while patient still in clinic so it prints on their AVS)

BELIEVE/VALUE

ACCESS TO

POSITIVE REINFORCEMENT

Accurate risk communication

Two online calculators accessed from within the medical record

Tracking and feedback of compliance with the tool.

Shared decision making

A communication tool to facilitate the discussion of the results.

This will be integrated into a larger comprehensive geriatric surgical program that includes many other programs and supports for patients that will improve surgical outcomes

INTENTION

ACCESS REMOVED

NEGATIVE REINFORCEMENT

Improve accuracy of patient expectations regarding surgery

 

Increased time spent discussing risks with patients

Allow patients to decide not to have surgery

 

Patients not wanting to hear negative information i.e. baseline mortality risk

OTHER

 

SOCIAL SUPPORT

 

 

Peer pressure

 

 

Pressure from surgical leaders

 

 

 

Re: Cohan Protocol 5

by Nicole Ling -

Hey Jess,

 

Great job. Sounds like the class is making you think and revise your project - which I totally can relate to.  It is both exciting (to have a better idea of what you're doing and where you're going) and frustrating (feeling somewhat stagnant in the progression of your work).  For the multi tool: enabling factors include skills such as being able to actually use and navigate the tool effectively (not sure if this counts, as this is your objective) but seems like a self evident thing. Also, I think Access removed includes things that I included in my protocol like "increased time demands on surgeons preoperatively before surgery" (or in clinic or something like that).  Looks great!

 

Nikki

Re: Cohan Protocol 5

by Ralph Gonzales -

Great Jessica.  No problem with adapting/revising your plan and program mid-stride.  Hopefully that’s a positive result of the class material/protocol development.  Always harder to switch after you’ve begun the project!

I like the concept b/c operative risk is often relegated to the anesthesiologist appointment, which occurs too far downstream in the decision making process to be very useful.  Primary care doctors also do a bit of risk assessment/counseling, but it’s never as effective as being delivered by the surgeon who is actually performing the procedure!

Re: Target Population…. Is this ALL surgeons, or would you focus on one particular type of surgeon, in one particular location, etc.?

Re: Platform:  there are ways you can embed a link to the tools in APEX, and this link could go to a secure server that houses the toolbox.

PER Worksheet:

KNOW: I think a key selling point for surgeons will be to know how much better the tool is than “guessing”, and how use of the tool changes decisions, improves liability risk, etc.

INTENTION:  include here the intention for doing the key target behavior:  using the toolbox with every 65 yo patient.

ACCESS REMOVED:  might include time/coordination during clinic appoitnments.

REINFORCING:  if you use any kind of structured templates for pre-procedure visits and counseling, you could embed a hardstop reminder there.  You can also create a smart set for these specific visits that have everything in one place.  Another reinforcing factor could be “upcoding” the visit to a level 5 with the additional counseling provided

Re: Cohan Protocol 5

by Grace -

Hey Jessica,

You're project is beginning to resemble mine a little more. For a "down the road" ultimate product, I was envisioning an IPad application with decision trees and logic that PCP's can use with patients during visits. I was wondering if that idea could also be applied to your toolbox. For example, if the calculator is embedded and a certain value was reached or not reached, it would automatically direct the surgeon to the next question. I also wonder how much time using something like an electronic decision aid would ultimately take. I imagine there might be a lot of push-back at first as the surgeons would have to learn how to use it. I imagine it would take time before it would be considered "enabling." I'm interested to see how this will progress as it helps give me ideas for my project,

Re: Cohan Protocol 5

by Brian -

applaud the decision to change projects- this project really fits with your research interests. 

I might add to the negative reinforcement- many of the patients may have issues with innumeracy and will need alot more education/explanation from the surgeon about risks, even before using the tool. this might cause frustration on both patient and surgeon perspectives.

Also- with tracking/compliance (or is it intention?)- if I were a surgeon, i would want access to tools that might help me characterize risk better, but also leave "wiggle room" for clinical gestault/impression. My take is that there are probably cases where the patients "numbers" or risk seems high but the surgeon feels the surgery is important and/or the surgeon feels it actually will be lower risk; and vice versa with patients who seem low risk on calculators but perhaps the surgeon knows something that may make the particular pt higher risk than advertised-- addressing these scenarios might be important to consider.