In the August 11th 2022 PAAD “Suicide risk screening in the emergency department: should we be doing this in PreOp?” Dr. David Nichols and I laid down the gauntlet and challenged all of you to use the preop visit and evaluation as a touchpoint in the healthcare system to identify adolescents suffering from major depression and suicide risk.
We can do so much more! 5-6 million American children undergo anesthesia annually, all of whom undergo a history and physical. This is an untapped health-care opportunity in which we, in our roles as pediatric doctors/practitioners, can step out of our traditional OR anesthesia mind-set (silo) and be the point of the spear to dramatically improve public health (yes, you are pediatricians as well as anesthesiologists!). Why is the preop period so ideal as a public health intervention touchpoint? Because general anesthesia and surgery are so fraught with fear and anxiety, it is a “teachable moment,”—that is, an event that “motivates individuals to spontaneously adopt risk-reducing health behaviors” and help overcome resistance to behaviors like smoking cessation.[1, 2] Dr Kim Strupp and her colleagues at the Children’s Hospital Colorado wondered if the perioperative period would be an ideal opportunity to increase the abominably low rate of influenza vaccination in children? (and to be completely transparent, I was actively involved in this study from its conception to its eventual submission for publication).
The results of her study were dramatic and presented at the Annual Meeting of the American Society of Anesthesiologists, San Diego, California, October 2021, as a poster, and at the meeting of Pediatric Academic Societies, Denver, Colorado, April 2022, and was accepted for publication in Anesthesiology. Normally, I wait for the printed version or an e-pub of a paper prior to review in the PAAD. I decided to bump this up because we are now entering the optimal flu (and Covid booster) vaccination period and if any of you want to duplicate her process the time to do it is now.
How dramatic was the improvement? In the first year of the intervention, influenza vaccination rates increased from 140/year to 930/year. Since the submission of the manuscript the vaccination rates have more than tripled again.
How did they do it? Drs. Strupp and colleagues implemented a standardized process to actively offer influenza vaccination to all of their patients undergoing elective general anesthesia. They developed “best practice” workflows with key stakeholders and end users and recognized the need for an organized processes system change, rather than individual change, which confirms other studies on the importance of collaboration and teamwork in process improvement.[3, 4] This standardized process substantially increased the number of perioperative vaccinations, particularly among Hispanic children, without increasing postoperative vaccine-related adverse events.
If you would like more information on how to implement this program in your practice please contact Kim directly (kim.strupp@childrenscolorado.org). I will review this paper in greater detail in a future PAAD when publication occurs.
References
1. Shi, Y. and David O. Warner, Surgery as a Teachable Moment for Smoking Cessation. Anesthesiology, 2010. 112(1): p. 102-107.
2. Shi, Y. and D.O. Warner, Pediatric surgery and parental smoking behavior. Anesthesiology, 2011. 115(1): p. 12-7.
3. Lovely, J.K., et al., Impact of a Program to Improve Venous Thromboembolism Prophylaxis on Incidence of Thromboembolism and Bleeding Rates in Hospitalized Patients During Implementation of Programs to Improve Venous Thromboembolism Prophylaxis. Mayo Clin Proc Innov Qual Outcomes, 2020. 4(2): p. 159-169.
4. Streiff, M.B., et al., The Johns Hopkins Venous Thromboembolism Collaborative: Multidisciplinary team approach to achieve perfect prophylaxis. J Hosp Med, 2016. 11 Suppl 2: p. S8-s14.