BC Surgical Prehabilitation Toolkit - SURGICAL PATIENT OPTIMIZATION COLLABORATIVE - Specialist Services ...
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TOOLKIT
PREHABILITATION
BC Surgical
Prehabilitation
Toolkit
SURGICAL PATIENT
OPTIMIZATION COLLABORATIVE
SEPTEMBER 2020 · V.3
PREHABILITATION
TOOLKIT
This toolkit includes primary
drivers and change ideas
which may be used to
prehabilitate patients prior
to surgery.
TOOLKIT OBJECTIVE
To improve patients’
surgical outcomes
and experiences,
through mental and
physical preparation
prior to surgery.
TABLE OF CONTENTS
Welcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Key Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Patient Activation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Clinical Components . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Nutrition . . . . . . . . . . . . . . . . . . . . 19 Pain management . . . . . . . . . . 47
Substance Use . . . . . . . . . . . . . 23 Social Supports . . . . . . . . . . . . . 51
VTE Prophylaxis . . . . . . . . . . . . 27 Anxiety . . . . . . . . . . . . . . . . . . . . 53
Sleep Apnea . . . . . . . . . . . . . . . . 31 Smoking Cessation . . . . . . . . . 55
Cardiac . . . . . . . . . . . . . . . . . . . . 35 Anemia . . . . . . . . . . . . . . . . . . . . 57
Glycemic Control . . . . . . . . . . 39 Frailty . . . . . . . . . . . . . . . . . . . . . 59
Physical Activity . . . . . . . . . . . . 43
Process Improvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Spread and Sustainability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
AN SSC LED INITIATIVE IN PARTNERSHIP WITH SHARED CARE AND GPSC | #SPOC 3
WELCOME Welcome to the BC Surgical Prehabilitation Toolkit. This toolkit was created by the BC Surgical Optimization Working Group and vetted by 15 provincial sites involved in the Surgical Patient Optimization Collaborative (SPOC), a provincial collaborative, bringing care teams from across the province together in the pursuit of improving patients’ readiness for elective surgery. Introduction to the Surgical Patient Optimization Collaborative (SPOC) Background After successful implementation of the Enhanced Recovery After Surgery (ERAS) Collaborative, a Doctors of BC and Specialist Services Committee initiative that aimed to improve outcomes for elective colorectal surgery patients in 2015-16, there was widespread specialist interest in continuing to improve surgical patient outcomes across different types of surgery. This impetus, along with literature highlighting the significant impact prehabilitation can have on improving a patient’s surgical outcomes, led to initiation of the Surgical Patient Optimization Collaborative (SPOC) launched in May of 2019. The Collaborative In May 2019 SPOC launched in 15 sites across the province, providing system change strategies, funding support, and shared learning to interdisciplinary teams. Quarterly learning sessions provide support as the teams work to implement process changes based on this toolkit. 4 BC SURGICAL PREHABILITATION TOOLKIT
Objectives
Over the course of 24 months, SPOC teams implemented models of care,
collected aggregate data, and engaged in system change strategies in order
to reach the following objectives of patient prehabilitation:
Reduce surgical complications
Reduce the length of hospital stay for elective surgical patients
Reduce the number of surgical cancellations due to patient health status
Improve patient reported experiences and outcomes
The Toolkit
This change toolkit is organized in a series of drivers that are important when
prehabilitating patients for surgery. There are four primary drivers:
1. Activate patients in their own care;
2. Implement clinical tools to prehabilitate patients prior to surgery;
3. Introduce a refined process to allow for surgical prehabilitation, and;
4. Improve the spread and sustainability of effected change.
Scope
This toolkit includes primary drivers and change ideas that may prove useful
for health care providers looking to prehabilitate patients before surgery.
This toolkit is not meant to dictate the practice of clinicians, rather to provide
options that are available to both providers and patients throughout British
Columbia. Clinicians are encouraged to use the toolkit at their own discretion
based on the best interest of the patient.
AN SSC LED INITIATIVE IN PARTNERSHIP WITH SHARED CARE AND GPSC 5
6 BC SURGICAL PREHABILITATION TOOLKIT
AN SSC LED INITIATIVE IN PARTNERSHIP WITH SHARED CARE AND GPSC 7
Prehabilitation Performance Indicators
The following measures can be used as indicators to alert a team of any
improvement that may be needed in the process of prehabilitation.
The Delta
# of patients change:
# of patients
# of patients requiring E.g. hgb increase,
Total # of who receive
screened for prehabilitation HgbA1C
Surgical Patients at least one
prehabilitation based on the decrease,
change idea
screening tools stopped
smoking
Post-operative patient outcomes should be recorded when optimizing
patients for surgery (Appendix A)
Family and Caregiver Partners
Patient partners such as family members or other caregivers should be
included as part of the prehabilitation team. To effectively involve patient
partners in the prehabilitation process, the language, culture, and health
literacy of both the patient and their partners should be considered.
The desired outcomes of both the patient and the patient partner should
be considered when making decisions about surgery. This includes, but is
not limited to, how much they would like to know about the process, what
to expect from surgery, and what they expect their condition to be like
after surgery.
The patient passport can be shared with the patient partner to facilitate their
involvement in the prehabilitation process.
Adapted from Agency for Clinical Innovation | The Perioperative Toolkit†
Implementing the Toolkit
For best chances of success in implementing the changes in this toolkit
there must be appropriate planning of objectives, team member roles, and
milestones. Communication with all relevant parties about the plan and the
8 BC SURGICAL PREHABILITATION TOOLKIT
reason for implementing the toolkit will also increase the chances of success
with patient prehabilitation. Finally, as with any process, assessment of the
process through objective and subjective measures allows for improvement
of the process and effective lasting change.
Adapted from Agency for Clinical Innovation | The Perioperative Toolkit†
Revisions to the Toolkit
This toolkit is a collection of the best practices and knowledge available at
the time of development. Any feedback can be directed to the Specialist
Services Committee, sscbc@doctorsofbc.ca and appropriate changes will
be made to the best ability of the development team.
KEY DEFINITIONS
Primary Drivers Secondary Drivers
These are areas of focus created from These are the details which need to be
literature which need to be addressed addressed to successfully implement
to create change. the primary drivers.
Patient Activation Screening Tool
A concept in health care that focuses Assessment of a surgical patient to
on encouragement of patients by determine whether or not prehabilitation
their health care provider to be is needed for each clinical component.
actively involved in understanding
of their own health care plan. Change Ideas
These are actionable items that
Clinical Components health care providers can use to
The aspects of a patient’s health that prehabilitate patients.
can affect surgical outcomes based
on available research. Measurement
This is a measure of whether the
Optimization patients selected for intervention were
Synonymous with prehabilitation. successfully prehabilitated.
†
www.aci.health.nsw.gov.au/__data/assets/pdf_file/0010/342685/The_Perioperative_Toolkit.pdf
AN SSC LED INITIATIVE IN PARTNERSHIP WITH SHARED CARE AND GPSC 9
ACKNOWLEDGEMENTS
The BC Surgical Prehabilitation Toolkit was first developed by
the Specialist Services Committee of Doctors of BC in 2019,
with the support and expertise of all members listed below.
Over countless hours, the following individuals came together as a working
group and faculty of experts to create and refine the contents of this toolkit.
We thank them for their contribution to BC health care.
Dr Kelly Mayson Dr Brenda Lau
Anesthesiologist Anesthesiologist
Prehabilitation Working Group Co-Chair Pain Faculty
Cardiac and Sleep Apnea Faculty Change Pain BC
Vancouver Coastal Health
Dr Martha Spencer
Dr Tom Wallace Geriatrician
General Surgeon Frailty Faculty
Prehabilitation Working Group Co-Chair St Paul’s Hospital
– Faculty
Royal Inland Hospital Mandy Kennedy
Dietitian
Dr Jacqueline Trudeau Nutrition Faculty
Anesthesiologist Interior Health
Anemia Faculty
Vancouver Coastal Health Marija Stefic-Cubic
Clinical Nurse Specialist
Dr Michelle Scheepers Frailty Faculty
Anesthesiologist St Paul’s Hospital
Glycemic Control Faculty
Interior Health Kyle Heppner
Physiotherapist
Dr Milan Khara Physical Activity Faculty
Addiction Medicine Specialist Interior Health
Smoking Cessation Faculty
Vancouver Coastal Health
10 BC SURGICAL PREHABILITATION TOOLKITJohn Warkentin Dr Leslie Wood
Pharmacist Faculty Family Practice Faculty
Langley Memorial Hospital Vancouver Coastal Health
Lila Gottenbos Karen Phenix
NSQIP Champion Faculty Consultant, Quality Improvement
Langley Memorial Hospital Nursing Faculty
Island Health
Melanie Rathgeber
Evaluation Faculty Vicki Kendall
Merge Consulting Patient Representative
Patient Voices Network
Michelle Montgomery
Project Manager Geoff Schierbeck
Substance Use Faculty SSC Portfolio Liaison
Fraser Health Social Support and Anxiety Faculty
Doctors of BC
Dr James McInnes
Orthopedic Surgeon Elizabeth Babcock
VTE Faculty SSC Project Coordinator
Island Health Doctors of BC
Claire Snyman Sarah White
Patient Activation Faculty SSC Administrative Assistant
TwoSteps.ca Doctors of BC
Karen Bowen Imayan Subramaniam
Spread and Medical Student
Sustainability Faculty Toolkit Consultant
Managerknowhow.com UBC Faculty of Medicine
Dr Sophia Chong
Family Practice Faculty
Vancouver Coastal Health
AN SSC LED INITIATIVE IN PARTNERSHIP WITH SHARED CARE AND GPSC 11PATIENT ACTIVATION
3
PRIMARY DRIVER
Activate patients in their care SECONDARY
DRIVERS
CLINICAL COMPONENTS
13
PRIMARY DRIVER
Implement clinical tools to prehabilitate SECONDARY
patients prior to surgery DRIVERS
PROCESS IMPROVEMENT
1
PRIMARY DRIVER
Introduce a refined process SECONDARY
to allow for prehabilitation DRIVER
S·P·R·E·A·D
PRIMARY DRIVER
Address the human aspects of change, to SECONDARY
ensure change endures and is spread widely
12 DRIVERS
BC SURGICAL PREHABILITATION TOOLKITPRIMARY DRIVER
PATIENT ACTIVATION
3
Activate patients
in their care
SECONDARY DRIVERS
Assess patient’s level of activation
3
Assist patients to self manage and
engage in actions supporting their
health and health care
Patients collaborate with
care provider
1 PATIENT PASSPORT
TEMPLATE FOR SURGICAL
PREHABILITATION
AN SSC LED INITIATIVE IN PARTNERSHIP WITH SHARED CARE AND GPSC 13PATIENT ACTIVATION
Activate patients in their care
Assess patients’ level of activation
Change Ideas
Understand the definition of Patient Activation
PATIENT
Measure HealthALiteracy
CTIVATIONlevels MEASURE®
PAM®)
Understand Health (Literacy
Use a Patient Activation scale in the discussion with your patients
Increasing Activation Starts with Measurement
to assess their level of activation
The Patient Activation Measure® (PAM®) is a 10- or 13-item survey that assesses a person’s underlying
knowledge, skills and confidence integral to managing his or her own health and healthcare.
PAMAppendices
segments individuals into one of four activation levels along an empirically derived 100-point scale.
Each level provides insight into an extensive array of health-related characteristics, including attitudes,
Appendix
motivators, B · Realm-SF
and behaviors. Score
Individuals Sheet
in the lowest activation level do not yet understand the importance of
their role in managing their own health, and have significant knowledge gaps and limited self-management
Appendix
skills. C the
Individuals in · Patient
highest Activation Measure
activation level are proactive with their health, have developed strong self-
management skills, and are resilient in times of stress or change.
PAM
14 is Backed by Extensive Research BC SURGICAL PREHABILITATION TOOLKIT
The Patient Activation Measure survey is a unidimensional, interval level, Guttman-style question scale
developed by Dr. Judith Hibbard, Dr. Bill Mahoney and colleagues at the University of Oregon. PAM wasPATIENT ACTIVATION
Activate patients in their care
Assist patients to self manage and
engage in actions supporting their
health and health care
Change Ideas
Initiate a shared decision making process with the patient
(See Appendix D)
Educate patients about their health condition, symptoms, surgery
and prehabilitation interventions
Assist patients in tracking symptoms with a symptom diary/tracker
(See Appendix E)
Guide patients on how to track their medications and medical records
Help patients develop skills to self manage their health and health care
Have patients participate in group activities promoting health
and wellbeing
Appendices
Appendix D · Shared Approach Model
Appendix E · Diary of Symptoms
AN SSC LED INITIATIVE IN PARTNERSHIP WITH SHARED CARE AND GPSC 15PATIENT ACTIVATION
Activate patients in their care
Patients collaborate with care provider
Change Ideas
Have patients set health care goals with health care providers
(See Appendix F)
Build a collaborative care plan with patient
Have patients ask questions about the diagnosis, treatment & support
(See Appendix G)
Identify and action any further opportunities for post-surgical management
Appendices
Appendix F · My Personal Action Plan
Appendix G · Ask Three Questions
16 BC SURGICAL PREHABILITATION TOOLKITPRIMARY DRIVER
CLINICAL COMPONENTS
Implement clinical
tools to prehabilitate
patients prior
to surgery
SECONDARY DRIVERS
Nutrition
Substance Use
VTE Prophylaxis
Sleep Apnea
Cardiac
Glycemic Control
Physical Activity
Pain management
Social Supports
Anxiety
Smoking Cessation
Anemia
Frailty
AN SSC LED INITIATIVE IN PARTNERSHIP WITH SHARED CARE AND GPSC 1718 BC SURGICAL PREHABILITATION TOOLKIT
CLINICAL COMPONENTS
Implement clinical tools to prehabilitate
patients prior to surgery
Nutrition
Screening Tools
· Canadian Nutrition Screening Tool
Change Ideas
Primary Care Provider assessment for motivational interviewing
and starting basic nutrition counselling
Dietitian assessment
Healthlinkbc.ca or *811
Healthy Eating for Seniors Handbook
* Ensure appropriate in-hospital and post-operative follow up and care
Measurements
· Repeat CNST
AN SSC LED INITIATIVE IN PARTNERSHIP WITH SHARED CARE AND GPSC 19NUTRITION ALGORITHM
Screening with
Canadian Nutrition
Screening Tool
Positive for Negative for
Nutrition Risk Nutrition Risk
If no dietician
available: No dietitian Share patient
Refer to dietitian
Refer to intervention accessible
if available
Primary Care required resources
Provider
Motivational
Interviewing + Basic Canada Food Guide
Nutritional Counselling
Healthy Eating
HealthlinkBC.ca *811
for Seniors Handbook
20 BC SURGICAL PREHABILITATION TOOLKITNUTRITION SCREENING TOOL
Canadian Nutrition Screening Tool
CANADIAN NUTRITION SCREENING TOOL (CNST)
Name: Age: Weight: Room:
Identify patients who are at risk for malnutrition
Date: Date:
Admission Rescreening
Ask the patient the following questions* Yes No Yes No
Have you lost weight in the past 6 months WITHOUT
TRYING to lose this weight?
If the patient reports a weight loss but gained it back, consider it as NO weight loss.
Have you been eating less than usual FOR MORE THAN
A WEEK?
Two “YES” answers indicate nutrition risk†
* If the patient is unable to answer the questions, a knowledgeable informant can be used to obtain the information. If the patient is uncertain regarding
weight loss, ask if clothing is now fitting more loosely.
Patients at nutrition risk need an assessment to confirm malnutrition
Nutrition screening using a valid tool can generate a significant volume of requests for nutrition evaluation.
Subjective Global Assessment (SGA) is a simple and efficient first-line assessment of nutritional status that
can be used following a positive screening and to help prioritize cases.
If a patient is malnourished (SGA B or C), an in-depth nutrition assessment, along with treatment, is required
by a registered dietitian.
The Canadian Nutrition Screening Tool was rigorously validated and tested for reliability in Canadian
hospitals. Non-expert raters completed the tool and it was compared to the SGA conducted by a
dietitian or trained nutrition researcher.
† If a patient is not at risk, rescreen within a week. Only consider weight change in the past week.
Validation and reliability testing of the Canadian
Nutrition Screening Tool was funded by an unrestricted
educational grant of Abbott Nutrition Canada.
AN SSC LED INITIATIVE IN PARTNERSHIP WITH SHARED CARE AND GPSC 2122 BC SURGICAL PREHABILITATION TOOLKIT
CLINICAL COMPONENTS
Implement clinical tools to prehabilitate
patients prior to surgery
Substance Use
Screening Tools
· CAGE-AID
Change Ideas
Primary Care Provider Alcohol abuse intervention
assessment for creating BC211.ca or *211
a substance use treatment
Referral to pharmacist
plan and to coordinate plan
with surgeon Counselling
Healthlinkbc.ca or 811 Medication supplements
Treatment group TAPS Tool (See Appendix H)
* Ensure appropriate in-hospital and post-operative follow up and care
Measurements
· Decreased substance usage
· Date of last substance use
AN SSC LED INITIATIVE IN PARTNERSHIP WITH SHARED CARE AND GPSC 23SUBSTANCE USE ALGORITHM
CAGE-AID Screening
Questionnaire
TAPS Tool Assessment Negative Result
Minimal Risk Problem Use High Risk Use Education on
importance
of abstaining from
intake
Education on Refer to Primary Assess stages pre-operatively
importance Care Provider of change
of abstaining from
intake
pre-operatively.
Assess stages If ready for If not ready,
of change change, then provide
then counsel motivational
abstinence interviewing
If ready for If not ready Refer to If available refer
change then provide support to appropriate
then counsel motivational groups e.g. substance use
abstinence interviewing AA clinics e.g. opioid
use Disorder and
Chronic Pain Clinic
Provide resources Create a specific Create treatment
e.g. substance use plan involving all
HealthlinkBC.ca/*811 treatment plan available resources
BC211.ca/*211
Communicate Communicate
plan with surgeon treatment plan
and allied health with surgeon
professionals and allied health
professionals
24 BC SURGICAL PREHABILITATION TOOLKITSUBSTANCE USE SCREENING TOOL CAGE-AID This tool was developed by Richard Brown, MD and Laura Saunders at the University of Wisconsin. AN SSC LED INITIATIVE IN PARTNERSHIP WITH SHARED CARE AND GPSC 25
26 BC SURGICAL PREHABILITATION TOOLKIT
CLINICAL COMPONENTS
Implement clinical tools to prehabilitate
patients prior to surgery
VTE Prophylaxis
Screening Tools
· Caprini Risk Assessment Model
Change Ideas
Follow health authority policy or Caprini recommendation
VTE Risk Calculator App
* Ensure appropriate in-hospital and post-operative follow up and care
Measurements
· VTE Prophylaxis given according to risk
AN SSC LED INITIATIVE IN PARTNERSHIP WITH SHARED CARE AND GPSC 27VTE PROPHYLAXIS ALGORITHM
Caprini Risk Assessment Screening
Score = 0 Score = 3-4
Score = 1-2 Score = 5+
Very low risk Moderate Risk
Low risk (~1.5%) High risk (~6%)
(VTE PROPHYLAXIS SCREENING TOOL
Caprini Risk Assessment Model · PG 1 of 2
Caprini score
Caprini risk assessment model
for venous thromboembolism
Complete the risk assessment to determine your patients’ risk level for venous thromboembolism (VTE).
1 point 2 points 3 points 5 points
per risk factor per risk factor per risk factor per risk factor
Age 41–60 years Age 61–74 years Age ≥75 years Stroke (25 kg/m2 Major open surgery Family history of VTE Hip, pelvis or leg fracture
Swollen legs (>45 minutes) Factor V Leiden Acute spinal cord injury
Varicose veins Laparoscopic surgery Prothrombin 20210A (45 minutes)
Pregnancy or postpartum Lupus anticoagulant
Malignancy
History of unexplained Anticardiolipin antibodies
or recurrent spontaneous Confined to bed (>72 hours)
Elevated serum
abortion Immobilizing plaster cast homocysteine
Oral contraceptives Central venous access Heparin-induced
or hormone replacement thrombocytopenia
Sepsis (VTE PROPHYLAXIS SCREENING TOOL
Caprini Risk Assessment Model · PG 2 of 2
Caprini score
Recommended intervention
for thromboprophylaxis based on risk of VTE
Applies to general and abdominal-pelvic nonorthopedic surgical patients,
including those undergoing GI, urological, gynecologic, bariatric, vascular,
and plastic and reconstructive surgery
High bleeding risk (~2%)
Caprini score VTE risk category Average bleeding risk (~1%)
or severe consequences
No specific pharmacologic (Grade 1B) or mechanical (Grade 2C) prophylaxis be used
0 Very low risk (CLINICAL COMPONENTS
Implement clinical tools to prehabilitate
patients prior to surgery
Sleep Apnea
Screening Tools
· STOP-Bang Questionnaire
Change Ideas
Primary Care Provider for education on the importance
of OSA management and use of the equipment.
Sleep Clinic assessment
Specialist assessment
If resources are limited then conduct overnight pulse oximetry
to determine need for sleep clinic referral
* Ensure appropriate in-hospital and post-operative follow up and care
Measurements
· One or more change ideas completed
AN SSC LED INITIATIVE IN PARTNERSHIP WITH SHARED CARE AND GPSC 31SLEEP APNEA ALGORITHM
STOP-Bang Questionnaire
Pre-existing OSA Diagnosis
Risk Assessment
Yes to 0-2 Yes to 3-4 Yes to 5-8 Yes to 2
questions questions questions or more STOP
questions
and male/
BMI>35/neck
Considered circumference
high risk >40 cm
If patient lost to follow, Refer to Primary Care
PAP therapy can be started Provider for managing
in the recovery room and assessment for OSA
de-saturation events
should be follow up in the
post-operative period by
primary Care Provider If resources are
limited conduct overnight
pulse oximetry to
determine need for sleep
Sleep Clinic for sleep study clinic referral
If diagnosed with OSA
then refer to Anesthesia
pre-admission clinic
Refer to Primary Care
Provider for education on
the importance of OSA
management and use of PAP
therapy if needed
32 BC SURGICAL PREHABILITATION TOOLKITSLEEP APNEA SCREENING TOOL STOP-Bang Questionnaire AN SSC LED INITIATIVE IN PARTNERSHIP WITH SHARED CARE AND GPSC 33
34 BC SURGICAL PREHABILITATION TOOLKIT
CLINICAL COMPONENTS
Implement clinical tools to prehabilitate
patients prior to surgery
Cardiac
Screening Tools
· Revised Cardiac Risk Index
Change Ideas
BNP or NT-proBNP
DASI Questionnaire if BNP or NT-proBNP not available (See Appendix I)
If pre-operative OR If no preoperative BNP OR DASI score < 34
BNP 92 ng/L or greater, or NG-proBNP available
or NT-proBNP 300ng/L but patient has met the
or greater criteria for screening
Then Obtain: ECG on arrival in PACU
Troponin on arrival in PACU & on postoperative days 1, 2, and 3
Primary Care Provider to arrange lab investigation and refer to cardiology if
BNP is elevated. Post-op follow up by Primary Care Provider is also warranted.
Cardiac Treatment algorithm
* Ensure appropriate in-hospital and post-operative follow up and care
Measurements
· One or more change ideas completed
AN SSC LED INITIATIVE IN PARTNERSHIP WITH SHARED CARE AND GPSC 35CARDIAC ALGORITHM
PATIENTS Patients age is ≥ 45 yrs, or 18-44 yrs with known significant
cardiovascular disease undergoing non cardiac surgery requiring
overnight hospital admission
TIMING OF
Elective Surgery
SURGERY
PREOPERATIVE
ASSESSMENT Assessment or preoperative Risk
Risk Stratification RCRI
If a patient’s age is ≥ 65 yrs, RCRI ≥ 1 or age 45-54 yrs
with significant cardiovascular disease
order NT - proBNP/BNP
Negative
Positive NT - proBNP
NT -proBNP
NT -proBNP or BNP
< 300 MG/L or
≥ 300 MG/L or not available
BNP < 92 mg/L
BNP ≥ 92 mg/L DASI 34
POSTOPERATIVE
MONITORING Measure Troponin daily x 48 - 72 hrs
Obtain ECG in PACU
Consider in-hospital shared
care management
No additional
Post-operative follow up by Primary
routine
Care Provider for management and
Postoperative
investigation of cardiac disease
monitoring
36 BC SURGICAL PREHABILITATION TOOLKITCARDIAC SCREENING TOOL Revised Cardiac Risk Index AN SSC LED INITIATIVE IN PARTNERSHIP WITH SHARED CARE AND GPSC 37
38 BC SURGICAL PREHABILITATION TOOLKIT
CLINICAL COMPONENTS
Implement clinical tools to prehabilitate
patients prior to surgery
Glycemic Control
Screening Tools
· Glycemic Control Screening Questions
Change Ideas
Primary Care Provider for counseling about diagnosis,
lifestyle modifications, and pharmacological management
Internal Medicine or Endocrinologist assessment
Diabetes clinic/educator assessment
Medication review
Limited resource settings can use telehealth to arrange specialty care
* Ensure appropriate in-hospital and post-operative follow up and care
Measurements
· HbA1c 90 days after first HbA1c
· Repeat HbA1c every 90 days or if clinically indicated
AN SSC LED INITIATIVE IN PARTNERSHIP WITH SHARED CARE AND GPSC 39GLYCEMIC CONTROL ALGORITHM
Any of the following:
Known diabetic Family history of diabetes History of hypertension,
Age >40 years BMI >25 dyslipidemia, steroid therapy
No pre-existing
Known Diabetic
diagnosis of diabetes
HbA1c 8.5 ≥ HbA1c HbA1c 8.5 ≥ HbA1c 6.4 ≥ HbA1c HbA1c
≤ 7.1 ≥ 7.1 > 8.5 ≥ 6.5 ≥ 6.0 ≤ 5.9
No action No action
required required
Refer to Primary Refer to Primary
Care Provider for Care Provider for
counselling about counselling about
lifestyle modifications lifestyle modifications
and review of
pharmacological
management
Refer to Primary Care Refer to
Provider for counselling diabetes clinic
about diagnosis, lifestyle /educator
Refer to diabetes modifications and
clinic/educator early pharmacological
management
Refer to Internal Medicine Refer to Primary Care
or Endocrinologist Provider for counselling
about lifestyle modifications
If in person consult is
unavailable, then telehealth Follow Up hemoglobin A1c every 3 months
consult should be arranged. or earlier if clinically indicated
40 BC SURGICAL PREHABILITATION TOOLKITGLYCEMIC CONTROL SCREENING TOOL
Glycemic Control Screening Questions
YES NO
Ever been diagnosed
with diabetes
Age over 40?
Family History
of diabetes
History of hypertension,
dyslipidemia or steroid use
BMI >25
If YES to any of the above questions then a pre-operative screening
hemoglobin A1c test is recommended.
AN SSC LED INITIATIVE IN PARTNERSHIP WITH SHARED CARE AND GPSC 4142 BC SURGICAL PREHABILITATION TOOLKIT
CLINICAL COMPONENTS
Implement clinical tools to prehabilitate
patients prior to surgery
Physical Activity
Screening Tools
· The Physical Activity Vital Sign Calculator
Change Ideas
Primary Care Provider for Clinical Frailty Score assessment
and preliminary counselling
Referral to Physiotherapist or Kinesiologist
Referral to Healthlinkbc.ca or *811
Canadian Physical Activity Guidelines †
6 Minute Walk Test
* Ensure appropriate in-hospital and post-operative follow up and care
Measurements
· Repeat Physical Activity Vital Sign Calculator
· Number of minutes of exercise for each day of the week
†
csep.ca/CMFiles/Guidelines/CSEP_PAGuidelines_0-65plus_en.pdf
AN SSC LED INITIATIVE IN PARTNERSHIP WITH SHARED CARE AND GPSC 43PHYSICAL ACTIVITY ALGORITHM
Physical Activity as a
Vital Sign Screening
If meeting Canadian If not meeting CPAG then refer to a Primary
Physical Activity Guidelines Care Provider for preliminary counselling and
(CPAG, eg. 150 minutes/ Clinical Frailty Scale (CFS) assessment
week of moderate to
vigorous activity) then no
action required. Can refer to
Healthlinkbc.ca/*811 CFS Score CFS Score CFS Score CFS Score
for more info. 1-2 3-4 of 5-6 7 or more
Requires Exercise not
Physiotherapy appropriate
referral
No Yes
- Follow CPAG of - 3x per week, - 3x per week PT will assess and
150 minutes per set up exercise
- 30 -60min. - 20–40 min.
week with 2 days program
per session per session
for strength and
resistance. - Emphasis on - Focus on aerobic
strength (50-75% training (50-75%
- No restriction on
of exercise time), of exercise time),
exertion (RPE 3-9)
then aerobic then strength,
exercise, then balance.
then balance.
- RPE 3-4
- RPE of 3-5
44 BC SURGICAL PREHABILITATION TOOLKITPHYSICAL ACTIVITY SCREENING TOOL
The Physical Activity Vital Sign Calculator
The Physical Activity Vital Sign
1. On average, how many days per week do you engage in moderate _____ days
to strenuous exercise (like a brisk walk)?
2. On average, how many minutes do you engage in exercise at this
_____ minutes
level?
Total minutes per week of physical activity (multiply #1 by #2) _____ minutes per week
Using the Physical Activity Vital Sign
National guidelines recommend 150 minutes per week of moderate intensity physical activity.
Moderate intensity activity is usually done where an individual can talk, but cannot “sing”.
Examples include: brisk walking, slow biking, general gardening, and ballroom dancing.
In place of moderate intensity activity, an individual can also complete 75 minutes of vigorous
intensity physical activity. Vigorous intensity activity is done at a pace where individuals can no
longer talk and are somewhat out of breath. Examples include: swimming laps, playing singles
tennis, and fast bicycling.
Individuals can also achieve 150 “minutes” through a combination of moderate and vigorous
intensity physical activity, with 1 minute of vigorous activity being equal to 2 minutes of moderate
activity.
If activity is done throughout the day, individuals are encouraged to perform activity in “bouts” that
are at least 10 minutes in length.
If your patient is NOT achieving 150 minutes a week of physical activity, advise them to gradually
increase either their frequency or duration until they are capable of safely performing 10 minutes
bouts of activity and achieve national recommendations.
The Physical Activity Vital Sign – Other Considerations
A comprehensive assessment of physical activity should include promotion of active living
throughout the day to reduce sedentary time, as well as muscle strengthening and flexibility
exercises as recommended by the Physical Activity Guidelines for Americans.
If you wish to add a question on muscle strengthening activities, we would recommend the
following question:
How many days a week do you perform muscle strengthening exercises, such as bodyweight
exercises or resistance training? _____ days
AN SSC LED INITIATIVE IN PARTNERSHIP WITH SHARED CARE AND GPSC 4546 BC SURGICAL PREHABILITATION TOOLKIT
CLINICAL COMPONENTS
Implement clinical tools to prehabilitate
patients prior to surgery
Pain Management
Screening Tools
· Pain Screening Questions
Change Ideas
Brief Pain Inventory Medication review
(See Appendix J) Painbc.ca
Post-op pain Opioid agonist therapy clinic
expectations education
Primary Care Provider for
Pain service assessment directed management and
Selfmanagementbc.ca post-op follow up.
Self-referral online group
medical visits
* Ensure appropriate in-hospital and post-operative follow up and care
Measurements
· Has the patient accessed one of more of the interventions?
AN SSC LED INITIATIVE IN PARTNERSHIP WITH SHARED CARE AND GPSC 47PAIN MANAGEMENT ALGORITHM
Pain Screening Questions
Screening Positive
Screening Negative
(Yes to one or more questions)
BPI Assessment Post-op pain
expectation education
Refer to Primary Care Refer to pain service Provide patient
Provider for directed for assessment accessible resources
management and
post-op follow up -selfmanagementbc.ca
-painbc.ca
-self-referral online
group meetings
Medication review
Post-op pain Refer to opioid agonist
expectation education clinic if needed
48 BC SURGICAL PREHABILITATION TOOLKITPAIN MANAGEMENT SCREENING TOOL
Pain Screening Questions
In the past 4 weeks, Yes No
have you been taking more
than twice a week any If yes, please describe:
non-prescription medications
or products to manage pain?
For example: Tylenol, anti-
inflammatory, cannabis products
In the past 4 weeks, Yes No
have you been using any
non-medical therapies If yes, please describe:
specifically to manage pain?
For example: Physiotherapy,
occupational therapy, massage
In the past 4 weeks, have you Yes No
been prescribed any medications
or products to manage pain? If yes, please describe:
For example: Gabapentin, Tylenol #3,
tramadol, anti-depressants
In the past 4 weeks, Not at all
how much did pain interfere A little bit
with your normal activities at Moderately
work or at home? Quite a bit
Extremely
Yes to one or more of the questions indicates a positive screen
AN SSC LED INITIATIVE IN PARTNERSHIP WITH SHARED CARE AND GPSC 4950 BC SURGICAL PREHABILITATION TOOLKIT
CLINICAL COMPONENTS
Implement clinical tools to prehabilitate
patients prior to surgery
Social Supports
Screening Tools
· All patients should be optimized for social support
Change Ideas
Confirm friend/family/caregiver BC211.ca or *211
support and include them in Healthlinkbc.ca or *811
meetings with patient
Connect with
Social worker assessment community supports
Homecare assessment
Primary Care Provider
assessment for preliminary
support and management of
allied health professional care
* Ensure appropriate in-hospital and post-operative follow up and care
Measurements
· One or more change ideas completed
AN SSC LED INITIATIVE IN PARTNERSHIP WITH SHARED CARE AND GPSC 5152 BC SURGICAL PREHABILITATION TOOLKIT
CLINICAL COMPONENTS
Implement clinical tools to prehabilitate
patients prior to surgery
Anxiety
Screening Tools
· All patients should be optimized for pre-operative anxiety
Change Ideas
Primary Care Provider Meditation or
assessment for preliminary mindfulness practices
counselling and Workplace wellness programs
coordinating referrals and
Heretohelp.bc.ca
additional resources.
BounceBackBC
Psychiatrist/psychologist
assessment Anxietybc.com
* Ensure appropriate in-hospital and post-operative follow up and care
Measurements
· One or more change ideas completed
AN SSC LED INITIATIVE IN PARTNERSHIP WITH SHARED CARE AND GPSC 5354 BC SURGICAL PREHABILITATION TOOLKIT
CLINICAL COMPONENTS
Implement clinical tools to prehabilitate
patients prior to surgery
Smoking Cessation
Screening Tools
· Has the patient used any form of tobacco in the past 6 months?
Change Ideas
Quitnow.ca BC Smoking Cessation Program
Primary Care Provider for Stop Smoking Video †
assessing willingness for change BC211.ca or *211
and motivational interviewing
Healthlinkbc.ca or *811
* Ensure appropriate in-hospital and post-operative follow up and care
Measurements
· Date of last tobacco usage
· Did patient decrease tobacco usage before surgery?
†
www.youtube.com/watch?v=nyIJo7VCdPE
AN SSC LED INITIATIVE IN PARTNERSHIP WITH SHARED CARE AND GPSC 55SMOKING CESSATION ALGORITHM
Has the patient used any form of
tobacco in the past 6 months?
Yes No
Refer to BC Smoking Cessation Program and direct patient to quitnow.ca
for additional information and counselling
Patient is unable to access Patient is trying to quit
above resources or is lost to follow
up refer to Primary Care Provider
Follow up in immediate
pre-operative period
Patient is unable to access
above resources or is lost to follow
up refer to Primary Care Provider
If ready If not ready
to quit to quit
56 BC SURGICAL PREHABILITATION TOOLKITCLINICAL COMPONENTS
Implement clinical tools to prehabilitate
patients prior to surgery
Anemia
Screening Tools
· Hemoglobin closest to surgical decision date (referral hemoglobin)
· Ferritin closest to surgical decision date (referral ferritin)
Change Ideas
Primary Care Provider Treatment Algorithm for Anemia
for management and > Oral Iron
investigation of anemia > IV Iron
Refer to internal medicine > Erythropoietin
or hematology
* Ensure appropriate in-hospital and post-operative follow up and care
Measurements
· Preoperative* Hemoglobin
· Calculate change from referral hemoglobin
· Calculate difference from hemoglobin target
* post treatment
* as close to surgery date as is feasible
AN SSC LED INITIATIVE IN PARTNERSHIP WITH SHARED CARE AND GPSC 57ANEMIA TREATMENT ALGORITHM *Ganzoni Formula:
Iron Deficit [mg] =
Patient Weight [kg] x
(target Hgb [g/L] – Actual
High risk: Historic Transfusion Rate of greater than 5-10% Hgb[g/L]) x 2.4 + Iron
Low Risk: Historic Transfusion Rate of less than 5-10% Stores [mg]
Referral Hemoglobin and Ferritin Blood Test
Hemoglobin 130g/L for high
procedures procedures procedures risk procedures
Assess for Iron Deficiency No action necessary
Iron deficiency FerritinCLINICAL COMPONENTS
Implement clinical tools to prehabilitate
patients prior to surgery
Frailty
Screening Tools
· Clinical Frailty Scale
Change Ideas
Medication Review Assessment of goals of care
> Beer’s Criteria and advance care plan
and Forta Classification Identification of substitute
Referral to Geriatric or decision maker
Internal medicine for medical Assess ability to consent
and frailty risk stratification
Cognitive testing for estimating
and prehabilitation
delirium risk
Referral to Physiotherapy
and Occupational Therapy
based on need
* Ensure appropriate in-hospital and post-operative follow up and care
Measurements
· One or more change ideas completed
AN SSC LED INITIATIVE IN PARTNERSHIP WITH SHARED CARE AND GPSC 59FRAILTY ALGORITHM
Clinical Frailty Score Screening Tool Age ≥ 65
No action necessary ScoreFRAILTY SCREENING TOOL
Clinical Frailty Scale · PG 1 of 2
Clinical Frailty Scale*
1 Very Fit – People who are robust, active, energetic
and motivated. These people commonly exercise
regularly. They are among the fittest for their age.
2 Well – People who have no active disease
symptoms but are less fit than category 1. Often, they
exercise or are very active occasionally, e.g. seasonally.
3 Managing Well – People whose medical problems
are well controlled, but are not regularly active
beyond routine walking.
4 Vulnerable – While not dependent on others for
daily help, often symptoms limit activities. A common
complaint is being “slowed up”, and/or being tired Scoring
during the day. The deg
Commo
5 Mildly Frail – These people often have more details o
evident slowing, and need help in high order IADLs repeatin
(finances, transportation, heavy housework, medica-
tions). Typically, mild frailty progressively impairs In mode
shopping and walking outside alone, meal preparation though t
and housework. They can
In severe
6 Moderately Frail – People need help with all
* 1. Canad
outside activities and with keeping house. Inside, they 2. K. Rockw
often have problems with stairs and need help with frailty in eld
bathing and might need minimal assistance (cuing,
© 2007-200
standby) with dressing. Research, Da
to copy for r
AN SSC LED INITIATIVE IN PARTNERSHIP WITH SHARED CARE AND GPSC 61FRAILTY SCREENING TOOL
Clinical Frailty Scale · PG 2 of 2
7 Severely Frail – Completely dependent for
energetic personal care, from whatever cause (physical or
cise cognitive). Even so, they seem stable and not at
age. high risk of dying (within ~ 6 months).
e 8 Very Severely Frail – Completely dependent,
ten, they approaching the end of life. Typically, they could
easonally. not recover even from a minor illness.
problems
ive
9. Terminally Ill - Approaching the end of life. This
Participating Sites:
category applies to people with a life expectancy
hers forPRIMARY DRIVER
PROCESS IMPROVEMENT
Introduce a refined
process to allow for
prehabilitation
SECONDARY DRIVERS
Adapt/modify existing processes
to allow for patient prehabilitation
to take place
AN SSC LED INITIATIVE IN PARTNERSHIP WITH SHARED CARE AND GPSC 63PROCESS IMPROVEMENT
Introduce a refined process
to allow for prehabilitation
Adapt/modify existing processes
to allow for patient prehabilitation
to take place
Change Ideas
Process map current and future state
Analysis of existing documentation
Facilitated discovery workshops
Individual staff or small group interviews
Direct work observation
Business analysis design
64 BC SURGICAL PREHABILITATION TOOLKITPRIMARY DRIVER
SPREAD AND SUSTAINABILITY
Address the human
aspects of change,
to ensure change
endures and is
spread widely
SECONDARY DRIVERS
S - Support
P - Positive Culture
R - Resources
E - Engagement
A - Adoption/Ability
D - Desired Results
AN SSC LED INITIATIVE IN PARTNERSHIP WITH SHARED CARE AND GPSC 65SPREAD AND SUSTAINABILITY
·P·R·E·A·D
SUPPORT
Effective and supportive leadership is critical in change. Leaders need
to be visible, encouraging, and authentic. Leaders solicit and respond to
feedback, demonstrating care and active listening.
Themes
· Visible and Visionary Leadership · Feedback and Ideas
· Encouragement and Support · Communication
POSITIVE CULTURE
Culture reflects the attributes, beliefs, perceptions & values employees
share. Change leaders must understand the role that culture plays on staff
behaviour and their ability to deliver improvements.
Themes
· Model the Way · Common Vision and Practices
· Rewarding Patient Care · Learning Culture
RESOURCES
Teams and individuals must feel capable to transition into the new
desired state. Change leaders need to be able to provide time and access
to knowledge needed (both intellectual and psychological) needed for staff
to implement the required skills and behaviours.
Themes
· Capacity · Training and Education
· Investment · Accessibility
66 BC SURGICAL PREHABILITATION TOOLKITBelow (pg. 66/67) is a high level summary of the
Spread and Sustainability Resource Cards.
Access a digital copy of the full resource cards here
ENGAGEMENT
The degree of person-centeredness in a system is reflected in superior
decision making, design and care. Large-scale engagement is the best way
to guarantee spread and sustainability in change. Change leaders need to
ensure everyone has a vested interest in the change, across all levels and
roles, and feels that they have a voice in the change process.
Themes
· Valued Contribution · Involvement
· Understanding Motivation · Ownership
ADOPTION
Understanding why errors occur and tackling poor design and procedures
is key to improvement. Hearing, listening and responding to the voices
of staff and patients is key to ensuring the successful implementation of a
change. Change leaders need ensure reasons for change, process, and skills
needed are clear to maximize adoption.
Themes
· Keep it simple · Reason for Change
· PDSA Cycles · Contextual Implementation
DESIRED RESULTS
All improvement will require change, but not all change will result in
improvement. Evaluation is vital to our understanding of which methods and
innovations work to improve quality. Where there is a clear benefit to any
change, innovation or improvement it will be adapted and spread more rapidly.
Themes
· Impact measurement · Data Collection
· Monitoring Improvement Outcomes · Innovation
AN SSC LED INITIATIVE IN PARTNERSHIP WITH SHARED CARE AND GPSC 67APPENDIX A
Post-Operative Patient Outcomes Definitions
Superficial Incisional SSI Superficial incisional SSI is an infection that involves only skin or subcutaneous tissue
of the surgical incision.
Deep Incisional SSI Deep Incisional SSI is an infection which involves deep soft tissues. Deep soft tissues are typically
any tissue beneath skin and immediate subcutaneous fat, for example fascial and muscle layers
Organ/Space SSI Organ/Space SSI is an infection that involves any part of the anatomy (e.g., organs or spaces),
other than the incision, which was opened or manipulated during an operation.
Wound disruption The spontaneous reopening of a previously surgically closed wound.
Pneumonia Pneumonia is an infection of one or both lungs caused by bacteria, viruses, fungi, or aspiration.
Pneumonia can be community acquired or acquired in a health care setting.
Intraoperative OR Postoperative The placement of an endotracheal tube or other similar breathing tube [Laryngeal Mask Airway (LMA),
Unplanned Intubation nasotracheal tube, etc.] and ventilator support.
On Ventilator > 48 Hours Total cumulative time of ventilator-assisted respirations exceeding 48 hours.
Pulmonary Embolism Lodging of a blood clot in the pulmonary artery with subsequent obstruction of blood supply
to the lung parenchyma. The blood clots usually originate from the deep leg veins or the pelvic
venous system.
Progressive Renal Progressive Renal Insufficiency: the reduced capacity of the kidney(s) to perform its function
Insufficiency/Acute Renal in comparison to the preoperative state.
Failure Requiring Dialysis Acute Renal Failure Requiring Dialysis: A clinical condition associated with significant decline
of kidney function in comparison to the preoperative state.
Urinary Tract Infection An infection in the urinary tract (kidneys, ureters, bladder, and urethra).
Stroke/Cerebral Vascular An interruption or severe reduction of blood supply to the brain resulting in severe dysfunction.
Accident (CVA)
Intraoperative or Postoperative The absence of cardiac rhythm or presence of a chaotic cardiac rhythm requiring the initiation
Cardiac Arrest Requiring CPR of cardiopulmonary resuscitation.
Intraoperative or Postoperative Blockage of blood flow to the heart causing damage or death to part of the heart muscle.
Myocardial Infarction
Transfusion Intra/Postop Transfusion of red blood cells, whole blood, autologous blood, and cell-saver products.
(RBC within the First 72 Hrs
of Surgery Start Time)
Vein Thrombosis Requiring New diagnosis of blood clot or thrombus within the venous system (superficial or deep) which may
Therapy be coupled with inflammation and requires treatment.
Sepsis Sepsis takes a variety of forms and spans from relatively mild physiologic abnormalities to septic shock
Sepsis: Sepsis is the systemic response to infection.
Septic Shock: Sepsis is considered severe when it is associated with organ and/or circulatory dysfunction.
Still in Hospital > 30 Days The patient remains in the acute care setting at your institution continuously for > 30 days after the
principal operative procedure.
Postoperative Death > 30 Days Death occurring > 30 days after the principal operative procedure, as a direct result of the surgery
of Procedure if in Acute Care and/or associated with postoperative complications and the patient has remained in the hospital in
the acute care setting at your site.
Hospital Readmission Patients who were discharged from their acute hospital stay for their principal operative procedure,
and subsequently readmitted as an inpatient to an acute care hospital setting.
Unplanned reoperation A return to the OR that was not planned at the time of the principal operative procedure.
Average Acute LOS Report at baseline, September 2019 to May 2021
Average Complication rate Report at baseline, September 2019 to May 2021
Average Readmission rate Report at baseline, September 2019 to May 2021
68 BC SURGICAL PREHABILITATION TOOLKITAPPENDIX B
Realm-SF Score Sheet
REALM-SF Score Sheet
Patient ID #: ________________________ Date: ___________ Examiner Initials: ____
Behavior _____
Exercise _____
Menopause _____
Rectal _____
Antibiotics _____
Anemia _____
Jaundice _____
TOTAL SCORE ______
Administering the REALM-SF:
Suggested Introduction:
“Providers often use words that patients don’t understand. We are looking at words providers often use
with their patients in order to improve communication between health care providers and patients. Here
is a list of medical words.
Starting at the top of the list, please read each word aloud to me. If you don’t recognize a word, you can
say ‘pass’ and move on to the next word.”
Interviewer: Give the participant the word list. If the participant takes more than 5 seconds on a words,
say “pass” and point to the next word. Hold this scoring sheet so that it is not visible to the participant.
AN SSC LED INITIATIVE IN PARTNERSHIP WITH SHARED CARE AND GPSC 69APPENDIX C
Patient Activation Measure
PATIENT ACTIVATION MEASURE®
(PAM®)
Increasing Activation Starts with Measurement
The Patient Activation Measure® (PAM®) is a 10- or 13-item survey that assesses a person’s underlying
knowledge, skills and confidence integral to managing his or her own health and healthcare.
PAM segments individuals into one of four activation levels along an empirically derived 100-point scale.
Each level provides insight into an extensive array of health-related characteristics, including attitudes,
motivators, and behaviors. Individuals in the lowest activation level do not yet understand the importance of
their role in managing their own health, and have significant knowledge gaps and limited self-management
skills. Individuals in the highest activation level are proactive with their health, have developed strong self-
management skills, and are resilient in times of stress or change.
PAM is Backed by Extensive Research
The Patient Activation Measure survey is a unidimensional, interval level, Guttman-style question scale
developed by Dr. Judith Hibbard, Dr. Bill Mahoney and colleagues at the University of Oregon. PAM was
created and tested using Rasch analysis and classical test theory psychometric methods. Related versions
include Caregiver PAM and Parent PAM, and over 35 validated translations.
To date, over 500 peer-reviewed published studies worldwide have documented the PAM survey’s ability to
measure activation and predict a broad range of health-related behaviors and outcomes. This foundation in
research consistently demonstrates that individual self-management improves significantly as activation
increases, and has led to endorsement of PAM as a performance measure by the National Quality Forum.
©2020 Insignia Health, LLC. All rights reserved. Rev.20200505
70 BC SURGICAL PREHABILITATION TOOLKITPAT I E N T A C T I VAT I O N M E A S U R E ®
PAM® Applications
The Patient Activation Measure survey is reliable and valid for use with all patients, including those managing
chronic conditions and engaged in disease prevention efforts. PAM is widely used today in population health
management programs, disease and case management systems, wellness programs, medical home projects,
care transitions, value-based programs, and much more. PAM is applied in three key manners:
1. Improving segmentation and risk identification. Traditional risk models rely upon past utilization and
have been shown to miss over half of the individuals in the lower two activation levels. Research
consistently shows that lower activation is an indicator for disease progression, like diabetes or depression,
as well as increased ED visits, hospital admissions, and ambulatory care sensitive (ACS) utilization.
2. Tailoring Support to PAM Level. Hundreds of health-related characteristics have been mapped to PAM
Levels, offering a wealth of insight into a person’s self-management abilities. This insight guides patient
support to establish goals and action steps that are realistic and achievable for each individual. An
activation-based approach to coaching and education, whether provided by phone, in clinic, online or in-
home, has been proven to deliver significantly improved outcomes. Insignia Health’s coaching model
(Coaching for Activation®) and consumer-facing Web-based program (Flourish®) make over a decade of
activation research and experience actionable for health care organizations and the people they serve.
3. Measuring Impact. Even a single point change in PAM score is meaningful. By periodically re-
administering the PAM survey, the impact of patient support strategies and programs can be understood
well in advance of traditional outcome measures.
About Insignia Health
Insignia Health specializes in helping health systems, health plans, hospitals, care management services, and other organizations
assess patient activation and develop strategies for helping individuals become more successful managers of their health and health
care. Insignia Health applies its proprietary family of health activation assessments to measure each individual's self-management
competencies. The Patient Activation Measure® and over 15 years of health activation research form the cornerstone of a
complementary suite of solutions that help clinicians, coaches and population health providers improve health outcomes and lower
costs. Insignia Health supports health activation efforts of over 250 health systems and organizations around the world.
InsigniaHealth.com
AN SSC LED INITIATIVE IN PARTNERSHIP WITH SHARED CARE AND GPSC 71APPENDIX D
Shared Approach Model
The SHARE Approach:
A Model for Shared Decision Making
The SHARE Approach is a five-step process for shared decision making that
includes exploring and comparing the benefits, harms, and risks of each option
through meaningful dialogue about what matters most to the patient.
S eek your patient’s
STEP
1 participation.
H elp your patient explore &
STEP
2 compare treatment options.
Assess your patient’s
STEP
3 values and preferences.
Reach a decision
STEP
4 with your patient.
E valuate your
STEP
5 patient’s decision.
Shared decision making occurs when a health care provider and a patient work
together to make a health care decision that is best for the patient. The optimal decision
takes into account evidence-based information about available options, the provider’s
knowledge and experience, and the patient’s values and preferences.
72 BC SURGICAL PREHABILITATION TOOLKITBenefits Both health care professionals and
patients benefit from using shared
of the decision making.
SHARE
Approach Benefits to Health care
Professionals:
• Improved quality of care delivered
• Increased patient satisfaction
Benefits to Patients:
• Improved patient experience of care
• Improved patient adherence to
treatment recommendations
Using the SHARE Approach builds
a trusting and lasting relationship
between health care professionals
and patients.
SHARE
The Agency for Healthcare Research and Quality (AHRQ) provides Approach
a collection of tools and training resources to support the implementation Resources
of shared decision making in practice. Refer to the AHRQ Shared
Decision Making Toolkit Website to locate resources such as:
SHARE Approach Workshop Curriculum:
Collection of training guides, slides, videos, and other resources to support the
training of health care professionals on shared decision making and SHARE
Approach implementation
SHARE Approach Tools:
Collection of reference guides, posters, and other resources designed to support
AHRQ’s SHARE Approach implementation
SHARE Approach Webinars:
Accredited webinars that review topics related to the implementation of patient-
centered outcomes research in shared decision making
SHARE Approach Success Stories:
AHRQ’s SHARE Approach tools and resources are used by organizations
nationwide to implement shared decision making in health care. These case
studies highlight stories of successes and best practices by describing the use
and impact of the AHRQ’s SHARE Approach strategies and tools by health
systems, clinicians, academicians, and other professionals.
These resources provide health care professionals with the training and tools they need
to implement the SHARE Approach in their practice.
Go to: www.ahrq.gov/shareddecisionmaking
AHRQ Pub. No. 14-0034-1-EF
April 2016
www.ahrq.gov
AN SSC LED INITIATIVE IN PARTNERSHIP WITH SHARED CARE AND GPSC 73You can also read
