Interactive voice response systems: A potential method to

track surgical site infections

Alan J. Forster MD FRCPC MScScientific Director, Clinical Quality and Performance

Management, The Ottawa Hospital Career Scientist, Ontario Ministry of Health and Long

Term Care

Acknowledgments

• TOH• OHRI• CPSI• Capital Health• Vocantas Inc

• Carl van Walraven• Natalie Oake• Alison Jennings• Nadea Saikaley

Surgical site infections

• Infection at site of surgery within 30 days of surgical date (1 year if foreign body)

• Common type of hospital acquired infection– 3rd most common HAI– Risk 2%-10%– 30% of SSI involve deep structures

• Costly• Timing: the majority of SSIs occur after

discharge

Importance of day surgery in Canada growing

0

0.5

1

1.5

2

2.5

Outpatient Inpatient Total

95-9605-06

+30%

-20%

+16%

No. of cases in millions; Source: CIHI 2007

Interactive voice response systems (IVRS)

• Information technology – connects people to database using a telephone interface

• Consists of specific hardware and software• Call scripts are programmed• These are activated by various triggers• Responses to prompts result in data fields being

populated • Subsequent prompts (or other actions) occur as a

result of new data• Commonly used in business

IVRS enables feed-back loops

• Reminders– Clinic appointments– Testing

• Monitoring– Condition– Compliance

Systematic review of published studies-Methodology

• MEDLINE search– Time period: 1950 to January 18, 2008– Terms: » interactive + voice + response

» calling + system» (telephony or telecommunications) + voice» automated + telephone

• Inclusion criteria– RCTs and CCTs that examined the effect of an IVRS intervention on

clinical and/or process outcomes

• Two reviewers independently abstracted study data

• Outcomes were grouped into 1 of the following categories– Clinical endpoints (e.g. hospitalization, death)– Surrogate outcomes (e.g. HbA1c, total cholesterol)– Patient process adherence (e.g. immunization)– Patient-reported quality-of-life (e.g. Addiction Severity Index)

Literature validating patient response

• > 60 studies have compared the validity and reliability of data collected using an IVRS with standard data collection methods (e.g. in-person interviews, paper-and-pencil questionnaires)

• Examples: » Reported alcohol consumption / substance abuse» Depression screening tools

• Overall, IVRS yields valid and reliable data– Cost and time-effective– Participation rates are generally high– Participants may be more willing to disclose sensitive

information to an IVRS

• 38 included studies (29 RCTs and 9 CCTs)– Median sample size: 230 (Interquartile range 122-648)– IVRS aimed at changing behavior: N=23

• E.g. immunization, physical activity– IVRS aimed at managing chronic disease: N=15

• E.g. diabetes, heart failure

• Clinical endpoints – 3 studies – IVRS intervention associated with improved outcomes in 2 studies

• Surrogate outcomes – 7 studies– Overall, the IVRS interventions were associated with non-significant

improvements in all outcomes• Patient process adherence – 28 studies

– Overall, the IVRS interventions were associated with improvements in outcomes(median effect 7.85% absolute improvement, 95% CI 2.8-19.5)

• Patient-reported quality-of-life – 8 studies – Overall, the IVRS interventions were not associated with improvements

Systematic review of published studies-Results (preliminary findings)

Systematic review of published studies-Conclusions

• IVRSs are increasingly being used in healthcare settings

• Some IVRSs are part of an overall strategy while others are stand alone interventions

• Patient process adherence and quality-of-life outcomes are the most frequently reported

• Few studies examine clinical endpoints or surrogate outcomes

• IVRSs are a potential solution for improving the quality of ambulatory care

(Am J Manag Care. 2008;14(7):429-436)

Objectives:•To determine acceptability and feasibility of IVRS based follow up system•To determine number of patients in whom intervention based on IVRS changes treatment•To determine adverse event frequency and type following discharge

IVRS

Hospital

RN enters Pt data into IVRS• Pt ID• Phone #• D/C date

WWW

Home phone

Cell phone

Other phone (work, family, friend, etc.)

Questions

1. Right Pt?2. New or worsening symptoms?3. (Problems with surgery?)4. Problems with medications?5. Desire connection to Health Link?

IF YES

Nurse

Post D/C

Intervention

Methods

• Prospective cohort design• Patients

– Surgical: Consecutive women planned for gynecological day-surgery

• Exclusion: No phone, dementia, failure to provide informed consent

PATIENT FLOW

Pt admitted to RAH Gyne Day Surgery Unit

Gyne Surgery

D/C from RAH

Routine Care

30 days

STUDY INTERVENTIONS

Info entered into study DB & Pt assigned study ID

Study ID, phone #, & D/C date entered into IVRS

IVRS calls Pt

Consent for study

Post D/C Day 1

Analysis of call results

Telephone survey

Capital Health DB access • Encounter Hx• Lab data

Health Link DB access• Call records

Analysis of outcomes

Analysis of Pt experience

Study flow

Potentially eligible patients

N=317

Patients enrolled:N=270 (85%)

Excluded patients:N=47 (15%)

Missed opportunityRefused consent

Entered into IVRSN=266 (99%)

30 day follow up completeN= 249 (92%)

Patient characteristics

• Surgery– Age: 38 years (31-48)– <10% had a chronic illness– 4% had no functional limitations in terms of

ADL’s – Discharged on day of discharge – 244 (98%)

Adverse events

• 33 patients (12% (95% CI: 8%-17%)• Preventable but almost no ameliorable• Major types: Therapeutic errors, adverse

drug events, other

IVRS call flow

• 381 automated calls recorded• 163 patients ‘answered’ calls• 130 patients (52% of all patients) answered ‘yes’

when asked whether they were the correct patient

• 129/130 patients answered at least one question• 104/130 patients answered all questions• Answered ‘yes’ to at least one question=17

Patient perceptions

n=96

Adverse events

• 40 patients (16% (95% CI: 12%-22%)• Major types: Wound infection, pain,

bleeding, UTIs, Anaesthesia complications• 31 patients required corrective actions for

their AE• Timing of event start: median delay 9 days

(IQR 3.0-15.5)– 90% of problems started after day 1

Interventions

• No IVRS call resulted in the provision of HealthLink advice!

• Most AEs happened after call• Therefore, IVRS did not result in the

identification of any AEs

Summary

• Patients accept IVRS intervention and find it useful

• System design issues need to be addressed particularly,– Timing– Response

• Efficient method of providing follow up calls

Proposal: Ambulatory care SSI surveillance using an IVRS

• Automated calls days 5, 15 and 30 post discharge

• Simple questionnaire– Do you have any of the following … at your

surgical site?– Have you seen an MD following your surgery?– Would you like to speak with a nurse?

• Notification to nurse working in surgical unit (PAU, SDCU)

If you do decide to implement, you need to consider implementation

barriers.

Consider technical and organizational factors.

Technical factors

• Patients do not dislike the program– It is relatively familiar technology and simple

to use– Often patients think it is a person calling– Operate on KISS principle

• Software and hardware– Well established– System design is relatively straight forward– System integration is not difficult

Organizational factors

• Financial barriers– In-house expertise?

• Technical barriers– IS/IT Departmental protocols– Ongoing support

• Administrative barriers– Competing priorities

Summary

• Surgical site infections• Description of IVRS technologies• Literature review of IVRS technologies in

healthcare• Review study using IVRS technologies to

monitor adverse events following day surgery

• Proposal: can an IVRS be used to monitor SSIs? - Yes