American College of physicians ACP high value care recommendations in rheumat...
Surgeon Champion Call 2010 - Dr Peter Doris
1. Highlights of our Journey
with ACS-NSQIP
Surrey Memorial Hospital
Surgeon Champion Call
August 2010
2. Data Quality Control
QI in NSQIP
Do we have to?
How ?
Who is responsible?
What is acceptable?
What`s the worst that could happen ?
3. Data Quality Control
SC and SCR meetings
SCR and Surgical Program Director meetings
Identify data errors
Multiple postop occurrences
Inpatient/Outpatients
Subspecialty
CPT Code
DOB
Wound Class
8. Data Quality Control
Date of Birth Errors
MM/DD/YYYY vs DD/MM/YYYY
Discharge Information
Multiple admissions
Multiple files on EMR for a single admission
Wound Classification Errors
15% error per cycle
10. Data Quality Control
Missing Data
Variables
Then
Now
Future
ASA
33%
2%
Height
37%
24%
Electronic
and
mandatory fields
Weight
9%
6%
OR Reports
Available 2-3
months after
OR
3-4 weeks
Smoking History
(ppy)
95%
30%
Enhanced preop
assessment
Labs
(Albumin)
79%
53%
Links with external
lab facilities
30-Day FF-up
92.1%
92.5%
Translation
Services
Synoptic
Reporting
11. Data Quality Control
Challenges
CPT Codes
*Discuss OR reports with Surgeon Champion
*CPT Code mapping on Validation Worksheet
ICD Codes
*Surgeon’s offices/MOA
Missing data
*Revised nurses notes, assessment forms,
anaesthesia record
30-day Follow-up
*Telephone script for NSQIP clerks
12. Database Design
Excel spreadsheet with trends and graphs for
each project
Quarterly updates
Formulas embedded in excel
Pivot tables
Access Database
13. Data Reporting and Sharing
Internal
Surgical Committee Meetings
OR Committee Meetings
Council of Chiefs
Chairs of Division
Newsletters
Intranet
Update – Teams
External
FHA
BCPSQC
Provincial and National
Other NSQIP participating sites
14. Data Reporting and Sharing
Education
Learning Sessions
Surgical Safety Collaborative Meetings
In-service for frontline nurses
Directors, executives and physicians
New surgeons
Posters
19. Postoperative Pneumonia
OE
Raw Data – trend over time
Rate/100 Surgical Procedures
Incidence of Pneumonia from
Jan 2007- Mar 2010
SMH
NSQIP
6%
5%
4%
3%
2%
1%
0%
Jan-Jun 2007
Jul-Dec 2007
Jan-Jun 2008
Jul-Dec 2008
Jan-Jun 2009
Jul-Dec 2009
Jan-Mar 2010
20. Postoperative Pneumonia
More Data
Emergency vs elective
Pneumonia Occurrence Emergent vs Elective
10%
8%
Rate
SMH Emergent
6%
NSQIP Emergent
4%
p-value <.0001
SMH Elective
NSQIP Elective
2%
0%
Jan-Jun 2008
Jul-Dec 2008
Jan-Jun 2009
Date
Pneumonia
RTO
2008
39 days
25 days
59 days
14 days
2008
31%
20%
2009
Mortality
Elective
2009
LOS
Emergent
23%
20%
2008
23%
10%
2009
15%
0%
21. Postoperative Pneumonia
More Data
Emergent surgeries
postop ventillation = 20/40 (50%)
postop ventillation + positive culture = 19/40 (48%)
Bugs were identified
Candida Albicans excluded
Pneum
onia Occurrence Em
ergent vs Elective
10%
8%
SMH Electiv
e
6%
NSQIP Electiv
e
SMH Emergent
4%
NSQIP Emergent
2%
0%
Jan-Jun 2008
Jul-Dec 2008
Jan-Jun 2009
22. Postoperative Pneumonia Prevention
Surrey Memorial Hospital
Team Goal:
Improvement Strategies
*NSQIP
data results July-Aug 2008:
3.4% Occurrence Rate
Pn
eum
onia Occurrence Tren Over Tim
d
e
Gen
eral and Vascular Surgeries
• Mobilization
- Dangle post op day 0 if tolerated or HOB elevated
- Increase activity as tolerated: Up to chair, walk X 1,2,3 etc.
• Meticulous Hand Hygiene
- Prevents transmission of micro-organisms between patients
- Infection control involvement on team
• Elevate Head of the Bed 30-40 Degrees
- HOB elevation during transport, post op bed or stretcher
- Rationale: Improves ventilation
- Prevents aspiration of stomach & nasopharyngeal secretions
Deep Breathing and Coughing Exercises
- Rationale: Improves ventilation and prevents atelectasis
- Assists with movement & expectoration of secretions
• Chlorhexidine Gargle
- Pre & post op oral decontamination
- Evidence indicates may decrease pneumonia rates post
surgery
Education & Support
- Patient and Family Education – Posters in rooms
“Prevent Pneumonia” coaching & education pre-& post
surgery for deep breathing & coughing
- assisting with mobilization
- encouraging self-care in recovery period post
surgery
- Staff Education – Huddles, emails, staff meetings, clinical
update, new staff orientation
Spot Check
Pneumonia Prevention
Action Team
Chart#__ ____ ____ Date_ ____ ____ ___
COMPLETE In Patient’s Room:
HOB elevated 30-40 degrees :
Yes No
N/A
Patient mobilized day 0:
Yes No
N/A
Patient dangled for 5 minutes X 1
Yes No
N/A
Or: HOB up 40 degrees for 5
minutes
Yes No
N/A
Preadmission
•Pre-op Education Pamphlet
with Pneumonia Prevention
Tips
•Encouraging Partnership
in Care
•Changes in Standard Orders
for Preoperative Oral
Decontamination
6%
5%
4%
%
To decrease the incidence of
pneumonia in postop bowel surgery
patients by 50% using NSQIP by
October 2009.
SMH
3%
2%
1%
0%
NSQIP
07 6-12/0
/0
6
0
1/07-06
/07 07/07 2/07 0
-1
1/08-0
6/08 07/08
-11/08
Dates
Risk-Adjusted Pneumonia with Comparison
to Other NSQIP Sites
Observed Rate: 2.73%
Expected Rate: 1.68%
O/E Ratio: 1.62
Status: As Exp ected
Spot Checks:
Pre -Implementation
October 2008: 50% HOB elevated
February 2009: 71% HOB elevated
Future Opportunities
• Bowel Resection Carepaths
• Changes in Preprinted Orders Reflecting
Initiatives
• Preadmission Education Pamphlets Revision
Focusing on Self-Management
• Spread and Integration of Bundles in Other
SMH Units and FHA Sites
TEAM MEMBERS
Linda Coleman, PT
Margaret Dyka-Gluzak, RN
Linda Nelson, Educator
Anne Edmond RN
Irene Harder, RN
Brenda Smith, RN
Melissa Idle, Physio
Raj Pandey, PT
Angela Wilson
RN
Christine
Donald, RN
Angela Tecson, SCNR
Sharon Parent, QI
Donna Rolph, Manager
3 South Surgical Front Line Staff
23. PDSA Cycles – Best Practices Audits
Pneumonia Prevention Audit
100%
HOB Elevated
60%
DBC Teaching
40%
DB&C Exercises
Mobility Documentation
20%
0%
Jun-09
Jul-09
Aug-09
Date of Audit
Mobility Postop Day #0
Colorectals
100%
80%
Rate
Rate
80%
HOB
60%
Dangle
40%
Walk
20%
0%
Jun-09
Jul-09
Aug-09
Date of Audit
Sep-09
25. CAUTI Prevention Action Team
Surrey Memorial Hospital
Team Goal:
Improvement Strategies
As determined by frontline staff
Initiation: reach 80% of staff
8 x 30 min education
sessions (UTI Jeopardy)
Picture
4 x 10 min unit based
education (create
awareness)
Creation of prompts to
stimulate awareness
Sustainability
Daily reminders with
morning rounds
Kardex Inserts
Weekly spot checks led by
frontline staff - continuing
awareness for practice
changes
UTI Section to Initiative
wall with current data of
CAUTI infection rates on
Unit
CAUTI huddles – in
presence of UTI infections
U & I can
eliminate UTI’s
Actions;
2 person insertion & use smallest possible french
Prewash perineal area & use chlore hexdine 2%
swabs
Secure safely (to unaffected side if limb trauma)
No droopy Loops (ke ep between bladder and bag)
Keep bag below the bladder and off the floor
Label drainage container with name and date
Rinse after every drain and discard q24hrs
(0600)
Always ask, why is this catheter in? Don’t forget...
“2 Days Too Long”
For everyday the catheter is in place, please assess,
document;
Reason why catheter is in place
Has any follow up/ trial been done re: removal of
catheter
What is the plan for removal
Is the patient exhibiting any signs and symptoms
of UTI?
If UTI suspected send C+S, and notify MD.
After catheter removal,mobilize,hydrate patient &
provide bowel care. If patient is unable to void
follow these steps;
consider the type of surgery, pt medical status and
orders.…
I/O catheter for volume >400cc, x 2
Obtaining Results
then,
if still unable to void
Foley Catheter overnight and remove in AM
If problem persists, consider urology consult
1. Silver Catheters:
Insertion documented
in chart, Kardex and
tracking tool. Follow up
audit to be done.
2. Practice Changes:
weekly spot checks led
by frontline staff.
3. CAUTI Rates:
5 patients with
catheters (selected
from weekly spot
check) to be audited on
weekly basis
General and Vascular Surgeries
Process Change
UTI T rend Over Time
1.Trial of silver impregnated catheter
In OR: insertion of silver catheters in bowel
procedures
On Unit: pre-operative insertion of silver catheters in
the fractured hip population
Practice Changes
1. Insertion
2 person insertion
Pre-wash perineal area
CHG 2% for aseptic urinary meatus cleaning
Statlock securement to unaffected leg
2. Maintenance
No droopy loops (dependant loops)
Drainage bag between bladder and floor
New drainage container q 24hrs
Rinse drainage container after each drain
3. Removal
“2 Days too Long” : Removing a urinary catheter at
max post op day 2 at 0600 unless contraindicated
If catheter remains in place: documenting reason for
catheter and plan of care
Encourage activities to promote voiding: Mobility,
Hydration, Bowel care, Relaxation
4
3
%
Decrease Catheter Associated
Urinary Tract Infection rates 50% in
the fractured hip population by June
2009
UTI Trend Over Time
SMH
2
NSQIP
1
0
01 /06-06 /06
0 7/0 6-1 2/06
0 1/07 -0 6/07
07 /0 7-12 /0 7
01/0 8-06/0 8
0 7/08 -1 1/08
Dates
Risk-Adjusted Overall Urinary Tract Infections
with Comparison to Other NSQIP Sites
Observed Rate: 2%
Expected Rate: 1.34%
O/E Ratio: 1.49
Status: As Exp ected
Future Opportunities
1. Clinical decision making for Catheter reinsertion (i.e.
bladder scan volume - what is acceptable? When
does a catheter need to be inserted?) Align with HPA.
1. Continue with Silver Catheter trial and determine
sustainability of long term use
1. Spread of CAUTI Prevention action items throughout
the site. Initial spread to General Surgical Unit and the
surgical program.
Team Members :
Jyotika Prasad
Nen Graces
Sharon Parent
Jane Mann
Felicia Laing
Loretta Castelino
Nicole Quilty
Cindy Yazlovsky
Linda Jennings
Racheal Bertram
Elizabeth Allan
Angela Tecson
3S Surgical Orthopaedic Frontline Staff!!
26. PDSA Cycle
Orthopedic Ward – Silver Catheter Audit
UTI TREND OVER TIME
n
40
20
0
Apr-09
May-09
Jun-09
Apr-09
May-09
Jun-09
Ag Cath w/ UTI
0
0
0
Ag Cath
7
3
2
Reg Cath
18
13
6
Reg Cath w/ UTI
7
2
0
GS Ward – Catheter care audit
Baseline
Sept 2009
Nov 2009
Statlock on
100%
100%
Plan for removal
50%
50%
Droopy loops
100%
100%
Bag above the bladder
0%
0%
Bag on the floor
0%
0%
Drainage container dated
0%
0%
Catheter LOS (ave)
5 days
3.5 days
27. Total Number of Cases
Cases with SSI
3
0
Lymphadenectomy/Other
0
Immediate
2
Reconstruction
14
Mastectomy with
3
Modified, Radical
12
Mastectomy, Complete,
15
Mastectomy, Partial
16
Breast Mass Excision
Gynecomastia
4
2
Mastectomy for
Number of Cases
Surgical Site Infection
From bowels to breasts
SSI Rates According to Type of Breast Surgery
14
14
10
10
8
6
0
2
1
0
28. Surgical Site Infection Initiatives
Safer Healthcare Now
Preop antibiotic
Warm air/blanket
Appropriate hair removal
Antibiotic timing/redosing
Normothermia
World Health Organization - Surgical Safety Checklist
Briefings, Crew Resource Management
Preadmission
Patient Education – Hygiene, preop scrubs
Preop risk factors/comorbidities review
Operating Room
Changes in skin prep, sutures, scrubs and sponge washes
Use of Chlorhexidine
Improved Wound Classification documentation
Surgical Floors
IV Training
Wound Care Champions
Culture Wounds
29. PDSA Cycles – Best Practices Audits
OR Initiatives – Breast Surgeries
Jan 2008
Feb 2009
Preop Antibiotic
Administration
50%
76%
Antibiotic Timing
42%
100%
Normothermia
95%
100%
Warm Air/Blanket
17%
40%
Appropriate Hair
Removal
90%
100%
30. Preop Antibiotic Administration
*Looking at compliance rate
*Dates: Dec 1, 2009 to Jan 31, 2010 (n=176)
*Sources of Data: Chart
*Results:
(154/176) 87.5% of surgeries received preoperative antibiotics
(24/154) 16% given 1 min before incision time
(14/154) 9% given >1hr before incision time
No SSI
No Preop Antiobiotics
Preop Antibiotics
Given
P-value: .001
SSI
14 8
141 13
No SSI
No Preop Antiobiotics
Preop Antibiotics
Given within 1hr
SSI
24 12
131 9
P-value: .00008
31. Length of Stay Review
Colorectal Surgery
Length-of-Stay
Obs erved R a te:
41.82%
E xpected R a te:
26.48%
O/E R a tio: 1.58
S ta tus : Needs
Improvement
32. Length of Stay
Colorectal Surgeries
Acute Care
Emergent Count
Average LOS
Elective Count
Average LOS
Acute Care Count
Acute Care Average LOS
2005 2006 2007 2008 2009
35
57
53
41
26
24
21
21
17
16
77
68
80
91
37
15
9
10
10
10
112 125 133 132
63
18
15
14
12
13
Ave LOS in 2006 – Ave LOS in 2008 = Ave saved bed day/case in 2008
15 – 12 = 3
Saved bed day/case x # of Colorectal Sx in 2008 = Saved bed day in 2008
3 x 132 = 396 bed days saved in 2008
33. Examples of Data Integration
Graph 10: Overall SSI O/E Ratio
January 1, 2007 – December 31, 2007
95% Confidence Interval
FHA Appendectomies
(2005-2009)
2006
2008
2009
Total
Acute
65%
49%
52%
40%
52%
Perfed
Status:
Hospital A: Needs Improvement
Hospital B: Needs Improvement
2007
30%
48%
41%
33%
38%
5%
2%
7%
27%
10%
Lap
Annual Incidence of Pneumonia from
Fiscal Year 2005 to 2009
Hospital A
5
Rate/100 Surgical Proced
Hospital B
4
2009 Postop SSI Summary
2
- NSQIP Average
1
0
2005
2006
2007
Fiscal Year
2008
2009
Site A
Site B
Site C
5.3%
3.4%
2.5%
Deep Incision SSI
3
Wound Occurrence
Superficial SSI
Hospital C
0.7%
1.0%
1.2%
Organ/Space SSI
5.1%
1.2%
0.6%
34. Replicate Published Studies
Time of Day Effects
Frequency of Surgical Start Time
12%
10%
8%
6%
4%
2 :3 - 3 0
2 0 2 :3
2 :3 - 1 0
0 0 2 :3
1 :3 - 9 0
8 0 1 :3
1 :3 - 7 0
6 0 1 :3
1 :3 - 5 0
4 0 1 :3
1 :3 - 3 0
2 0 1 :3
1 :3 - 1 0
0 0 1 :3
8 09 0
:3 - :3
6 07 0
:3 - :3
4 05 0
:3 - :3
2 03 0
:3 - :3
0%
0 :3 - :1 0
0 00 3
2%
Kelz, R., Tran, T., Hosokawa, P., Henderson, W., Paulson, C., Spitz, F., Hamilton, B., & Hall, B. (2009) Time-of-Day Effects on Surgical Outcomes in the Private Sector: A Retrospective Cohort
Study: Journal of the American College of Surgeons, 209-4, 434-445.
36. Custom Fields
1. Anastomotic Leak
2. True Wait Time
3. True LOS
4. Readmission
5. DNR/Palliative Postop
Literature review
Standard definition
Data entry format
Source of data
Study duration – time dependent?
Trial
Revision of guidelines if needed
37. Appendectomies
Perfed vs Non-perfed
2006-2009 cases
n = 326
Perforated
Non-perforated
112 (34.36%)
214 (65.64%)
Wait Time
Door to Skin (Average)
5 hours
7 hours
Length of Stay
4 Days
2 Days
5.4%
3.4%
3.4%
3.3%
2.3%
0%
Distribution
Postop SSI
Superficial
Deep
Organ/Space
38. Patient Feedback
• 33% average return rate per cycle
• NSQIP clerk sorts and sends to Department Heads
• Challenging issues -forwarded to Client Relations Office
• Patient/Family meets with CRO and Chief of Surgery
39. Preop Albumin
Frequency of Preop Albumin Order for Emergent and Elective
Surgeries from 2006 to 2009
100%
80%
60%
Emergent
Elective
40%
20%
0%
2006
2007
2008
2009
40. Wait Time Reviews
Lap Chole
Average wait time: 78 hours
Appy
Wait Time
0 to 4hrs
5 to 8hrs
9 to 12hrs
>12hrs
Perfed
74(42%)
19(32%)
12(23%)
7(19%)
Nonperfed
104(58%)
41(68%)
40(77%)
29(81%)
Postop
Complications
13(7.3%)
5(8.3%)
5(9.6%)
7(19.4%)
Data shows increased postop complications as wait time increases
42. Data Review for Planning and Decision Making
PACU
-LOS by procedure, LOS by type of anaesthesia (OR to PACU discharge)
Preadmission Clinic
Patient feedback – patient education needs
Risk assessments
OR Reorganization
RTO rates, length of surgery, time of surgery
Surgical Units
Discharge by day of the week – staffing
LOS and Outcomes
1South/Stepdown Unit
Admission criteria, LOS
Other hospital departments (housekeeping, dietary, pain service,
etc)
Patient Feedback
45. Cost Analysis
Cost of SSI after breast surgery: $ 4,091.00 USD ¹
Mastect omy SSI Tren d ov er Time
14%
12%
10%
8%
6%
4%
2%
0%
Q4
2007
Q1
2008
Q2
2008
Q3
2008
Q4
2008
Q1
2009
Q2
2009
Q3
2009
Q4
2009
Cost differential between inpt and outpt partial mastectomy: $ 2,800.00 CAD
Outpatient Partial Mastectomy
with Axillary Node Dissection (19302)
SMH
NSQIP
2008
17.9 %
78.9 %
2009
10.3 %
77.3 %
Reduction Rates between 2007 and 2009 for cases with at least 1 postoperative occurrence
Emergent: 27.40 % Elective: 9.05 %
Cost of postop UTI: $ 3,535 CAD (excluding physician fees)
Cost of Silver-coated catheter: $ 15.00
Averted UTI in 3 months: 18
¹Hospital-Associated Cost Due to Surgical Site Infection After Breast Surgery. Division of Infectious Disease, Washington University 2004
Canadian Institute for Health Information, The Cost of Hospital Stays: Why Costs Vary (Ottawa:CIHI 2008), does not include physician compensation, 2004-2005 data
49. The Wisdom of Crowds
James Surowiecki
Why the Many Are Smarter Than the Few
diversity of opinion
independence
decentralization
aggregation
50. We vs Me
Who will speak up before I make a mistake?
flatten hierarchy
Does Team Have Patient Safety Focus?
checklist
How Do You “Stop The Line”?
CUS words
Is There Fear Of Retaliation?
need support from organization
Is Work Fun?
We are doing a great job!
51. Observations
Data is accepted as valid
No finger pointing developed
Change was viewed as necessary
Culture change underway
Flattened hierarchy
Safety and Quality articulated as goals
Learning “how to improve”
improve”
Patients notice change
It works!