surgical care improvement

Surgical Care Improvement Project

National Initiatives to Improve Care for Medicare Patients

(modified from Dale W. Bratzler, DO, MPH, Principal Clinical Coordinator, Oklahoma Foundation for Medical Quality, Inc.

Lee A. Fleisher, M.D.

Robert D. Dripps Professor and Chair

Department of Anesthesiology and Critical Care

University of Pennsylvania School of Medicine

fleishel@uphs.upenn.edu

Surgical Infection PreventionPerformance Stratified by Risk Class

7%41%Readmission

$3,844$7,531Median direct cost

6 days11 daysLength of Stay

18%29%ICU admission

3.5%7.8%Mortality

Un-infectedInfected

Kirkland. Infect Control Hosp Epidemiol. 1999;20:725.

Medicare Surgical Infection Prevention (SIP) Project Objective

To decrease the morbidity and mortality associated with postoperative infection in the Medicare patient population

Quality IndicatorsNational Surgical Infection Prevention Project

• Quality Indicator #1

– Proportion of patients who receive antibiotics within 1 hour before surgical incision

Because of the longer required infusion times, vancomycin or fluoroquinolones, when indicated for beta-lactam allergy, may be started within 2 hours before the incision.

Quality IndicatorsNational Surgical Infection Prevention Project

• Quality Indicator #3

– Proportion of patients whose prophylactic antibiotics were discontinued within 24 hours of surgery end time

Surgical Infection PreventionPerformance Stratified by Surgery1

Surgery (N)

Antibiotic within 1 hour2

% (95% CI)Cardiac (3,287) 58.5 (56.8-60.2)

Vascular (1,116) 47.0 (44.0-49.9)

Hip/knee (2,694) 59.7 (58.3-61.2)

Colon (732) 46.0 (43.5-48.4)

Hysterectomy (432) 54.8 (51.4-58.3)

All Surgeries (11,220) 55.7 (54.8-56.6)

1 All results are weighted to reflect adjustment based on the state-specific sampling scheme.

2 Reflects data for only 11 220 cases that had an explicitly documented incision time.

These results include patients who received vancomycin between one and two hours before the incision (N=213).

Cases were excluded from this performance measure if there was insufficient data to determine the time interval between prophylactic antimicrobial dose and surgical incision (N=22,902). In addition, patients undergoing colon surgery who received oral antimicrobials only for prophylaxis were excluded from the denominator (N=11).

Bratzler DW, Houck PM, et al. Arch Surg. 2005;140:174-182.

Surgical Infection PreventionPerformance Stratified by Surgery1

Surgery (N)

Antibiotic Stopped within 24 hours

% (95% CI)

Median Time to Discontinuation

(Hours)

Cardiac (7,635) 34.4 (33.4-35.5) 40.9

Vascular (2,913) 45.2 (43.4-47.0) 42.7

Hip/knee (14,575) 36.7 (35.9-37.4) 39.0

Colon (4,911) 40.8 (39.5-42.2) 57.0

Hysterectomy (2,569) 77.9 (76.3-79.5) 21.4

All Surgeries (32,603) 40.7 (40.2-41.2) 40.4

1 All results are weighted to reflect adjustment based on the state-specific sampling scheme.

Antimicrobials were considered “prophylactic” if they were given before surgery, given intraoperatively, or given within 24 hours after the end of surgery.

Cases were excluded from this performance measure if no antimicrobials were administered, if no antimicrobials administered were considered “prophylactic,” or if there was insufficient data to make the determination of timing (N=344). Any patient with documentation in the medical record of an infection during surgery or within 48 hours after the end of surgery was excluded from the denominator (N=634). In addition, patients who underwent more than one surgical procedure of interest during the hospitalization were excluded from the denominator (N=552).

Bratzler DW, Houck PM, et al. Arch Surg. 2005;140:174-182.

Copyright restrictions may apply.

Khuri, S. F. et al. Arch Surg 2002;137:20-27.

The Veterans Affairs National Surgical Quality Improvement Program (NSQIP) collects data from each of its participating sites, ascertains their cleanliness and reliability, and processes them

into comparative risk-adjusted outcomes

Copyright restrictions may apply.

Khuri, S. F. et al. Arch Surg 2002;137:20-27.

The 30-day postoperative mortality (A) and 30-day postoperative morbidity (B) for all major operations performed in the Department of Veterans Affairs hospitals throughout the duration of

the National Surgical Quality Improvement Program data collection process

Crossing the Quality Chasm

“In its current form, habits, and environment, the health care system is incapable of giving Americans the health care they want and deserve….The current care systems cannot do the job. Trying harder will not work. Changing systems of care will.”

What Works to Improve Care?

• CME and didactic programs have little impact on changing behavior!

• Effective strategies include» reminder systems» standing orders» clinical pathways or protocols» opinion leaders and physician champions» self-monitoring and feedback

Davis DA, et al. JAMA. 1995;274:700-706.

SCIP Steering Committee

• American College of Surgeons

• American Hospital Association

• American Society of Anesthesiologists

• Association of peri-Operative Registered Nurses

• Agency for Healthcare Research and Quality

• Centers for Medicare & Medicaid Services

• Centers for Disease Control and Prevention

• Department of Veteran’s Affairs

• Institute for Healthcare Improvement

• Joint Commission on Accreditation of Healthcare Organizations

Surgical Care Improvement Project(SCIP)

• Preventable Complication Modules– Surgical infection prevention– Cardiovascular complication prevention– Venous thromboembolism prevention– Respiratory complication prevention

Surgical Care Improvement Project(Draft Global Outcome Measures)

• Motality within 30 days of surgery

• Readmission within 30 days of surgery

Surgical Care Improvement ProjectPerformance measures

• Surgical infection prevention» Antibiotics

– Administration within one hour before incision– Use of antimicrobial recommended in guideline– Discontinuation within 24 hours of surgery end

» Glucose control in cardiac surgery patients • <200 gm/dl at 6am postoperatively

» Proper hair removal» Normothermia in colorectal surgery patients

• Immediate postoperative

» SSI rates during index hospitalization (test outcome)

0

1

2

3

4

≤-3 -2 -1 0 1 2 3 4 ≥5

Classen, et al. N Engl J Med. 1992;328:281.

Perioperative AntibioticsTiming of Administration

Hours From Incision

14/369

5/6995/1009

2/180

1/81

1/411/47

15/441

Paradigms

• Antiobiotics– Ordered by whom?– Given by whom?

» Nurse» Surgeon» Anesthesiologist

Antibiotic Posters

Pre-operative shaving

• Shaving the surgical site with a razor induces small skin lacerations– potential sites for infection– disturbs hair follicles which are often colonized

with S. aureus– Risk greatest when done the night before– Patient education

» be sure patients know that they should not do you a favor and shave before they come to the hospital!

Perioperative Glucose Control• 1,000 cardiothoracic surgery patients• Diabetics and non-diabetics with hyperglycemia

Patients with a blood sugar > 300 mg/dL during or within 48 hours of surgery had more than 3X the likelihood of a wound infection!

Latham R, et al. Infect Control Hosp Epidemiol. 2001.

Perioperative Glucose Control

Carr J Thor Surg 2005

Temperature Control• 200 colorectal surgery patients

– control - routine intraoperative thermal care (mean temp 34.7°C)

– treatment - active warming (mean temp on arrival to recovery 36.6°C)

• Results– control - 19% SSI (18/96)– treatment - 6% SSI (6/104), P=0.009

– Measure: Colorectal surgery patients with immediate postoperative normothermia

Kurz A, et al. N Engl J Med. 1996.

Also: Melling AC, et al. Lancet. 2001. (preop warming)

Surgical Care Improvement ProjectDraft performance measures

• Perioperative cardiac events» Surgery patients on a beta-blocker prior to

arrival that received a beta-blocker during the perioperative period

Perioperative is defined as preoperatively on the day of surgery or intraoperatively prior to extubation.

Leape et al. JAMA 2002

Mangano DT, et al. N Engl J Med. 1996;335:1713-20.

Postoperative Survival

• 6-month survival 100% vs 92% (P<0.001)

• 2-yr survival 90% vs 79% (P=0.019)

Bisoprolol in high risk vascular patients

05

101520253035

%

Bisoprolol Placebo

Perioperative cardiac complications

• 1351 screened– 846 with risk factors– 173 positives

» 59 bisoprolol» 53 standard care» 53 excluded for prior

beta-blocker or extensive WMA

Poldermans et al. NEJM 1999;341:1789*p<0.001

Perioperative beta blocker withdrawal more common than new therapy

U Chicago '97-'99 Preop Clinic - Vascular

0

0.2

0.4

0.6

0.8

1

Clinic BB No Clinic BB

No hosp BBHosp BB

withdrawal

new Rx

Ellis et al. SCA 2001 (abstract)

Rates and Risks of In-Hospital Death and the Numbers Needed to Treat and to Harm among Patients in the Entire Study Cohort Who Did Not Receive Perioperative Beta-Blockade,

According to the RCRI Score and the Presence of Individual Risk Factors

Lindenauer, P. et al. N Engl J Med 2005;353:349-361

Beta-Blocker Withdrawal

Hoeks et al. Eur J Vasc Endovasc Surg 2006

Fleisher et al. AHA/ACC Guidelines 2006

Potential to Reduce Perioperative Complications in SCIP

3.35

2.28

0.72 0.58

2.49

0.490.29

0

0.5

1

1.5

2

2.5

3

3.5

4

SSI Pneumonia AMI VTE

Pe

rce

nt

Current Complication Rate Potential Complication Rate

25.7% relative reduction

31.9% relative reduction 50.0% relative

reduction

Based on the goal of achieving near-complete guideline compliance to prevent each of these complications as compared to current national rates

of guideline compliance for each complication.

Preliminary Results – CMS Three State Pilot

91.5

60.8

70.9

84.1

59.5

70.865.6

0

20

40

60

80

100

Per

cent

Surgical Care ImprovementPreliminary Results – CMS Pilot

Surgical Infection Module

47.2

75.8

46.1

0

20

40

60

80

100

Per

cent

Surgical Care ImprovementPreliminary Results – CMS Pilot

Cardiac Complications Module

Summary

• There remain substantial opportunities to improve outcomes from surgery

• There is a national commitment to performance measurement and improvement of surgical outcomes

• Through a broad national partnership hospitals across the nation will be encouraged to participate in activities to reduce the complications of surgery in the US

www.medqic.org/sip

www.medqic.org/scip