nsqip at smh september 2010
DESCRIPTION
NSQIP at SMH September 2010. NSQIP. NSQIP Information Semiannual Report on Colorectal Surgery Colorectal Initiatives Implemented Colorectal Data 2009 Emergency Colorectal Surgery. What is NSQIP?. Program Overview. Outcomes-based program. Risk-adjusted. - PowerPoint PPT PresentationTRANSCRIPT
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NSQIP at SMHSeptember 2010
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NSQIP
• NSQIP Information
• Semiannual Report on Colorectal Surgery
• Colorectal Initiatives Implemented
• Colorectal Data 2009
• Emergency Colorectal Surgery
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What is NSQIP?
Program Overview
• Outcomes-based program
• Risk-adjusted
• Reports – SAR , benchmarking, ,ad-hoc,
• 240 Participating Sites
• 5 Canadian Sites
• General, Vascular, ENT, Thoracic
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More about NSQIP
• Systematic sampling process
• Inclusion/exclusion criteria
• Data
Preoperative
Intraoperative
Postoperative (30-day outcome) • Sources of Data - Chart, EMR, phone call/letter,
Dr office visits
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Semiannual Report, June 2010Dates of Surgery: January 1, 2009-December 31,
2009Fraser Health - Surrey Memorial Hospital
American College of SurgeonsNational Surgical Quality Improvement Program
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Results
• Risk adjustment use of preoperative risk factors to account for “patient risk”
• O/E Ratio “O” number of observed adverse events
“E” number of expected adverse events based on patients’ characteristics or preoperative risk factors
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Interpretation of Results
Observed to Expected (O/E) Ratio• Represents the hospital’s outcomes compared to the other ACS NSQIP hospitals, adjusted for inter-hospital differences in patients’ characteristics, comorbidities, and preoperative laboratory values
LOW OUTLIER: If the upper bound of the O/E confidence interval is <1.0, the hospital’s outcomes are statistically better than expected. Thus, the hospital’s outcomes are “Exemplary.”
ACS NSQIP Hospital ID Number
HIGH OUTLIER: If the lower bound of the O/E ratio is >1.0, the hospital’s outcomes are statistically worse than expected. Thus, the hospital’s outcomes “Need Improvement.”
AS EXPECTED
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Interpretation of Results
ACS NSQIP Hospital ID Number
Over-Time Performance• Represents the hospital’s previous O/E ratios from the 10 most recent semi-annual reports
Current O/E Ratio
Low Outlier
High OutlierAs Expected
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Semiannual Report Statistics:
Jan 1, 2009 – Dec 31, 2009
NSQIP - 268143 cases SMH - 1321
General Surgery cases - 1251 Colorectal cases - 130
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Colorectal Surgery 30-Day Mortality
Observed Rate: 9.23%Expected Rate: 5.87%O/E Ratio: 1.57Status: As Expected
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Colorectal Surgery 30-Day Morbidity
Observed Rate: 29.23%Expected Rate: 34.53%O/E Ratio: 0.85Status: As Expected
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Colorectal Surgery Length of Stay
Observed Rate: 42.39%Expected Rate: 37.43%O/E Ratio: 1.13Status: As Expected
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Colorectal Surgery Surgical Site Infection
Observed Rate: 13.08%Expected Rate: 17.01%O/E Ratio: 0.77Status: As Expected
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Colorectal Initiatives
• Colorectal carepath and orderset
Best practices for pneumonia and UTI
prevention
• Use of silver catheter in the OR
• Enhanced Stoma care
• Patient Education
• Colorectal Education Day
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Colorectal Data
130 colorectal cases in 2009
Emergent 54 (42%) Elective 76 (58%)
Mortality Rate 12 ( 9.2%) Emergent 66.7% Elective 33.3%
SMH NSQIP
25,815 cases
16 %84%
4.1%62.9%37.1%
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Colorectals
• Preop Risk Factors:
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Colorectals
Preop Risk Factors: SMH NSQIP
Dyspnea 16.9% 11.7%DNR 6.2% 1.1%Partially Dependent 24.6% 7.1%Totally Dependent 6.2% 3.8%Ascites 2.3% 1.5%CVA 10.8% 4.9%Weight Loss 8.5% 5.6%Radiotherapy 7.7% 3.7%Sepsis/Shock 14.7% 9.2%
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Preop Documentation
Missing data
Height 26/130 (20 %)Weight 24/130 (18 %)
Smoking History 55/130 (42 %) Functional Status Chemo/Radiotherapy Open Wounds Weight Loss
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• Outcome SMH NSQIP
Pneumonia 6.2% 3.6%
PE 2.3% 0.7%
UTI 5.4% 4.0%
Cardiac Arrest 3.8% 1.1%
MI 3.8% 1.0%
Colorectals
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Colorectal LOSAverage LOS Emergency vs Elective Colorectals
Trend over Time
0
5
10
15
20
25
2008 2009
YearNu
mber
of D
ays
Emergent SMH
Emergent NSQIP
Elective SMH
Elective NSQIP
Length of Stay Colorectal Surgeries (2008-2009)
0
10
20
30
40
50
60
< 4 4 to 6 7 to 9 10 to12
13 to15
16 to18
19 to21
22 to24
> 25
Number of Days
Num
ber o
f Pat
ient
s
Average: 13.5 daysMode: 6 daysMedian: 9 daysSD: 17
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Mortality Report
Postop DNR 6/12 (50%)
Emergent cases: 8/12 (67%)
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Wait TimeEmergent Case Wait Time (Door to Skin)
n = 54average 44 Hoursmode 3 Hoursmedian 4 Hourssd 152min 1.5 Hoursmax 762 Hours
Wait Time
0
20
40
60
80
100
120
24 48 72 96 120 144 168 More
Hours
# P
atie
nts
Wait Time Log(Hr)
0
10
20
30
40
50
0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2 2.2 2.4 2.6 2.8 3 3.2
Log(Hr)
# of
Cas
es
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Emergency Colorectals
ASA Class Elective Emergent Total
1-No Disturb 7 5 (9.3%) 12
2-Mild Disturb 39 16 (29.6%) 55
3-Sever Disturb 28 19 (35.2%) 47
4-Lfe Threat 2 12 (22.2%) 14
5-Moribund 0 2 (3.7%) 2
Total 76 54 (100%) 130
NSQIP: Emergent with 0 risk factor: 11%ASA 1 vs NSQIP 0 Risk Factor :McNemar Test: p-value = <.001
Pearson Chi2 p-value = 0.001
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Emergency Colorectals
Pearson chi2(2) = 24.3839 Pr = 0.000
Total 76 54 130 4-Dirty/Infected 8 23 31 3-Contaminated 22 19 41 2-Clean/Contaminated 46 12 58 Wound Classification NO YES Total Emergent Case
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Emergency Colorectals
Pearson chi2(3) = 18.7420 Pr = 0.000
Total 76 54 130 4 14 0 14 3 24 9 33 2 26 34 60 1 12 11 23 Surgery NO YES Total Length of Emergent Case
Pearson chi2(3) = 66.8328 Pr = 0.000
Total 76 54 130 7:31 to 11:30 51 3 54 19:31 to 7:30 1 21 22 15:31 to 19:30 3 14 17 11:31 to 15:30 21 16 37 In Room Time NO YES Total Day - Patient Emergent Case Time of the
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Emergency Colorectals
Outcome:
Cases with at least 1 postoperative occurrence 24/54 = 44%
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Is our data reflective of what our patients are really like?
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Request
• Enhance preoperative assessment
• Improve documentation
• Resume PDSA OR and Surgical Units
• Patient and staff education