dellinger: acting on the data
TRANSCRIPT
Acting on the Data---
Surgical leadership
E. Patchen Dellinger, MD, FACS
Professor of Surgery, Chief of General Surgery, Chief of Staff,
University of Washington Medical Center (UWMC), Seattle, Washington
Or
How I Got Involved
With NSQIP and What
I Think I’ve Learned
Development of Surgical Outcomes Research Center
(SORCE) at UW, 2000
Analysis of Washington State discharge data base -• Bile duct injuries after lap chole• Negative appendectomy• Survival advantage after gastric bypass
Support of clinical trials
Development of Surgical Care Outcomes Assessment Program (SCOAP), 2002
Sponsored by• SORCE• Foundation for Health Care Quality (FHCQ)• Washington State ACS Chapter
Supported by• Life Science Discovery Fund• Third party payers
Initial Focus of SCOAP• Colorectal Surgery• Bariatric Surgery• Appendectomy
Quarterly feedback • Outcomes• process measures
Have now added• Gastrectomies• Pediatric Surgery• Vascular Interventions• Spine Surgery
Surgical Care and Outcomes Assessment
Program
•Voluntary, grassroots clinician collaborative in WA•Surveillance, benchmarking, practice change
interventions
•58 hospitals (~95%)-rural and urban
Surgical Care and Outcomes Assessment
Program
•Modules in general, pediatrics, bariatrics, vascular interventions(cardiology/IR/surgery), spine (neuro/ortho), advanced cancer care
•SCOAP reports;•Focus on risk adjusted outcomes (up to 12 months)
•Best practices (20-30) and ~50 “exploratory” metrics
How To Read A SCOAP Report
Surgical Care and Outcomes Assessment
Program
Conducts statewide campaigns aimedat practice change
•Preop nutritional interventions
•Glycemic control
•Checklist
•Lymph node sampling for colorectal cancer
•Accurate interpretation of imaging for appendicitis
BeforeElective Colorectal Resection, CHARS 2000-2003
17.7±38.2%
After Elective Colorectal Resection CHARS 2006-2009
9.6±29.4%
Re-operative Complications
Elective Colon/Rectal Resections
Why the Improvement?Testing Low Rectal Anastomoses for
Leak
Reducing Unnecessary Appendectomy
Improving the Use of Dx Imaging
Use of US/CT in Women with Suspected Appendicitis
Improves SCIP Performance
SCOAP Glycemic Metrics
• Glucose checked periop (pre-op to recovery)
• Insulin started• POD 1• POD 2• Lowest blood sugar
Avoiding Hypoglycemia
SCOAP Data on Perioperative Glucose Levels and Insulin Use
11630 patients from 2005-2010 withBariatric operation (5360)
Colectomy (6273)
Who eitherExperienced hyperglycemia [glucose > 180] (3383)
Or did not (8247)
During the perioperative period or onPOD 1 or POD 2
Kwon. Ann Surg. 2013; 257: 8-14
SCOAP Data on Perioperative Glucose Levels and Insulin Use
Diabetic pts 4098 (35%)Hyperglycemic 2369 (58%)
Nondiabetic pts 7532 (65%)Hyperglycemic 1014 (13%)
30% of all hyperglycemic patients were not diabetic!
Kwon. Ann Surg. 2013; 257: 8-14
Composite InfectionHyperglycemia vs No Hyperglycemia
All Patients
02468
10121416
All Pts Bariatric Colectomy
Normal
Gluc>180
All p<0.01
Kwon. Ann Surg. 2013; 257: 8-14
Composite InfectionHyperglycemia vs No Hyperglycemia
Diabetic Patients
0
2
4
6
8
10
12
14
Both Ops Bariatric Colectomy
Normal
Gluc>180**
* p<0.05** p<0.01
*
Kwon. Ann Surg. 2013; 257: 8-14
Composite InfectionHyperglycemia vs No Hyperglycemia
Nondiabetic Patients
0
5
10
15
20
All Pts Bariatric Colectomy
Normal
Gluc>180
All p<0.01
Kwon. Ann Surg. 2013; 257: 8-14
Composite Infection in Hyperglycemic Patients With
and Without Use of Insulin
0
0.5
1
1.5
2
2.5
No Insulin Insulin
Odds Ratios
Kwon. Ann Surg. 2013; 257: 8-14
Operative Reintervention in Hyperglycemic Patients With
and Without Use of Insulin
0
0.5
1
1.5
2
2.5
No Insulin Insulin
Odds Ratios
Kwon. Ann Surg. 2013; 257: 8-14
Mortality in Hyperglycemic Patients With and Without Use
of Insulin
00.5
11.5
22.5
33.5
No Insulin Insulin
Odds Ratios
Kwon. Ann Surg. 2013; 257: 8-14
SCOAP Data on Perioperative Hyperglycemia - Odds Ratios
Multivariate regressions accounting for
Age
Sex
Charlson’s comorbidity
BMI
Smoking
Immunosuppression
Preop antibiotics
Cancer
Year
Surgical Procedure
Diabetes
SCOAP data courtesy of Sung (Steve) Kwon
SCOAP Data on Perioperative Hyperglycemia - Odds Ratios
Multivariate regressions
Death 2.71 (1.72–4.28)
Operative intervention 1.80 (1.41-2.30)
Anastomotic leak 2.43 (1.38-4.28)
Composite infection 2.00 (1.63-2.44)
SCOAP data courtesy of Sung (Steve) Kwon
UWMC Glucose Values, 1999 - 2005
NSQIP Moves to the “Private” Sector in 2004
Ann Surg. 2008 Aug; 248(2): 329-36.
Medicare National Coverage Decision for Bariatric Surgery
– February 2006
• UWMC cancels 30 scheduled cases
• UWMC completes its planned BSCN certification and joins NSQIP
• We get introduced to the infectious enthusiasm of a NSQIP meeting
The Power of
Collaborative Groups of
Clinicians Working Together
to Achieve High-Quality Effective
Surgical Care for Patients:
Colorectal Surgery as an Example
Literature Search on NSQIP and Colorectal
SSI risk 4
Procedure specific 1
Lap v. Open 8
Mortality risk 4
Indications 7
UTI risk 1
VTE risk 2
Elderly 4
QI opportunities 5
Risk calculations 8
Length of stay 2
Resident education 2
Obesity 1
Anemia/transfusion 2
50 references from 2002 to 2012
Using NSQIP to Demonstrate Improved Outcomes in
Colorectal Surgery
Berenguer. Improving SSI Using NSQIP Data. JACS 2010;210: 737-43
*p=0.041
Multiinstitutional Collaboratives Linked to NSQIP Focusing on
Improving Colorectal Outcomes
• Michigan Surgical Quality Collaborative (MSQC) - Colectomy Best Practices Project
• Joint Commission Center for Transforming Healthcare - Colorectal Surgical Site Infection Collaborative – underway & initial results presented at national NSQIP meeting 2012
• TNACS/TNSQC – just getting started
• SUSP/Johns Hopkins/Armstrong Institute/NSQIP
Bowel Preparation Prior to Elective Colectomy in Michigan (n=1648)
Overall SSI Rate in Michigan is 8.0%
Englesbe. Ann Surg 2010;252: 514–520
All patientsGet I.V. antibiotics
Surgical Site Infection Rates following Elective Colectomy
The Michigan Surgical Quality Collaborative
Propensity Matched Analysis(n=740)
Englesbe. Ann Surg 2010;252: 514–520
n=195
All patientsGet I.V. antibiotics
0%
5%
10%
15%
DeepIncisional
OrganSpace
SuperficialIncisional
Overall SSI
No Oral Antibiotics
Oral Antibiotics
Per
cent
of
patie
nts
* P < 0.05
*
*
Oral Antibiotics with a Bowel Preparation
A Propensity Matched Analysis (n=740)
*
Englesbe. Ann Surg 2010;252: 514–520
All patientsGet I.V. antibiotics
0%
5%
10%
15%
C.difficile colitis Prolonged Ileus
No Oral Antibiotics
Oral Antibiotics
Pe
rce
nt o
f pa
tient
s
* P < 0.05
Oral Antibiotics with a Bowel Preparation
A Propensity Matched Analysis (n=740)
Englesbe. Ann Surg 2010;252: 514–520
All patientsGet I.V. antibiotics
Krapohl, G.L., Bowel preparation for colectomy and risk of Clostridium difficile
infection.Dis Col Rectum, 2011. 54:810-7
C. diff No C. diff
No prep (n=578) 2.4% 97.6%
Prep (n=1685) 2.4% 97.6%
No Ab (n=1001)* 2.9% 97.1%
Oral Ab (n=684)* 1.6% 98.4%
* p=0.09
MSQC/NSQIP Colorectal ProjectProphylactic Antibiotic Use
Scheduled Emergency
(2743) (248)
SCIP compliant 84% 52%
Within 1 hr 93% 64% --------------------------------------------------------------------------
Weight adjusted dosing (922) 57%
Redosed when indicated (398) 6%
Hendren. Am J Surg 2011; 201: 290-4
MSQC/NSQIP Colorectal Project
2008 2009
(1387) (1592)
Ab given 99.8% 100%
Within 1 hr 79% 93%
SSI* 9.4% 7.4% p=0.062
Hendren. Am J Surg 2011; 201: 290-4
Oral Antibiotics Without Bowel Prep?
VASQIP, 9940 patients, 112 hospitals
Incidence SSI
Bowel prep, no oral Ab 39% 20%
No prep at all, no oral Ab 20% 18%
Bowel prep + oral Ab 34% 9%
No prep + oral Ab 7% 8%
Cannon. Dis Col Rectum 2012; 55: 1160-6
Oral Antibiotics for Colorectal Operations
Cannon. Dis Col Rectum 2012; 55: 1160-6
Bowel Prep & Oral AntibioticsVASQIP Data – 8180 patients
Hawn. So Surgical Assoc. Palm Beach, FL, 12 Dec 2012
Oral antibiotic bowel prep 44%
Mechanical prep alone 39%
No prep at all 17%
Bowel Prep & Oral AntibioticsVASQIP Data
Hawn. So Surgical Assoc. Palm Beach, FL, 12 Dec 2012
Bowel Prep & Oral AntibioticsVASQIP Data
Hawn. So Surgical Assoc. Palm Beach, FL, 12 Dec 2012
Antibiotic Choice & SSI After Colectomy
Hendren. Ann Surg 2013;257.469
Surgical Unit-based Safety Program (SUSP)
• Funded by AHRQ
• Sponsored by Johns Hopkins and ACS/NSQIP
• Based on teamwork and the wisdom of the frontline staff
• Focused on Colorectal SSI
• Presented in detail at national NSQIP mtg
• All NSQIP hospitals eligible to participate
Surgical Unit-based Safety Program (SUSP)
Experience with joining national projects previously to kick start a local QI effort and realization of the critical importance of interdisciplinary teamwork has led us to join this important national effort to reduce SSI and other postoperative complications, led by Johns Hopkins and ACS and funded by AHRQ.
Normothermia Project Johns Hopkins
Interventions
• Confirmed that temperature probes were accurate (trial comparing foley and esophageal sensors)
• Initiated forced air warming in the pre-operative area
• Heightened awareness
Wick. J Am Coll Surg. 2012; 215: 193-200
JHU Colorectal CUSP
Other changes – based on input from frontline staff:
– Changing instruments after anastomosis– Weight based dosing for prophylaxis– Having adequate amounts of antibiotic in the
O.R.– Colorectal specific check list
Wick. J Am Coll Surg. 2012; 215: 193-200
JHU Colorectal CUSP
*p < 0.05 Wick. J Am Coll Surg. 2012; 215: 193-200
The Effect of Retrospective Review on Post-Operative Transfusion RatesPrior to 2009, UWMC consistently had higher
than average post-op transfusion rates.In 2010, we began a program of regular
reporting and discussion of post-op transfusion at weekly M&M conference.
Here is what has happened since…
Year UWMC Transfusion Rate
NSQIP Transfusion Rate
UWMC CR Transfusion Rate
NSQIP CR Transfusion Rate
2007 6.2 4.2 16.4 11.4
2008 6.3 4.0 18.9 10.6
2009 5.4 3.8 14.8 10.2
2010 3.2 4.5 6.1 12.0
2011 4.0 5.6 5.4 14.8
2012 3.0 4.9 6.9 13.5
43% decrease for all GS cases (95%CI 42.5%-43.5%, p=<0.001)
63% decrease for colorectal cases (95%CI 61-65%, p=<0.001)
Year UWMC SCOAP Transfusion Free Rate
SCOAP Benchmark Transfusion Free Rate
% Transfusions with Low Hgb (≤ 7)
2009 79.9% 99.2% NA
2010 86.3% 98.5% 38.1%
2011 87.8% 97.8% 70%
More transfusions with associated low Hgb
We are still not a top-performer among SCOAP hospitals
Take AwaysReview and discussion changes practice.We didn’t just give less transfusions, we gave
fewer transfusions that were not evidence-based.
We minimized our patient’s exposure to transfusion-associated risks!
We are better stewards of a scarce resource.We decreased costs.We still have room for improvement.
Final Thoughts• A surgeon (champion) can’t do “quality” alone.
• Others can’t do surgical quality without surgeon involvement and commitment.
• Without interdisciplinary teamwork no one can do quality.
• Without good data (NSQIP/SCOAP) you don’t know what you need to work on or if your are succeeding.
• Those on the front line have a unique perspective.
• The job never stops.
Slides Gladly Sharedon Request