2 Surgical Care Improvement Project Dr. Philmore J. Joseph Memorial Hermann NE Humble, Texas

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  • 2 Surgical Care Improvement Project Dr. Philmore J. Joseph Memorial Hermann NE Humble, Texas
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  • 4 "It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm" Florence Nightingale
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  • 5 Nosocomial infection = Any infection that is not present or incubating at the time the patient is admitted to the hospital
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  • 6 History of infection control and hospital epidemiology l Pre 1800: Early efforts at wound prophylaxis l 1800-1940: Nightingale, Semmelweis, Lister, Pasteur l 1940-1960: Antibiotic era begins, Staph. aureus nursery outbreaks, hygiene focus l 1960-1970s: Documenting need for infection control programs, surveillance begins l 1980s: focus on patient care practices, intensive care units, resistant organisms, HIV l 1990s: Hospital Epidemiology = Infection control, quality improvement and economics l 2000s: ??Healthcare system epidemiology modified from McGowan, SHEA/CDC/AHA training course
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  • 8 History of infection control and hospital epidemiology l Pre 1800: Early efforts at wound prophylaxis l 1800-1940: Nightingale, Semmelweis, Lister, Pasteur l 1940-1960: Antibiotic era begins, Staph. aureus nursery outbreaks, hygiene focus l 1960-1970s: Documenting need for infection control programs, surveillance begins l 1980s: focus on patient care practices, intensive care units, resistant organisms, HIV l 1990s: Hospital Epidemiology = Infection control, quality improvement and economics l 2000s: ??Healthcare system epidemiology modified from McGowan, SHEA/CDC/AHA training course
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  • Medicare Surgical Infection Prevention (SIP) Project Objective To decrease the morbidity and mortality associated with postoperative infection in the Medicare patient population
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  • Surgical Infection Prevention Performance 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.
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  • SCIP Steering Committee l American College of Surgeons l American Hospital Association l American Society of Anesthesiologists l Association of peri-Operative Registered Nurses l Agency for Healthcare Research and Quality l Centers for Medicare & Medicaid Services l Centers for Disease Control and Prevention l Department of Veterans Affairs l Institute for Healthcare Improvement l Joint Commission on Accreditation of Healthcare Organizations
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  • Surgical Care Improvement Project (SCIP) l Preventable Complication Modules Surgical infection prevention Cardiovascular complication prevention Venous thromboembolism prevention Respiratory complication prevention
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  • 16 Surgical Care Improvement Project (Draft Global Outcome Measures) l Motality within 30 days of surgery l Readmission within 30 days of surgery
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  • Surgical Care Improvement Project Performance measures l 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
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  • Classen, et al. N Engl J Med. 1992;328:281. Perioperative Antibiotics Timing of Administration Hours From Incision 14/369 5/699 5/1009 2/180 1/81 1/41 1/47 15/441
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  • Pre-operative shaving l 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!
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  • Perioperative Glucose Control l 1,000 cardiothoracic surgery patients l 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.
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  • 21 Perioperative Glucose Control Carr J Thor Surg 2005
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  • Temperature Control l 200 colorectal surgery patients control - routine intraoperative thermal care (mean temp 34.7C) treatment - active warming (mean temp on arrival to recovery 36.6C) l 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)
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  • Surgical Care Improvement Project Draft performance measures l 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.
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  • 24 Leape et al. JAMA 2002
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  • Mangano DT, et al. N Engl J Med. 1996;335:1713-20. Postoperative Survival l 6-month survival 100% vs 92% (P
  • 62 DVT/PE Solution, contd l NB issue regarding counter pulsation pressure devices l NB chemoprophylaxis vs pressure devices l Age >40, general anesthesia > 30 minutes l Bleeding too remote l Geerts - Chest.2004, 126:3385-4005
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  • 63 DVT/PE Interventions l Education l DVT/PE Awareness programs l Process to assess patients at risk l Pre-printed order sets with guidelines by procedures
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  • 64 Beta Blocker Barriers l Dont believe literature. l Patient has asthma, COPD. l Patient has bradycardia. l Patient has diabetes. l Patient has hypotension.
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  • 65 Beta Blocker Responses l Evidence based literature (recent controversy) l Only relative contraindications
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  • 66 VAP Barriers l I elevate bed. l Nurses lower bed. l I see no difference. l Patient more comfortable. l I dont believe peptic ulcer prophylaxis necessary. l Dont believe weaning protocol necessary.
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  • 67 VAP Responses l Data supports (recent controversy) l No difference regarding patient comfort l Weaning protocols effects l Show physician profile
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  • 68 Dealing with Non-Compliant Physicians l Carrot vs stick l Education l Physician profile (bubble graph) l Counseling Chief of service, Chief of Staff Physician advisor VPMA/CMO
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  • 69 Dealing with Non-Compliant Physicians, contd Letter to support action (evidence based) Meet with MEC Peer Review Credentialing Track and trend
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  • 70 MEC Action l Additional counseling. l Letter of reprimand. l Mandate CME. l Mandate second opinion. l Possible corrective action (possible suspension).
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  • 71 Risk for Hospital (Allowing Physicians to be Non-Compliant with Quality Indicators) l Poor outcome data. l Public reporting implications (state, CMS, national, ? impact referral pattern). l Financial implications (P4P). l Legal implications Physician was non-compliant. Hospital no oversight.
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  • 72 Physician Quality Reporting Initiative (PQRI) l Tax Relief and Healthcare Act (TRHCA) Section 101 Implementation Eligible Professionals Quality Measures Form and Manner of Reporting Determination of Successful Reporting Bonus Payment Validation Appeals Confidential Feedback Reports 2008 Considerations Outreach and Education
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  • 73 Physician Quality Reporting Initiative (PQRI) l Eligible Professionals Medicare physician, as defined in Social Security Act (SSA) Section 1861(r): Doctor of Medicine Doctor of Osteopathy Doctor of Podiatric Medicine Doctor of Optometry Doctor of Oral Surgery Doctor of Dental Medicine Chiropractor
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  • 74 Physician Quality Reporting Initiative (PQRI) l Eligible Professionals Practitioners described in Social Security Act (SSA) Section 1842(b)(18)(C) Physician Assistant Nurse Practitioner Clinical Nurse Specialist Certified Registered Nurse Anesthetist Certified Nurse-Midwife Clinical Social Worker Clinical Psychologist Registered Dietitian Nutrition Professional
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  • 75 Physician Quality Reporting Initiative (PQRI) l Eligible Professionals Therapists Physical Therapist Occupational Therapist Qualified Speech-Language Pathologist
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  • 76 Physician Quality Reporting Initiative (PQRI) l Eligible Professionals All Medicare-enrolled eligible professionals may participate, regardless of whether they have signed a Medicare participation agreement to accept assignment on all claims No registration is required to participate in PQRI.
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  • 77 Physician Quality Reporting Initiative (PQRI) l Bonus Payment Participating eligible professionals who successfully report may earn a 1.5% bonus, subject to c