spine center of excellence - medical school

Spine Center of Excellence

First Joint Commission Designated

Spine Center of Excellence in MN

Since 11/17

Why A Community Hospital

Would Want to Pursue

Joint Commission Designation

As A Center of Excellence

for Spine

Joint Commission

Provides a framework for

organizational structure and management

for compliance with National evidence-

based clinical practice guidelines

with ordersets, protocols and

outcome analysis

For best quality of patient care

HealthEast Neurosurgery & Spine

SPINE COUNCIL

4 Practices 15 Surgeons

Neurosurgery & SpineHealthEast

Neurosurgery and Spine

Midwest Brain and Spine

HealthGrades Hospital Compares

Comparison of Complication Rate for Spine Fusion *

Complications Actual Predicted # of cases

St. Joes 12.12% 10.86 66 +++

St Johns 21.02 13.67 176 +

Woodwinds 13.00 9.12 100 +++

Natl. Average 11.15 11.17 185

*data from medicare.gov 2012-13

Medicare’s listed complications

Surgical Site Infections

Pressure sores (pressure ulcers)

Collapsed lung that results from medical treatment (Iatrogenic

pneumothorax)

Infections from a large venous catheter (central venous

catheter-related blood stream infection)

Broken hip from a fall after surgery (postoperative hip fracture)

Blood clots, in the lung or a large vein, after surgery

(perioperative pulmonary embolism or deep vein thrombosis)

Blood stream infection after surgery (postoperative sepsis)

A wound that splits open after surgery (postoperative wound

dehiscence)

Accidental cuts and tears (accidental puncture or laceration)

8

SPINE COUNCIL

VBI PROJECT ON SSI 4 Practices 15 Surgeons

HealthEast


Midwest Brain and Spine

Project Parameters

Reported Data: July through December of 2014

SSI within 30 days of spine surgery at Joes/Johns

639 inpatient spine surgeries

341 fusions (lumbar, cervical, thoracic)

298 nonfusions

Chart reviews conducted by Kathy Miller and

Annette Lund With Dr. Boyd

Project Parameters

Reported Data: July through December of 2014

SSI within 30 days of spine surgery at Joes/Johns

639 inpatient spine surgeries

341 fusions (n=7) 2.0%

298 nonfusions (n=2) 0.7%

Chart reviews conducted by Kathy Miller and

Annette Lund

Organisms Among Infections

0

1

2

3

4

5

6

7

8

Outcome of 9 Infected Patients

0123456789

Distribution of Infections by

Number of Levels Fused

0 1 2 3 4 5 6 7

lumbar

thoracolumbar

cervicalthoraco

cervical

Age Distribution of Surgical Spine

Patients with Infections

0

1

2

3

4

30 35 40 45 50 55 60 65 70 75 80 85 90

Age Distribution of Inpatient

Spine Cases

3 4

34

69

128

171

119

63

40

20

40

60

80

100

120

140

160

180

10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90-99

Inpatient Age Range Distribution July 2014-December 2014

Volume

Age Distribution of Surgical Spine


0

1

2

3

4

30 35 40 45 50 55 60 65 70 75 80 85 90

Cases 34 69 128 171 119 63 4

Rate % 0 0.8 1.2 1.7 4.8 0

Comorbidites of Elective Surgical


0

10

20

30

40

50

60

70

80

90

100

Diabetes BMI > 40 BMI 38 BMI 25-30 D/C to TCU recent MI

% total cases 19 23.4

% infections 38 25Infection rate 3.5% 4.1%

Of the 7 fusion cases with Infections

Intra-Operative Prep

0

1

2

3

4

5

6

7

Duraprep Scrub

Prep Type

6/212

2.8%

1/52

1.9%

Distribution of Infections By

Surgeons in 2014

0

1

2

3

4

5

A B C D E F G H I J K L M

Total Infections 7/341 Cervical Lumbar/Thoracic Fusion Cases

surgeon specific infection rate

P-value 0.0033 for Surgeon B

Cases 54 37 79 0 11 12 13 24 23 30 49 0 14

Rate 1.9 10.8 1.3 0 9

Number of Patients Returned to OR

for I/D 1/15 – 6/15

0

1

2

3

4

5

6

7

Cases 3 71 93 61 68 64 118

Rate 4.2 1 9.8 1.5 1.6 1.7

•Now 9 cases from 3/15 – 9/15,

National Healthcare Safety

Network

Analysis of 49,120 cases Operation Risk Index* Pooled

Mean

Median T value

Minute

Spinal Fusion 0 0.72 0.37 240

1 1.95 1.54 240

2, 3 4.13 4.0 240

Lami 0 0.73 0.56 167

1 1.11 0.98 167

2, 3 2.44 1.67 167

Risk Index: 1 if ASA 3,4,5; 1 if time > T value; 1 if contaminated wound

Quality Goal

Reduce complications and readmissions

Increase quality of care

Build a team with common purpose

Provide the best patient care

Joint Commission Certification

Provides a framework for

organizational structure and management

compliance with National evidence-based

clinical practice guidelines

with ordersets, protocols and

outcome analysis

Team - staff recruitment and development

12 new CNRNs in first year of classes

Joint Commission

Site of Distinction for Spine

Selected + Monitored 4 Criteria for Improvement

Surgical Site Infections

Early Mobilization (Day of surgery)

Pain Management

Indwelling Catheters

Established Protocols, Enlisted Stakeholders,

Collected Data Presented at Site Visit 8/2017

Surgical Site Infection

Preop Hibiclens shower x 2 prior to surgery

Preop Sage Wipe and Nasal Swab

Abx Irrigation for higher risk patients

(diabetes, obesity etc.) when hardware placed

All others dilute betadine or saline

Infection rate (goal < 1 %)

Surgical Site Infection

Providine Iodine SSI Prevention

Nasal decolonization + sage cloth

in Preop

Both Nasal Swab and Sage Wipe in Preop

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18

SJ 88% 93% 94% 92% 96% 92%

JN 57% 94% 100% 90% 100% 92%

WW 100% 95% 95% 84% 88% 88%

% SAU Povidone Iodine Nasal Swab

CAUTI Watch

Nurse driven protocol on Floor and Postop

to Recognize and Manage Postop

Retention with Straight Cath

Indwelling Urinary Catheter

% Pts w/ Documented reason for retention of foley

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


SJ 100% 75% 100% 100% 100% 100%

JN 67% 100% 100% 100% 100% 0%

WW 100% 100% 100% 100% 100% 100%

Nursing Protocol for bladder scan and straight cath

Ambulation Watch

OT/PT Video seen by pt in Preop Area

‘just in time’ repetition for adult learners

PT scheduled on Day of surgery

Goal ambulate 30 feet by 12 hours postop

Early Mobilization

Ambulate 30 feet within 12 hours after PACU

0%

20%

40%

60%

80%

100%


SJ 81% 71% 60% 81% 87% 67%

JN 50% 44% 44% 50% 33% 22%

WW 68% 74% 63% 70% 59% 67%

PAINStandard Orders for

Preop Protocols for Pain Cocktails

(oral Tylenol, Neurontin, oxycodone)

Anesthesia Engagement for Intraop Methadone for

inpatients with surgeries >3 hours

Surgeon Engagement Injections of Marcaine

Presently Monitoring ER - 30 day returns for pain

Multimodal Pain Management

0%10%20%30%40%50%60%70%80%90%

100%


SJ 98% 100% 100% 100% 100% 100%

JN 100% 100% 100% 100% 100% 100%

WW 100% 100% 100% 100% 100% 100%

% Patients offered pharm and 2 non-pharm forms of pain management

Future – Protocol for Preop and Intra-Operative Pain Interventions

Associated Watch Measures

Readmission

Use of ER for Postop Issues

Preop Patient Education

(constructed 6 videos preop education-

awaiting implementation on web site)

Nursing Education CNRN

(2 day class put on by neuro providers)




Since 11/17

Is Quality Better?

Rate of SSI for Fusions

0

0.5

1

1.5

2

2.5

2014 2015 2016 2017

percent SSI

N=341 N=384

N=622 N=471

HealthGrades 2015

Comparison of Complication Rate for Spine Fusion *


St. Joes 12.12% 10.86 66 +++

St Johns 21.02 13.67 176 +

Woodwinds 13.00 9.12 100 +++

Natl. Average 11.15 11.17 185

*data from medicare.gov 2012-13

HealthGrades 2016

Comparison of Complication Rate for Spine Fusion


St. Joes 13.79% 11.10 58 ***

St Johns 25.36 13.51 209 *

WoodWinds 17.50 9.59 120 ***

United 9.0 11.18 100 ***

Natl. Average 11.15 11.17 185

data from medicare.gov 2012-14

HealthGrades 2017



St. Joes 12.00% 10.00 75 ***

St Johns 26.97 13.39 241 *

WoodWinds 18.47 9.24 157 *

Natl. Average 11.15 11.17 185


Regions *, U of M * Mayo ***, United ***

HealthGrades 2018-2019



St. Joes 19.74% 10.01 76 *

St Johns 31.53 11.35 222 *

WoodWinds 12.98 8.41 208 *

Natl. Average 10.8


Regions *, U of M * , United *

Data lags

QUALITY

OUTCOMES

ANALYSIS

HealthEast


Outcomes Analysis

With Structured Patient Education

Individualized, Classes, Videos

Patient Surveys pre and postop by surgery

(ODI, NDI as outcomes measures)

Redcaps Statistical Analysis 2017 -present

Follow-up Data by Year

2017

268 patients completed pre-op and at least one follow-up

427 follow-up records

2018



2019



0.0

10.0

20.0

30.0

40.0

50.0

60.0

All Lumbar(n=313)

Laminectomy(n=185)

Microdiscectomy(n=97)

Fusion (n=50)

ODI Pre and Post Lumbar Surgery

Pre-op 6 weeks 3 months 6 months 1 year

0.0

10.0

20.0

30.0

40.0

50.0

60.0

Laminectomy (n=185) Artifical disk (n=97)

p=0.0001 p=0.0003

Patient Disability Ratings Pre and Post SurveyFollow-up to 1 year

Pre-op Post-op

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

50.0

Lumbar Fusion (n=50) Cervical Fusion (n=28) Mobi-c (n=41)

p = .0004 p = 0.0001 p = 0.001

Patient Disability Ratings Pre and Post SurgeryFollow-up to 1 year

Pre-op Post-op

0

5

10

15

20

25

30

35

Yes definitely Probably No Not sure

Knowing what you know now, would you have this surgery again?

0

10

20

30

40

50

60

70

80

90

100

5-Completelyprepared

4 3 2 1-Not at allprepared

How prepared did you feel for your surgery?

Average: 4.7 out of 5

SPINE COUNCIL

VBI I – Surgical Site Infections

VBI II – Center of Excellence

VBI III – Value - Cost and Quality




Since 11/17

spine center of excellence - medical school

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