Highlights of our Journey with ACS-NSQIP

Surrey Memorial Hospital

Surgeon Champion CallAugust 2010

QI in NSQIPDo we have to?How ?Who is responsible?What is acceptable?What`s the worst that could happen ?

Data Quality Control

Data Quality Control

SC and SCR meetingsSCR and Surgical Program Director meetings

Identify data errorsMultiple postop occurrencesInpatient/OutpatientsSubspecialtyCPT CodeDOB Wound Class

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Overall Renal ComplicationsIncludes General and Vascular Surgery Cases

Outlier status:Needs improvement

Good outcomes

Poor outcomes

ACS-NSQIP Hospital ID Number

Our Hospita

Data Quality ControlCase Detail Report

Data Quality Control

Data Quality Control

Date of Birth ErrorsMM/DD/YYYY vs DD/MM/YYYY

Discharge Information Multiple admissionsMultiple files on EMR for a single admission

Wound Classification Errors15% error per cycle

Data Quality Control

Wound Classification Guidelines

Data Quality ControlMissing Data

Variables Then Now FutureASA 33% 2% Electronic

andmandatory fieldsHeight 37% 24%

Weight 9% 6%OR Reports Available 2-3

months after OR

3-4 weeksSynopticReporting

Smoking History(ppy)

95% 30% Enhanced preop assessment

Labs(Albumin)

79% 53% Links with external lab facilities

30-Day FF-up 92.1% 92.5% Translation Services

ChallengesCPT Codes

*Discuss OR reports with Surgeon Champion*CPT Code mapping on Validation Worksheet

ICD Codes*Surgeon’s offices/MOA

Missing data*Revised nurses notes, assessment forms, anaesthesia record

30-day Follow-up*Telephone script for NSQIP clerks

Data Quality Control

Database Design

Excel spreadsheet with trends and graphs for each projectQuarterly updatesFormulas embedded in excelPivot tablesAccess Database

Data Reporting and SharingInternal

Surgical Committee MeetingsOR Committee MeetingsCouncil of ChiefsChairs of DivisionNewslettersIntranetUpdate – Teams

ExternalFHABCPSQCProvincial and NationalOther NSQIP participating sites

Data Reporting and Sharing

Education

Learning SessionsSurgical Safety Collaborative MeetingsIn-service for frontline nursesDirectors, executives and physiciansNew surgeonsPosters

Input/Output

2007 Semiannual Report

OE trend over time

Action Time

Postoperative Pneumonia

OE

Raw Data – trend over timeIncidence of Pneumonia from

Jan 2007- Mar 2010

0%

1%

2%

3%

4%

5%

6%

Jan-Jun 2007 Jul-Dec 2007 Jan-Jun 2008 Jul-Dec 2008 Jan-Jun 2009 Jul-Dec 2009 Jan-Mar 2010Rat

e/10

0 Su

rgic

al P

roce

dure

s

SMH

NSQIP

Postoperative PneumoniaMore Data

Emergency vs electivePneumonia Occurrence Emergent vs Elective

0%

2%

4%

6%

8%

10%

Jan-Jun 2008 Jul-Dec 2008 Jan-Jun 2009

Date

Rat

e

SMH EmergentNSQIP EmergentSMH ElectiveNSQIP Elective

Pneumonia Emergent ElectiveLOS 2008 39 days 25 days

2009 59 days 14 daysMortality 2008 31% 20%

2009 23% 20%RTO 2008 23% 10%

2009 15% 0%

p-value <.0001

Emergent surgeries postop ventillation = 20/40 (50%)postop ventillation + positive culture = 19/40 (48%)Bugs were identifiedCandida Albicans excluded

Postoperative PneumoniaMore Data

Pneumonia Occurrence Emergent vs Elective

0%

2%

4%

6%

8%

10%

Jan-Jun 2008 Jul-Dec 2008 Jan-Jun 2009

SMH ElectiveNSQIP ElectiveSMH EmergentNSQIP Emergent

Postoperative Pneumonia PreventionSurrey Memorial Hospital

Team Goal:

Future Opportunities• Bowel Resection Carepaths• Changes in Preprinted Orders Reflecting

Initiatives• Preadmission Education Pamphlets Revision

Focusing on Self-Management• Spread and Integration of Bundles in Other

SMH Units and FHA Sites

To decrease the incidence of pneumonia in postop bowel surgerypatients by 50% using NSQIP byOctober 2009.

*NSQIP data results July-Aug 2008: 3.4% Occurrence Rate

Improvement StrategiesPneumonia Occurrence Trend Over Time

General and Vascular Surgeries

0%1%2%3%4%5%6%

07/06-12/06 01/07-06/07 07/07-12/07 01/08-06/08 07/08-11/08

Dates

%

SMH

NSQIP

Spot Checks: Pre -Implementation

October 2008: 50% HOB elevatedFebruary 2009: 71% HOB elevated

Preadmission•Pre-op Education Pamphletwith Pneumonia Prevention

Tips•Encouraging Partnership in Care•Changes in Standard Orders for Preoperative Oral Decontamination

• Mobilization- Dangle post op day 0 if tolerated or HOB elevated - Increase activity as tolerated: Up to chair, walk X 1,2,3 etc.

• Meticulous Hand Hygiene- Prevents transmission of micro-organisms between patients- Infection control involvement on team

• Elevate Head of the Bed 30-40 Degrees- HOB elevation during transport, post op bed or stretcher - Rationale: Improves ventilation- Prevents aspiration of stomach & nasopharyngeal secretions

Deep Breathing and Coughing Exercises- Rationale: Improves ventilation and prevents atelectasis - Assists with movement & expectoration of secretions

• Chlorhexidine Gargle - Pre & post op oral decontamination- Evidence indicates may decrease pneumonia rates post

surgery

Education & Support- Patient and Family Education – Posters in rooms“Prevent Pneumonia” coaching & education pre-& post

surgery for deep breathing & coughing - assisting with mobilization- encouraging self-care in recovery period post surgery- Staff Education – Huddles, emails, staff meetings, clinical

update, new staff orientation

TEAM MEMBERS

Linda Coleman, PT Margaret Dyka-Gluzak, RNLinda Nelson, Educator Anne Edmond RNIrene Harder, RN Brenda Smith, RNMelissa Idle, Physio Raj Pandey, PTAngela Wilson RN Christine Donald, RNAngela Tecson, SCNR Sharon Parent, QIDonna Rolph, Manager

3 South Surgical Front Line Staff

Observed Rate: 2.73%Expected Rate: 1.68%O/E Ratio: 1.62Status: As Exp ected

Risk-Adjusted Pneumonia with Comparisonto Other NSQIP Sites

COMPLETE In Patient’s Room:

HOB elevated 30-40 degrees :Yes No N/A

Patient mobilized day 0:Yes No N/A

Patient dangled for 5 minutes X 1 Yes No N/A Or: HOB up 40 degrees for 5 minutesYes No N/A

Chart#__________Date____________

Spot CheckPneumonia Prevention

Action Team

PDSA Cycles – Best Practices Audits

Pneumonia Prevention Audit

0%

20%

40%

60%

80%

100%

Jun-09 Jul-09 Aug-09

Date of Audit

Rate

HOB ElevatedDBC TeachingDB&C ExercisesMobility Documentation

Mobility Postop Day #0Colorectals

0%

20%

40%

60%

80%

100%

Jun-09 Jul-09 Aug-09 Sep-09

Date of Audit

Rate

HOBDangleWalk

Postoperative UTI

CAUTI Prevention Action TeamSurrey Memorial Hospital

Team Goal:

1. Clinical decision making for Catheter reinsertion (i.e. bladder scan volume - what is acceptable? When does a catheter need to be inserted?) Align with HPA.

1. Continue with Silver Catheter trial and determine sustainability of long term use

1. Spread of CAUTI Prevention action items throughout the site. Initial spread to General Surgical Unit and the surgical program.

UTI Trend Over TimeGeneral and Vascular Surgeries

Team Members:

Jyotika PrasadNen GracesSharon Parent Jane Mann

Improvement Strategies

UTI Trend Over Time

0

1

2

3

4

01/06-06/06 07/06-12/06 01/07-06/07 07/07-12/07 01/08-06/08 07/08-11/08

Dates

%

SMH

NSQIP

1. Silver Catheters:Insertion documented in chart, Kardex and tracking tool. Follow up audit to be done.

Picture

Decrease Catheter Associated Urinary Tract Infection rates 50% in

the fractured hip population by June 2009

As determined by frontline staff

Process Change

1.Trial of silver impregnated catheterIn OR: insertion of silver catheters in bowel proceduresOn Unit: pre-operative insertion of silver catheters in the fractured hip population

Practice Changes

1. Insertion2 person insertionPre-wash perineal areaCHG 2% for aseptic urinary meatus cleaningStatlock securement to unaffected leg

2. MaintenanceNo droopy loops (dependant loops)Drainage bag between bladder and floorNew drainage container q 24hrsRinse drainage container after each drain

3. Removal“2 Days too Long” : Removing a urinary catheter at max post op day 2 at 0600 unless contraindicatedIf catheter remains in place: documenting reason for catheter and plan of careEncourage activities to promote voiding: Mobility, Hydration, Bowel care, Relaxation

Felicia LaingLoretta CastelinoNicole Quilty Cindy Yazlovsky

Linda JenningsRacheal BertramElizabeth AllanAngela Tecson

3S Surgical Orthopaedic Frontline Staff!!

8 x 30 min education sessions (UTI Jeopardy)

4 x 10 min unit based education (create awareness)

Creation of prompts to stimulate awareness

Daily reminders with morning rounds

Kardex Inserts Weekly spot checks led by

frontline staff - continuing awareness for practice changes

UTI Section to Initiative wall with current data of CAUTI infection rates on Unit

CAUTI huddles – in presence of UTI infections

2. Practice Changes: weekly spot checks led by frontline staff.

3. CAUTI Rates:5 patients with catheters (selected from weekly spot check) to be audited on weekly basis

Future Opportunities

Initiation: reach 80% of staff

Sustainability

Obtaining Results

Risk-Adjusted Overall Urinary Tract Infections with Comparison to Other NSQIP Sites

Observed Rate: 2%Expected Rate: 1.34%O/E Ratio: 1.49Status: As Exp ected

U & I can eliminate UTI’s

Actions;

2 person insertion & use smallest possible frenchPrewash perineal area & use chlorehexdine 2%

swabsSecure safely (to unaffected side if limb trauma) No droopy Loops (keep between bladder and bag)Keep bag below the bladder and off the floorLabel drainage container with name and dateRinse after every drain and discard q24hrs

(0600)

Always ask, why is this catheter in? Don’t forget.. .“2 Days Too Long”

For everyday the catheter is in place, please assess, document;

Reason why catheter is in placeHas any follow up/ trial been done re: removal of

catheterWhat is the plan for removalIs the patient exhibiting any signs and symptoms

of UTI?If UTI suspected send C+S, and notify MD.

After catheter removal,mobilize,hydrate patient & provide bowel care. If patient is unable to void follow these steps;consider the type of surgery, pt medical status and orders.…

I/O catheter for volume >400cc, x 2 if still unable to void then,

Foley Catheter overnight and remove in AMIf problem persists, consider urology consult

PDSA Cycle

UTI TREND OVER TIME

0

20

40

Apr-09 May-09 Jun-09

n

Ag Cath w/ UTI 0 0 0

Ag Cath 7 3 2

Reg Cath 18 13 6

Reg Cath w/ UTI 7 2 0

Apr-09 May-09 Jun-09

Orthopedic Ward – Silver Catheter Audit

Baseline Sept 2009 Nov 2009

Statlock on 100% 100%

Plan for removal 50% 50%

Droopy loops 100% 100%

Bag above the bladder 0% 0%

Bag on the floor 0% 0%

Drainage container dated 0% 0%

Catheter LOS (ave) 5 days 3.5 days

GS Ward – Catheter care audit

Surgical Site InfectionFrom bowels to breasts

SSI Rates According to Type of Breast Surgery

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Surgical Site Infection InitiativesSafer Healthcare Now

Preop antibiotic Antibiotic timing/redosingWarm air/blanket NormothermiaAppropriate hair removal

World Health Organization - Surgical Safety ChecklistBriefings, Crew Resource ManagementPreadmission

Patient Education – Hygiene, preop scrubsPreop risk factors/comorbidities review

Operating RoomChanges in skin prep, sutures, scrubs and sponge washesUse of ChlorhexidineImproved Wound Classification documentation

Surgical FloorsIV Training Wound Care ChampionsCulture Wounds

PDSA Cycles – Best Practices Audits

OR Initiatives – Breast Surgeries

Jan 2008 Feb 2009

Preop Antibiotic Administration

50% 76%

Antibiotic Timing 42% 100%

Normothermia 95% 100%

Warm Air/Blanket 17% 40%

Appropriate Hair Removal

90% 100%

Preop Antibiotic Administration

*Looking at compliance rate*Dates: Dec 1, 2009 to Jan 31, 2010 (n=176)*Sources of Data: Chart *Results:

(154/176) 87.5% of surgeries received preoperative antibiotics(24/154) 16% given 1 min before incision time(14/154) 9% given >1hr before incision time

No SSI SSI

No Preop Antiobiotics 14 8Preop Antibiotics Given 141 13

P-value: .001

No SSI SSI

No Preop Antiobiotics 24 12Preop Antibiotics Given within 1hr 131 9

P-value: .00008

Length of Stay Review

Colorectal Surgery Length-of-Stay

Observed Ra te: 41.82%E xpected Ra te: 26.48%O/E Ra tio: 1.58S ta tus : Needs Improvement

Length of Stay

Colorectal Surgeries

2005 2006 2007 2008 2009Acute Care Emergent Count 35 57 53 41 26

Average LOS 24 21 21 17 16Elective Count 77 68 80 91 37

Average LOS 15 9 10 10 10Acute Care Count 112 125 133 132 63Acute Care Average LOS 18 15 14 12 13

Ave LOS in 2006 – Ave LOS in 2008 = Ave saved bed day/case in 200815 – 12 = 3

Saved bed day/case x # of Colorectal Sx in 2008 = Saved bed day in 20083 x 132 = 396 bed days saved in 2008

Examples of Data IntegrationGraph 10: Overall SSI O/E RatioJanuary 1, 2007 – December 31, 200795% Confidence Interval

Status:Hospital A: Needs ImprovementHospital B: Needs Improvement

Annual Incidence  of Pneumonia fromFiscal Year 2005 to 2009

0

1

2

3

4

5

2005 2006 2007 2008 2009

Fiscal Year

Rate/100 Surgical Proced

Hospital A

Hospital B

Hospital C

- NSQIP Average

FHA Appendectomies (2005-2009)

2006 2007 2008 2009 Total

Acute 65% 49% 52% 40% 52%

Perfed 30% 48% 41% 33% 38%

Lap 5% 2% 7% 27% 10%

2009 Postop SSI SummaryWound Occurrence Site A Site B Site C

Superficial SSI 5.3% 3.4% 2.5%

Deep Incision SSI 0.7% 1.0% 1.2%

Organ/Space SSI 5.1% 1.2% 0.6%

Replicate Published StudiesTime of Day Effects

0%

2%

4%

6%

8%

10%

12%

00:30-

0:13

0

2:30

-3:30

4:30

-5:30

6:30

-7:30

8:30

-9:30

10:30-

11:30

12:30-

13:30

14:30-

15:30

16:30-

17:30

18:30-

19:30

20:30-

21:30

22:30-

23:30

Frequency of Surgical Start Time

Kelz, R., Tran, T., Hosokawa, P., Henderson, W., Paulson, C., Spitz, F., Hamilton, B., & Hall, B. (2009) Time-of-Day Effects on Surgical Outcomes in the Private Sector: A Retrospective Cohort Study: Journal of the American College of Surgeons, 209-4, 434-445.

Time of Day Effects

Custom Fields

Literature reviewStandard definitionData entry formatSource of dataStudy duration – time dependent?TrialRevision of guidelines if needed

1. Anastomotic Leak2. True Wait Time3. True LOS4. Readmission5. DNR/Palliative Postop

AppendectomiesPerfed vs Non-perfed

2006-2009 casesn = 326

Perforated Non-perforatedDistribution 112 (34.36%) 214 (65.64%)Wait Time Door to Skin (Average) 5 hours 7 hoursLength of Stay 4 Days 2 DaysPostop SSI

SuperficialDeepOrgan/Space

5.4%3.4%3.4%

3.3%2.3%0%

Patient Feedback

• 33% average return rate per cycle• NSQIP clerk sorts and sends to Department Heads• Challenging issues -forwarded to Client Relations Office• Patient/Family meets with CRO and Chief of Surgery

Preop Albumin

Frequency of Preop Albumin Order for Emergent and Elective Surgeries from 2006 to 2009

0%

20%

40%

60%

80%

100%

2006 2007 2008 2009

EmergentElective

Wait Time ReviewsLap Chole

Average wait time: 78 hours

Appy

Data shows increased postop complications as wait time increases

Wait Time 0 to 4hrs 5 to 8hrs 9 to 12hrs >12hrs

Perfed 74(42%) 19(32%) 12(23%) 7(19%)

Nonperfed 104(58%) 41(68%) 40(77%) 29(81%)

Postop Complications 13(7.3%) 5(8.3%) 5(9.6%) 7(19.4%)

DNR Review

Examples of case reviews

Data Review for Planning and Decision Making

PACU-LOS by procedure, LOS by type of anaesthesia (OR to PACU discharge)

Preadmission ClinicPatient feedback – patient education needsRisk assessments

OR ReorganizationRTO rates, length of surgery, time of surgery

Surgical UnitsDischarge by day of the week – staffingLOS and Outcomes

1South/Stepdown UnitAdmission criteria, LOS

Other hospital departments (housekeeping, dietary, pain service,etc)Patient Feedback

DVT/VTE Review

DVT/VTE ReviewID Score Risk1473 9 Highest Risk

1491 9 Highest Risk

3070 6 Highest Risk

3207 8 Highest Risk

3223 10 Highest Risk

4573 9 Highest Risk

5505 12 Highest Risk

5675 6 Highest Risk

5752 6 Highest Risk

1798 7 Highest Risk

2484 4 High Risk

3269 8 Highest Risk

3499 8 Highest Risk

3683 5 Highest Risk

3710 2 Moderate Risk

4155 8 Highest Risk

4892 4 High Risk

5325 7 Highest Risk

5528 5 Highest Risk

Jan 1, 2007 – Mar 31, 2010• 19 DVT/PE Cases• 3/19 (16%) RTO• 2/19 (10.5%) Died

Cost AnalysisCost of SSI after breast surgery: $ 4,091.00 USD ¹

Cost differential between inpt and outpt partial mastectomy: $ 2,800.00 CAD

Reduction Rates between 2007 and 2009 for cases with at least 1 postoperative occurrenceEmergent: 27.40 % Elective: 9.05 %

Cost of postop UTI: $ 3,535 CAD (excluding physician fees)Cost of Silver-coated catheter: $ 15.00Averted UTI in 3 months: 18

Outpatient Partial Mastectomy with Axillary Node Dissection (19302)

SMH NSQIP

2008 17.9 % 78.9 %

2009 10.3 % 77.3 %

Q42007

Q12008

Q22008

Q32008

Q42008

Q12009

Q22009

Q32009

Q42009

0%

2%

4%

6%

8%

10%

12%

14%

Mastectomy SSI Trend over Time

¹Hospital-Associated Cost Due to Surgical Site Infection After Breast Surgery. Division of Infectious Disease, Washington University 2004Canadian Institute for Health Information, The Cost of Hospital Stays: Why Costs Vary (Ottawa:CIHI 2008), does not include physician compensation, 2004-2005 data

Cost Analysis

Do the math!

$$$

July 2010 Semiannual Report

Structure and Process Evaluation

The Wisdom of Crowds

Why the Many Are Smarter Than the Fewdiversity of opinionindependencedecentralizationaggregation

James Surowiecki

We vs Me

Who will speak up before I make a mistake?flatten hierarchy

Does Team Have Patient Safety Focus?checklist

How Do You “Stop The Line”?CUS words

Is There Fear Of Retaliation?need support from organization

Is Work Fun?We are doing a great job!

Data is accepted as validData is accepted as validNo finger pointing developedNo finger pointing developedChange was viewed as necessaryChange was viewed as necessaryCulture change underwayCulture change underway

Flattened hierarchyFlattened hierarchySafety and Quality articulated as goalsSafety and Quality articulated as goalsLearning Learning ““how to improvehow to improve””Patients notice changePatients notice changeIt works!It works!

ObservationsObservations