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Surgeon Champion Call 2010 - Dr Peter Doris

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This document summarizes the journey of Surrey Memorial Hospital in implementing the ACS-NSQIP program to track surgical outcomes and improve quality. It describes initial challenges with data quality including missing data, coding errors and inconsistencies that were addressed through staff education and updated processes. It provides examples of pneumonia and catheter-associated urinary tract infection prevention initiatives that were undertaken using a team-based approach including practice changes, education and audits to reduce infection rates. Graphics show outcomes data over time comparing the hospital to NSQIP benchmarks.

Health & MedicineTechnology
Related topics:
Quality Improvement
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Highlights of our Journey with ACS-NSQIP Surrey Memorial Hospital Surgeon Champion Call August 2010
Data Quality Control QI in NSQIP Do we have to? How ? Who is responsible? What is acceptable? What`s the worst that could happen ?
Data Quality Control SC and SCR meetings SCR and Surgical Program Director meetings Identify data errors Multiple postop occurrences Inpatient/Outpatients Subspecialty CPT Code DOB Wound Class
3.5 2.5 108.00 114.00 141.00 89.00 66.00 113.00 88.00 19.00 111.00 8.00 80.00 135.00 128.00 127.00 45.00 15.00 24.00 122.00 75.00 72.00 26.00 100.00 32.00 58.00 31.00 52.00 147.00 124.00 9.00 64.00 68.00 12.00 43.00 38.00 16.00 148.00 40.00 50.00 85.00 44.00 51.00 41.00 129.00 83.00 10.00 54.00 143.00 86.00 48.00 94.00 107.00 49.00 102.00 29.00 20.00 104.00 60.00 13.00 132.00 145.00 97.00 81.00 91.00 65.00 98.00 56.00 116.00 144.00 27.00 123.00 55.00 87.00 134.00 28.00 2.00 103.00 63.00 36.00 67.00 62.00 126.00 73.00 34.00 69.00 70.00 138.00 4.00 120.00 105.00 78.00 92.00 57.00 99.00 119.00 96.00 37.00 53.00 142.00 77.00 14.00 130.00 76.00 93.00 146.00 90.00 95.00 131.00 106.00 35.00 71.00 137.00 79.00 11.00 84.00 117.00 140.00 110.00 139.00 115.00 82.00 33.00 3.00 101.00 21.00 121.00 74.00 22.00 30.00 46.00 112.00 136.00 47.00 23.00 25.00 5.00 59.00 42.00 39.00 118.00 152.00 109.00 61.00 Overall Renal Complications Includes General and Vascular Surgery Cases 4 Outlier status: Needs improvement Good outcomes ACS-NSQIP Hospital ID Number Poor outcomes 3 Our Hospita 2 1.5 1 0.5 0
Data Quality Control Case Detail Report
Data Quality Control
Data Quality Control
Data Quality Control Date of Birth Errors MM/DD/YYYY vs DD/MM/YYYY Discharge Information Multiple admissions Multiple files on EMR for a single admission Wound Classification Errors 15% error per cycle
Wound Classification Guidelines
Data Quality Control Missing Data Variables Then Now Future ASA 33% 2% Height 37% 24% Electronic and mandatory fields Weight 9% 6% OR Reports Available 2-3 months after OR 3-4 weeks 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 Synoptic Reporting
Data Quality Control Challenges CPT 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
Database Design Excel spreadsheet with trends and graphs for each project Quarterly updates Formulas embedded in excel Pivot tables Access Database
Data Reporting and Sharing Internal Surgical Committee Meetings OR Committee Meetings Council of Chiefs Chairs of Division Newsletters Intranet Update – Teams External FHA BCPSQC Provincial and National Other NSQIP participating sites
Data Reporting and Sharing Education Learning Sessions Surgical Safety Collaborative Meetings In-service for frontline nurses Directors, executives and physicians New surgeons Posters
Input/Output
2007 Semiannual Report
OE trend over time
Action Time
Postoperative Pneumonia OE Raw Data – trend over time Rate/100 Surgical Procedures Incidence of Pneumonia from Jan 2007- Mar 2010 SMH NSQIP 6% 5% 4% 3% 2% 1% 0% Jan-Jun 2007 Jul-Dec 2007 Jan-Jun 2008 Jul-Dec 2008 Jan-Jun 2009 Jul-Dec 2009 Jan-Mar 2010
Postoperative Pneumonia More Data Emergency vs elective Pneumonia Occurrence Emergent vs Elective 10% 8% Rate SMH Emergent 6% NSQIP Emergent 4% p-value <.0001 SMH Elective NSQIP Elective 2% 0% Jan-Jun 2008 Jul-Dec 2008 Jan-Jun 2009 Date Pneumonia RTO 2008 39 days 25 days 59 days 14 days 2008 31% 20% 2009 Mortality Elective 2009 LOS Emergent 23% 20% 2008 23% 10% 2009 15% 0%
Postoperative Pneumonia More Data Emergent surgeries postop ventillation = 20/40 (50%) postop ventillation + positive culture = 19/40 (48%) Bugs were identified Candida Albicans excluded Pneum onia Occurrence Em ergent vs Elective 10% 8% SMH Electiv e 6% NSQIP Electiv e SMH Emergent 4% NSQIP Emergent 2% 0% Jan-Jun 2008 Jul-Dec 2008 Jan-Jun 2009
Postoperative Pneumonia Prevention Surrey Memorial Hospital Team Goal: Improvement Strategies *NSQIP data results July-Aug 2008: 3.4% Occurrence Rate Pn eum onia Occurrence Tren Over Tim d e Gen eral and Vascular Surgeries • 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 Spot Check Pneumonia Prevention Action Team Chart#__ ____ ____ Date_ ____ ____ ___ 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 minutes Yes No N/A Preadmission •Pre-op Education Pamphlet with Pneumonia Prevention Tips •Encouraging Partnership in Care •Changes in Standard Orders for Preoperative Oral Decontamination 6% 5% 4% % To decrease the incidence of pneumonia in postop bowel surgery patients by 50% using NSQIP by October 2009. SMH 3% 2% 1% 0% NSQIP 07 6-12/0 /0 6 0 1/07-06 /07 07/07 2/07 0 -1 1/08-0 6/08 07/08 -11/08 Dates Risk-Adjusted Pneumonia with Comparison to Other NSQIP Sites Observed Rate: 2.73% Expected Rate: 1.68% O/E Ratio: 1.62 Status: As Exp ected Spot Checks: Pre -Implementation October 2008: 50% HOB elevated February 2009: 71% HOB elevated 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 TEAM MEMBERS Linda Coleman, PT Margaret Dyka-Gluzak, RN Linda Nelson, Educator Anne Edmond RN Irene Harder, RN Brenda Smith, RN Melissa Idle, Physio Raj Pandey, PT Angela Wilson RN Christine Donald, RN Angela Tecson, SCNR Sharon Parent, QI Donna Rolph, Manager 3 South Surgical Front Line Staff
PDSA Cycles – Best Practices Audits Pneumonia Prevention Audit 100% HOB Elevated 60% DBC Teaching 40% DB&C Exercises Mobility Documentation 20% 0% Jun-09 Jul-09 Aug-09 Date of Audit Mobility Postop Day #0 Colorectals 100% 80% Rate Rate 80% HOB 60% Dangle 40% Walk 20% 0% Jun-09 Jul-09 Aug-09 Date of Audit Sep-09
Postoperative UTI
CAUTI Prevention Action Team Surrey Memorial Hospital Team Goal: Improvement Strategies As determined by frontline staff Initiation: reach 80% of staff 8 x 30 min education sessions (UTI Jeopardy) Picture 4 x 10 min unit based education (create awareness) Creation of prompts to stimulate awareness Sustainability 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 U & I can eliminate UTI’s Actions; 2 person insertion & use smallest possible french Prewash perineal area & use chlore hexdine 2% swabs Secure safely (to unaffected side if limb trauma) No droopy Loops (ke ep between bladder and bag) Keep bag below the bladder and off the floor Label drainage container with name and date Rinse 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 place Has any follow up/ trial been done re: removal of catheter What is the plan for removal Is 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 Obtaining Results then, if still unable to void Foley Catheter overnight and remove in AM If problem persists, consider urology consult 1. Silver Catheters: Insertion documented in chart, Kardex and tracking tool. Follow up audit to be done. 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 General and Vascular Surgeries Process Change UTI T rend Over Time 1.Trial of silver impregnated catheter In OR: insertion of silver catheters in bowel procedures On Unit: pre-operative insertion of silver catheters in the fractured hip population Practice Changes 1. Insertion 2 person insertion Pre-wash perineal area CHG 2% for aseptic urinary meatus cleaning Statlock securement to unaffected leg 2. Maintenance No droopy loops (dependant loops) Drainage bag between bladder and floor New drainage container q 24hrs Rinse drainage container after each drain 3. Removal “2 Days too Long” : Removing a urinary catheter at max post op day 2 at 0600 unless contraindicated If catheter remains in place: documenting reason for catheter and plan of care Encourage activities to promote voiding: Mobility, Hydration, Bowel care, Relaxation 4 3 % Decrease Catheter Associated Urinary Tract Infection rates 50% in the fractured hip population by June 2009 UTI Trend Over Time SMH 2 NSQIP 1 0 01 /06-06 /06 0 7/0 6-1 2/06 0 1/07 -0 6/07 07 /0 7-12 /0 7 01/0 8-06/0 8 0 7/08 -1 1/08 Dates Risk-Adjusted Overall Urinary Tract Infections with Comparison to Other NSQIP Sites Observed Rate: 2% Expected Rate: 1.34% O/E Ratio: 1.49 Status: As Exp ected Future Opportunities 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. Team Members : Jyotika Prasad Nen Graces Sharon Parent Jane Mann Felicia Laing Loretta Castelino Nicole Quilty Cindy Yazlovsky Linda Jennings Racheal Bertram Elizabeth Allan Angela Tecson 3S Surgical Orthopaedic Frontline Staff!!
PDSA Cycle Orthopedic Ward – Silver Catheter Audit UTI TREND OVER TIME n 40 20 0 Apr-09 May-09 Jun-09 Apr-09 May-09 Jun-09 Ag Cath w/ UTI 0 0 0 Ag Cath 7 3 2 Reg Cath 18 13 6 Reg Cath w/ UTI 7 2 0 GS Ward – Catheter care 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
Total Number of Cases Cases with SSI 3 0 Lymphadenectomy/Other 0 Immediate 2 Reconstruction 14 Mastectomy with 3 Modified, Radical 12 Mastectomy, Complete, 15 Mastectomy, Partial 16 Breast Mass Excision Gynecomastia 4 2 Mastectomy for Number of Cases Surgical Site Infection From bowels to breasts SSI Rates According to Type of Breast Surgery 14 14 10 10 8 6 0 2 1 0
Surgical Site Infection Initiatives Safer Healthcare Now Preop antibiotic Warm air/blanket Appropriate hair removal Antibiotic timing/redosing Normothermia World Health Organization - Surgical Safety Checklist Briefings, Crew Resource Management Preadmission Patient Education – Hygiene, preop scrubs Preop risk factors/comorbidities review Operating Room Changes in skin prep, sutures, scrubs and sponge washes Use of Chlorhexidine Improved Wound Classification documentation Surgical Floors IV Training Wound Care Champions Culture 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 No Preop Antiobiotics Preop Antibiotics Given P-value: .001 SSI 14 8 141 13 No SSI No Preop Antiobiotics Preop Antibiotics Given within 1hr SSI 24 12 131 9 P-value: .00008
Length of Stay Review Colorectal Surgery Length-of-Stay Obs erved R a te: 41.82% E xpected R a te: 26.48% O/E R a tio: 1.58 S ta tus : Needs Improvement
Length of Stay Colorectal Surgeries Acute Care Emergent Count Average LOS Elective Count Average LOS Acute Care Count Acute Care Average LOS 2005 2006 2007 2008 2009 35 57 53 41 26 24 21 21 17 16 77 68 80 91 37 15 9 10 10 10 112 125 133 132 63 18 15 14 12 13 Ave LOS in 2006 – Ave LOS in 2008 = Ave saved bed day/case in 2008 15 – 12 = 3 Saved bed day/case x # of Colorectal Sx in 2008 = Saved bed day in 2008 3 x 132 = 396 bed days saved in 2008
Examples of Data Integration Graph 10: Overall SSI O/E Ratio January 1, 2007 – December 31, 2007 95% Confidence Interval FHA Appendectomies (2005-2009) 2006 2008 2009 Total Acute 65% 49% 52% 40% 52% Perfed Status: Hospital A: Needs Improvement Hospital B: Needs Improvement 2007 30% 48% 41% 33% 38% 5% 2% 7% 27% 10% Lap Annual Incidence  of Pneumonia from Fiscal Year 2005 to 2009 Hospital A 5 Rate/100 Surgical Proced Hospital B 4 2009 Postop SSI Summary 2 - NSQIP Average 1 0 2005 2006 2007 Fiscal Year 2008 2009 Site A Site B Site C 5.3% 3.4% 2.5% Deep Incision SSI 3 Wound Occurrence Superficial SSI Hospital C 0.7% 1.0% 1.2% Organ/Space SSI 5.1% 1.2% 0.6%
Replicate Published Studies Time of Day Effects Frequency of Surgical Start Time 12% 10% 8% 6% 4% 2 :3 - 3 0 2 0 2 :3 2 :3 - 1 0 0 0 2 :3 1 :3 - 9 0 8 0 1 :3 1 :3 - 7 0 6 0 1 :3 1 :3 - 5 0 4 0 1 :3 1 :3 - 3 0 2 0 1 :3 1 :3 - 1 0 0 0 1 :3 8 09 0 :3 - :3 6 07 0 :3 - :3 4 05 0 :3 - :3 2 03 0 :3 - :3 0% 0 :3 - :1 0 0 00 3 2% 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 1. Anastomotic Leak 2. True Wait Time 3. True LOS 4. Readmission 5. DNR/Palliative Postop Literature review Standard definition Data entry format Source of data Study duration – time dependent? Trial Revision of guidelines if needed
Appendectomies Perfed vs Non-perfed 2006-2009 cases n = 326 Perforated Non-perforated 112 (34.36%) 214 (65.64%) Wait Time Door to Skin (Average) 5 hours 7 hours Length of Stay 4 Days 2 Days 5.4% 3.4% 3.4% 3.3% 2.3% 0% Distribution Postop SSI Superficial Deep Organ/Space
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 100% 80% 60% Emergent Elective 40% 20% 0% 2006 2007 2008 2009
Wait Time Reviews Lap Chole Average wait time: 78 hours Appy 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%) Data shows increased postop complications as wait time increases
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 Clinic Patient feedback – patient education needs Risk assessments OR Reorganization RTO rates, length of surgery, time of surgery Surgical Units Discharge by day of the week – staffing LOS and Outcomes 1South/Stepdown Unit Admission criteria, LOS Other hospital departments (housekeeping, dietary, pain service, etc) Patient Feedback
DVT/VTE Review
DVT/VTE Review ID Score Risk 1473 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 Analysis Cost of SSI after breast surgery: $ 4,091.00 USD ¹ Mastect omy SSI Tren d ov er Time 14% 12% 10% 8% 6% 4% 2% 0% Q4 2007 Q1 2008 Q2 2008 Q3 2008 Q4 2008 Q1 2009 Q2 2009 Q3 2009 Q4 2009 Cost differential between inpt and outpt partial mastectomy: $ 2,800.00 CAD Outpatient Partial Mastectomy with Axillary Node Dissection (19302) SMH NSQIP 2008 17.9 % 78.9 % 2009 10.3 % 77.3 % Reduction Rates between 2007 and 2009 for cases with at least 1 postoperative occurrence Emergent: 27.40 % Elective: 9.05 % Cost of postop UTI: $ 3,535 CAD (excluding physician fees) Cost of Silver-coated catheter: $ 15.00 Averted UTI in 3 months: 18 ¹Hospital-Associated Cost Due to Surgical Site Infection After Breast Surgery. Division of Infectious Disease, Washington University 2004 Canadian 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 James Surowiecki Why the Many Are Smarter Than the Few diversity of opinion independence decentralization aggregation
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!
Observations Data is accepted as valid No finger pointing developed Change was viewed as necessary Culture change underway Flattened hierarchy Safety and Quality articulated as goals Learning “how to improve” improve” Patients notice change It works!

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Surgeon Champion Call 2010 - Dr Peter Doris

  • 1. Highlights of our Journey with ACS-NSQIP Surrey Memorial Hospital Surgeon Champion Call August 2010
  • 2. Data Quality Control QI in NSQIP Do we have to? How ? Who is responsible? What is acceptable? What`s the worst that could happen ?
  • 3. Data Quality Control SC and SCR meetings SCR and Surgical Program Director meetings Identify data errors Multiple postop occurrences Inpatient/Outpatients Subspecialty CPT Code DOB Wound Class
  • 4. 3.5 2.5 108.00 114.00 141.00 89.00 66.00 113.00 88.00 19.00 111.00 8.00 80.00 135.00 128.00 127.00 45.00 15.00 24.00 122.00 75.00 72.00 26.00 100.00 32.00 58.00 31.00 52.00 147.00 124.00 9.00 64.00 68.00 12.00 43.00 38.00 16.00 148.00 40.00 50.00 85.00 44.00 51.00 41.00 129.00 83.00 10.00 54.00 143.00 86.00 48.00 94.00 107.00 49.00 102.00 29.00 20.00 104.00 60.00 13.00 132.00 145.00 97.00 81.00 91.00 65.00 98.00 56.00 116.00 144.00 27.00 123.00 55.00 87.00 134.00 28.00 2.00 103.00 63.00 36.00 67.00 62.00 126.00 73.00 34.00 69.00 70.00 138.00 4.00 120.00 105.00 78.00 92.00 57.00 99.00 119.00 96.00 37.00 53.00 142.00 77.00 14.00 130.00 76.00 93.00 146.00 90.00 95.00 131.00 106.00 35.00 71.00 137.00 79.00 11.00 84.00 117.00 140.00 110.00 139.00 115.00 82.00 33.00 3.00 101.00 21.00 121.00 74.00 22.00 30.00 46.00 112.00 136.00 47.00 23.00 25.00 5.00 59.00 42.00 39.00 118.00 152.00 109.00 61.00 Overall Renal Complications Includes General and Vascular Surgery Cases 4 Outlier status: Needs improvement Good outcomes ACS-NSQIP Hospital ID Number Poor outcomes 3 Our Hospita 2 1.5 1 0.5 0
  • 8. Data Quality Control Date of Birth Errors MM/DD/YYYY vs DD/MM/YYYY Discharge Information Multiple admissions Multiple files on EMR for a single admission Wound Classification Errors 15% error per cycle
  • 10. Data Quality Control Missing Data Variables Then Now Future ASA 33% 2% Height 37% 24% Electronic and mandatory fields Weight 9% 6% OR Reports Available 2-3 months after OR 3-4 weeks 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 Synoptic Reporting
  • 11. Data Quality Control Challenges CPT 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
  • 12. Database Design Excel spreadsheet with trends and graphs for each project Quarterly updates Formulas embedded in excel Pivot tables Access Database
  • 13. Data Reporting and Sharing Internal Surgical Committee Meetings OR Committee Meetings Council of Chiefs Chairs of Division Newsletters Intranet Update – Teams External FHA BCPSQC Provincial and National Other NSQIP participating sites
  • 14. Data Reporting and Sharing Education Learning Sessions Surgical Safety Collaborative Meetings In-service for frontline nurses Directors, executives and physicians New surgeons Posters
  • 19. Postoperative Pneumonia OE Raw Data – trend over time Rate/100 Surgical Procedures Incidence of Pneumonia from Jan 2007- Mar 2010 SMH NSQIP 6% 5% 4% 3% 2% 1% 0% Jan-Jun 2007 Jul-Dec 2007 Jan-Jun 2008 Jul-Dec 2008 Jan-Jun 2009 Jul-Dec 2009 Jan-Mar 2010
  • 20. Postoperative Pneumonia More Data Emergency vs elective Pneumonia Occurrence Emergent vs Elective 10% 8% Rate SMH Emergent 6% NSQIP Emergent 4% p-value <.0001 SMH Elective NSQIP Elective 2% 0% Jan-Jun 2008 Jul-Dec 2008 Jan-Jun 2009 Date Pneumonia RTO 2008 39 days 25 days 59 days 14 days 2008 31% 20% 2009 Mortality Elective 2009 LOS Emergent 23% 20% 2008 23% 10% 2009 15% 0%
  • 21. Postoperative Pneumonia More Data Emergent surgeries postop ventillation = 20/40 (50%) postop ventillation + positive culture = 19/40 (48%) Bugs were identified Candida Albicans excluded Pneum onia Occurrence Em ergent vs Elective 10% 8% SMH Electiv e 6% NSQIP Electiv e SMH Emergent 4% NSQIP Emergent 2% 0% Jan-Jun 2008 Jul-Dec 2008 Jan-Jun 2009
  • 22. Postoperative Pneumonia Prevention Surrey Memorial Hospital Team Goal: Improvement Strategies *NSQIP data results July-Aug 2008: 3.4% Occurrence Rate Pn eum onia Occurrence Tren Over Tim d e Gen eral and Vascular Surgeries • 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 Spot Check Pneumonia Prevention Action Team Chart#__ ____ ____ Date_ ____ ____ ___ 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 minutes Yes No N/A Preadmission •Pre-op Education Pamphlet with Pneumonia Prevention Tips •Encouraging Partnership in Care •Changes in Standard Orders for Preoperative Oral Decontamination 6% 5% 4% % To decrease the incidence of pneumonia in postop bowel surgery patients by 50% using NSQIP by October 2009. SMH 3% 2% 1% 0% NSQIP 07 6-12/0 /0 6 0 1/07-06 /07 07/07 2/07 0 -1 1/08-0 6/08 07/08 -11/08 Dates Risk-Adjusted Pneumonia with Comparison to Other NSQIP Sites Observed Rate: 2.73% Expected Rate: 1.68% O/E Ratio: 1.62 Status: As Exp ected Spot Checks: Pre -Implementation October 2008: 50% HOB elevated February 2009: 71% HOB elevated 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 TEAM MEMBERS Linda Coleman, PT Margaret Dyka-Gluzak, RN Linda Nelson, Educator Anne Edmond RN Irene Harder, RN Brenda Smith, RN Melissa Idle, Physio Raj Pandey, PT Angela Wilson RN Christine Donald, RN Angela Tecson, SCNR Sharon Parent, QI Donna Rolph, Manager 3 South Surgical Front Line Staff
  • 23. PDSA Cycles – Best Practices Audits Pneumonia Prevention Audit 100% HOB Elevated 60% DBC Teaching 40% DB&C Exercises Mobility Documentation 20% 0% Jun-09 Jul-09 Aug-09 Date of Audit Mobility Postop Day #0 Colorectals 100% 80% Rate Rate 80% HOB 60% Dangle 40% Walk 20% 0% Jun-09 Jul-09 Aug-09 Date of Audit Sep-09
  • 25. CAUTI Prevention Action Team Surrey Memorial Hospital Team Goal: Improvement Strategies As determined by frontline staff Initiation: reach 80% of staff 8 x 30 min education sessions (UTI Jeopardy) Picture 4 x 10 min unit based education (create awareness) Creation of prompts to stimulate awareness Sustainability 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 U & I can eliminate UTI’s Actions; 2 person insertion & use smallest possible french Prewash perineal area & use chlore hexdine 2% swabs Secure safely (to unaffected side if limb trauma) No droopy Loops (ke ep between bladder and bag) Keep bag below the bladder and off the floor Label drainage container with name and date Rinse 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 place Has any follow up/ trial been done re: removal of catheter What is the plan for removal Is 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 Obtaining Results then, if still unable to void Foley Catheter overnight and remove in AM If problem persists, consider urology consult 1. Silver Catheters: Insertion documented in chart, Kardex and tracking tool. Follow up audit to be done. 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 General and Vascular Surgeries Process Change UTI T rend Over Time 1.Trial of silver impregnated catheter In OR: insertion of silver catheters in bowel procedures On Unit: pre-operative insertion of silver catheters in the fractured hip population Practice Changes 1. Insertion 2 person insertion Pre-wash perineal area CHG 2% for aseptic urinary meatus cleaning Statlock securement to unaffected leg 2. Maintenance No droopy loops (dependant loops) Drainage bag between bladder and floor New drainage container q 24hrs Rinse drainage container after each drain 3. Removal “2 Days too Long” : Removing a urinary catheter at max post op day 2 at 0600 unless contraindicated If catheter remains in place: documenting reason for catheter and plan of care Encourage activities to promote voiding: Mobility, Hydration, Bowel care, Relaxation 4 3 % Decrease Catheter Associated Urinary Tract Infection rates 50% in the fractured hip population by June 2009 UTI Trend Over Time SMH 2 NSQIP 1 0 01 /06-06 /06 0 7/0 6-1 2/06 0 1/07 -0 6/07 07 /0 7-12 /0 7 01/0 8-06/0 8 0 7/08 -1 1/08 Dates Risk-Adjusted Overall Urinary Tract Infections with Comparison to Other NSQIP Sites Observed Rate: 2% Expected Rate: 1.34% O/E Ratio: 1.49 Status: As Exp ected Future Opportunities 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. Team Members : Jyotika Prasad Nen Graces Sharon Parent Jane Mann Felicia Laing Loretta Castelino Nicole Quilty Cindy Yazlovsky Linda Jennings Racheal Bertram Elizabeth Allan Angela Tecson 3S Surgical Orthopaedic Frontline Staff!!
  • 26. PDSA Cycle Orthopedic Ward – Silver Catheter Audit UTI TREND OVER TIME n 40 20 0 Apr-09 May-09 Jun-09 Apr-09 May-09 Jun-09 Ag Cath w/ UTI 0 0 0 Ag Cath 7 3 2 Reg Cath 18 13 6 Reg Cath w/ UTI 7 2 0 GS Ward – Catheter care 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
  • 27. Total Number of Cases Cases with SSI 3 0 Lymphadenectomy/Other 0 Immediate 2 Reconstruction 14 Mastectomy with 3 Modified, Radical 12 Mastectomy, Complete, 15 Mastectomy, Partial 16 Breast Mass Excision Gynecomastia 4 2 Mastectomy for Number of Cases Surgical Site Infection From bowels to breasts SSI Rates According to Type of Breast Surgery 14 14 10 10 8 6 0 2 1 0
  • 28. Surgical Site Infection Initiatives Safer Healthcare Now Preop antibiotic Warm air/blanket Appropriate hair removal Antibiotic timing/redosing Normothermia World Health Organization - Surgical Safety Checklist Briefings, Crew Resource Management Preadmission Patient Education – Hygiene, preop scrubs Preop risk factors/comorbidities review Operating Room Changes in skin prep, sutures, scrubs and sponge washes Use of Chlorhexidine Improved Wound Classification documentation Surgical Floors IV Training Wound Care Champions Culture Wounds
  • 29. 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%
  • 30. 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 No Preop Antiobiotics Preop Antibiotics Given P-value: .001 SSI 14 8 141 13 No SSI No Preop Antiobiotics Preop Antibiotics Given within 1hr SSI 24 12 131 9 P-value: .00008
  • 31. Length of Stay Review Colorectal Surgery Length-of-Stay Obs erved R a te: 41.82% E xpected R a te: 26.48% O/E R a tio: 1.58 S ta tus : Needs Improvement
  • 32. Length of Stay Colorectal Surgeries Acute Care Emergent Count Average LOS Elective Count Average LOS Acute Care Count Acute Care Average LOS 2005 2006 2007 2008 2009 35 57 53 41 26 24 21 21 17 16 77 68 80 91 37 15 9 10 10 10 112 125 133 132 63 18 15 14 12 13 Ave LOS in 2006 – Ave LOS in 2008 = Ave saved bed day/case in 2008 15 – 12 = 3 Saved bed day/case x # of Colorectal Sx in 2008 = Saved bed day in 2008 3 x 132 = 396 bed days saved in 2008
  • 33. Examples of Data Integration Graph 10: Overall SSI O/E Ratio January 1, 2007 – December 31, 2007 95% Confidence Interval FHA Appendectomies (2005-2009) 2006 2008 2009 Total Acute 65% 49% 52% 40% 52% Perfed Status: Hospital A: Needs Improvement Hospital B: Needs Improvement 2007 30% 48% 41% 33% 38% 5% 2% 7% 27% 10% Lap Annual Incidence  of Pneumonia from Fiscal Year 2005 to 2009 Hospital A 5 Rate/100 Surgical Proced Hospital B 4 2009 Postop SSI Summary 2 - NSQIP Average 1 0 2005 2006 2007 Fiscal Year 2008 2009 Site A Site B Site C 5.3% 3.4% 2.5% Deep Incision SSI 3 Wound Occurrence Superficial SSI Hospital C 0.7% 1.0% 1.2% Organ/Space SSI 5.1% 1.2% 0.6%
  • 34. Replicate Published Studies Time of Day Effects Frequency of Surgical Start Time 12% 10% 8% 6% 4% 2 :3 - 3 0 2 0 2 :3 2 :3 - 1 0 0 0 2 :3 1 :3 - 9 0 8 0 1 :3 1 :3 - 7 0 6 0 1 :3 1 :3 - 5 0 4 0 1 :3 1 :3 - 3 0 2 0 1 :3 1 :3 - 1 0 0 0 1 :3 8 09 0 :3 - :3 6 07 0 :3 - :3 4 05 0 :3 - :3 2 03 0 :3 - :3 0% 0 :3 - :1 0 0 00 3 2% 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.
  • 35. Time of Day Effects
  • 36. Custom Fields 1. Anastomotic Leak 2. True Wait Time 3. True LOS 4. Readmission 5. DNR/Palliative Postop Literature review Standard definition Data entry format Source of data Study duration – time dependent? Trial Revision of guidelines if needed
  • 37. Appendectomies Perfed vs Non-perfed 2006-2009 cases n = 326 Perforated Non-perforated 112 (34.36%) 214 (65.64%) Wait Time Door to Skin (Average) 5 hours 7 hours Length of Stay 4 Days 2 Days 5.4% 3.4% 3.4% 3.3% 2.3% 0% Distribution Postop SSI Superficial Deep Organ/Space
  • 38. 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
  • 39. Preop Albumin Frequency of Preop Albumin Order for Emergent and Elective Surgeries from 2006 to 2009 100% 80% 60% Emergent Elective 40% 20% 0% 2006 2007 2008 2009
  • 40. Wait Time Reviews Lap Chole Average wait time: 78 hours Appy 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%) Data shows increased postop complications as wait time increases
  • 41. DNR Review Examples of case reviews
  • 42. Data Review for Planning and Decision Making PACU -LOS by procedure, LOS by type of anaesthesia (OR to PACU discharge) Preadmission Clinic Patient feedback – patient education needs Risk assessments OR Reorganization RTO rates, length of surgery, time of surgery Surgical Units Discharge by day of the week – staffing LOS and Outcomes 1South/Stepdown Unit Admission criteria, LOS Other hospital departments (housekeeping, dietary, pain service, etc) Patient Feedback
  • 44. DVT/VTE Review ID Score Risk 1473 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
  • 45. Cost Analysis Cost of SSI after breast surgery: $ 4,091.00 USD ¹ Mastect omy SSI Tren d ov er Time 14% 12% 10% 8% 6% 4% 2% 0% Q4 2007 Q1 2008 Q2 2008 Q3 2008 Q4 2008 Q1 2009 Q2 2009 Q3 2009 Q4 2009 Cost differential between inpt and outpt partial mastectomy: $ 2,800.00 CAD Outpatient Partial Mastectomy with Axillary Node Dissection (19302) SMH NSQIP 2008 17.9 % 78.9 % 2009 10.3 % 77.3 % Reduction Rates between 2007 and 2009 for cases with at least 1 postoperative occurrence Emergent: 27.40 % Elective: 9.05 % Cost of postop UTI: $ 3,535 CAD (excluding physician fees) Cost of Silver-coated catheter: $ 15.00 Averted UTI in 3 months: 18 ¹Hospital-Associated Cost Due to Surgical Site Infection After Breast Surgery. Division of Infectious Disease, Washington University 2004 Canadian Institute for Health Information, The Cost of Hospital Stays: Why Costs Vary (Ottawa:CIHI 2008), does not include physician compensation, 2004-2005 data
  • 46. Cost Analysis Do the math! $$$
  • 48. Structure and Process Evaluation
  • 49. The Wisdom of Crowds James Surowiecki Why the Many Are Smarter Than the Few diversity of opinion independence decentralization aggregation
  • 50. 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!
  • 51. Observations Data is accepted as valid No finger pointing developed Change was viewed as necessary Culture change underway Flattened hierarchy Safety and Quality articulated as goals Learning “how to improve” improve” Patients notice change It works!