Leap and SCIP Your Way to Better Outcomes

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Leap and SCIP Your Way to Better Outcomes

• Jennifer Joiner, MSN, RN, CCRN-CSC
• Clinical Nurse Educator, Cardiac Surgery
• Robert Wood Johnson University Hospital

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SCIP

• Surgical Care Improvement Project
• Goals
• Decrease the incidence of surgical complications
  by 25 by 2010
• Decrease mortality and morbidity through
  collaborative efforts

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In 2003

• Post-op complications accounted for 22 of
  preventable deaths
• Focused on 18 types of medical injuries related
  to 2.4 million additional hospital days and 9.3
  billion in extra costs

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Surgical Site Infections (SSIs)

• Account for 14-16 of all hospital acquired
  infections
• BUT- 40 of surgical patients infections are
  related to SSIs

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Several Organizations Contribute to Better
Outcomes

• National Surgical Quality Improvement Program
  (NSQIP)- decreased mortality rate at the VA by
  27
• National Nosocomial Infections Surveillance
  (NNIS) System of the CDC- decreased up to 44 in
  device-associated complications and infection
  rates
• Medicares Quality Improvement Organizations
  (QIOs)- Decreased SSIs by 27 at 56 centers in
  the US ( contracts with CMS)

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Main Focus Areas of SCIP

• Infection
• Antibiotics given within 1 hr of incision time
  (91.2)
• Right Antibiotic ordered (100)
• Antibiotic discontinued within 24/48hr (83.8)
• 6am Blood Sugar (cardiac surgery patients) less
  than 200 (92)
• Post-op wound infections (0 Deep SWI)
• Appropriate hair removal (100)

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Adverse Cardiac Events

• Occurs in
• 2-5 of non-cardiac surgery patients
• 34 of vascular surgery patients
• BUT- Perioperative MI is related to a 40-70
  mortality rate plus
• Increased LOS, costs and morbidity
• Nearly ½ of fatal cardiac events could have been
  prevented with Beta Blocker therapy during the
  perioperative period (by decreasing cardiac
  ischemia)

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• Cardiac
• Beta Blocker given during the perioperative
  period if on one pre-op (100)
• Acute MI within 30 days of surgery

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Venous Thromboembolism (VTEs)

• For all major surgeries without prophylaxis
  ordered
• 25 DVT rate
• 7 PE rate
• High risk Orthopedic surgery without prophylaxis
  ordered
• Over 50 DVT rate
• 30 PE rate
• Problem Underused or inappropriate treatment
  used for prophylaxis

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VTE (Venous Thromboembolism)

• VTE Prophylaxis (95.3)
• VTE Prophylaxis from 24hr before surgery to 24 hr
  after surgery (94.6)
• PE within 30 days of surgery
• DVT within 30 days of surgery

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Respiratory Complications

• Post-op pneumonia-- 9-40 incidence rate
• Pneumonia is associated with a 30-45 mortality
  rate as a complication after surgery

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Data Collection to be added at a later date

• Respiratory
• of days vent patient had HOB documented through
  POD 7
• VAP rate
• of days PUD prophylaxis ordered through POD 7
• of patients with vent weaning orders documented

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• Mortality Rate within 30 days of surgery (1.49
  vs. 3.4 expected rate)
• Readmission Rate within 30 days of surgery

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The Leap Frog Group

• Late 1990s, a number of large US health care
  purchasers formed the Leap Frog Group to develop
  breakthroughs in safety and value of health care
  to US consumers.
• Long-term goal to reward hospitals and MDs on
  the basis of excellence in quality and quality
  improvement.
• Inadequate IT systems and public reporting is not
  consistent to benchmark against thus, group is
  focusing on patient safety

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Leap Frog Group

• Offers valuable benchmarking capabilities to
  hospitals
• Provide consumers and purchasers of health care
  with information on the quality and safety of
  their hospitals
• Increases health care transparency by encouraging
  adoption of health IT standards, provision of
  options that promote quality and efficiency in
  health, and makes pricing and quality information
  publicly available

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RWJUH Named One of Top 33 Hospitals in Quality
and Safety by the 2008 Leap Frog Group Survey

• RWJUH is one of 2 hospitals in NJ
• 33 hospitals chosen out of 1200 nationwide
• 26 hospitals, 7 childrens hospitals

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Leap Frog Patient Safety Standards

• Computer Physician Order Entry
• costs r/t startup, equipment, training,
  maintanence
• decreased med errors and adverse drug events-
  180-900K/year
• decreased repeated tests, lab, radiology,
  history, losing paper charts increased
  efficiency
• ICU Physician Staffing
• costs r/t salary decreased LOS, inappropriate
  ICU admissions, inappropriate testing and
  consults, complications- 800K-3.4 million
• Evidenced-Based Hospital Referral for high risk
  surgeries and neonatal intensive care
• Idea is the more you do, the better you are at
  it
• costs r/t administrative, moving patients,
  redundancy in testing and evaluation, more costly
  care in academic centers smaller hospitals would
  suffer

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• Never Events
• 28 serious reportable events by NQF
• Leaving foreign objects in patients after
  surgery/procedure
• Death or serious injury related to
• Med error
• ABO/HLA incompatible blood or blood product
  causing a hemolytic reaction
• Electric shock or electric cardioversion
• Fall
• Hypoglycemia
• Air embolism
• Use or function of a device in a manner other
  than intended
• Wrong patient, site, or procedure performed
• Intra-operative or immediate post-op death in an
  ASA Class 1 patient
• Stage 3 or 4 hospital-acquired pressure ulcer
• Surgeon Mortality Rates

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• National Quality Forum Safe Practices (NQF-SP)
• Resource Utilization Measures (Core Measures)
• CABG
• PCI
• AMI
• Pneumonia
• AAA Repair
• NICU

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Cardiac Surgery Measures

• ASA/Plavix at discharge- 99.3
• Use of IMA- 99.3
• Beta Blocker w/in 24h of sx 73.9
• Beta Blocker at discharge 94
• Anti-Lipid meds at discharge 95.5

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Percutaneous Coronary Intervention (PCI)

• PCI within 90 min of arrival- AMI 88.2
• ASA on arrival 98.4
• ASA at discharge 99.1

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Acute Myocardial Infarction (AMI)

• ASA on arrival 98.4
• ASA at discharge 99.1
• ACE-I or ARB for LVSD 95
• Adult Smoking Cessation Advice/Counseling
  100
• Beta Blocker at discharge 100
• Beta Blocker on arrival 97.9
• PCI within 90min 88.2

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Pneumonia

• Oxygenation assessment-ABG within 24hr 100
• Pneumococcal vaccine for all with pneumonia (and
  all 65) given prior to discharge 54.8
• Blood cultures within 24hr of admission to the
  ICU 100
• Smoking cessation advice/counseling 100
• Initial Antibiotic within 6hr of arrival 94.6
• Flu vaccine given prior to discharge (n/a for 2nd
  qtr)

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Hospital Acquired Conditions

• Pressure Ulcers
• Injuries
• In addition-
• Severity adjusted average LOS inflated by a 14day
  all-cause readmission rate

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How Can The RN Impact Outcomes?

• Perioperative RN
• Abx within 1hr of incision time
• Right Abx ordered/given
• Appropriate hair removal
• Beta Blocker prior to surgery
• VTE prophylaxis
• Peridex given prior to intubation
• DOCUMENTATION!!!
• Dont be afraid to speak up!!!

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• ICU RN
• Antibiotics stopped within the right time period?
  (cardiac sugery up to 48hr all others 24hr)
• 6am blood sugar under control (cardiac surgery)
• Post-op wound infection- incision care and
  assessments
• VTE prophylaxis?
• VAP prevention bundle
• Pulmonary toileting, ambulation
• Vent weaning documentation (yes/no/why)
• ASA/plavix, Beta Blocker, and Anti-Lipid on
  transfer out of ICU? (For AMI, ACE-I and/or ARB?)
• Vaccine status/orders for discharge dose
• ABG, blood cultures within 24hr and antibiotic
  given within 6hr for pneumonia?
• Smoking cessation counseling for all smokers
• Prevention of pressure ulcers and injuries
• Get the Red Out!!!
• DOCUMENTATION AND ADVOCACY!!!

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Med-Surg and Telemetry RN

• Antibiotics stopped within right time period?
• 6am blood sugar under control? (cardiac surgery)
• PUD, VTE prophylaxis ordered through POD 7
• Pulmonary toileting, ambulation
• ASA/Plavix, Beta Blocker, Anti-Lipid, (ACE-I and
  ARB for AMI) at discharge?
• Smoking cessation counseling
• ABG, blood cultures within 24hr, antibiotic given
  within 6hr of arrival?
• Vaccine status addressed and orders entered for
  day of discharge
• Prevention of pressure ulcers and injuries
• Get the Red Out!!!
• DOCUMENTATION AND ADVOCACY!!!

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Resources

• www.leapfroggroup.org
• www.pronj.org
• www.medqic.org
• www.sts.org
• www.va.gov
• www.ihi.org
• www.jcaho.org
• www.ahrq.gov
• www.cms.hhs.gov
• www.hospitalcompare.hhs.gov