Acting on the Data --- Surgical leadership

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Acting on the Data---Surgical leadership

• E. Patchen Dellinger, MD, FACS
• Professor of Surgery, Chief of General Surgery,
  Chief of Staff,
• University of Washington Medical Center (UWMC),
  Seattle, Washington

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Or
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How I Got InvolvedWith NSQIP and WhatI Think
Ive Learned
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Development of Surgical Outcomes Research Center
(SORCE) at UW, 2000

• Analysis of Washington State discharge data base
  -
• Bile duct injuries after lap chole
• Negative appendectomy
• Survival advantage after gastric bypass
• Support of clinical trials

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Development of Surgical Care Outcomes Assessment
Program (SCOAP), 2002

• Sponsored by
• SORCE
• Foundation for Health Care Quality (FHCQ)
• Washington State ACS Chapter
• Supported by
• Life Science Discovery Fund
• Third party payers

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Initial Focus of SCOAP

• Colorectal Surgery
• Bariatric Surgery
• Appendectomy
• Quarterly feedback
• Outcomes
• process measures
• Have now added
• Gastrectomies
• Pediatric Surgery
• Vascular Interventions
• Spine Surgery

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Surgical Care and Outcomes Assessment Program

• Voluntary, grassroots clinician collaborative in
  WA
• Surveillance, benchmarking, practice change
  interventions
• 58 hospitals (95)-rural and urban

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Surgical Care and Outcomes Assessment Program

• Modules in general, pediatrics, bariatrics,
  vascular interventions(cardiology/IR/surgery),
  spine (neuro/ortho), advanced cancer care
• SCOAP reports
• Focus on risk adjusted outcomes (up to 12 months)
• Best practices (20-30) and 50 exploratory
  metrics

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How To Read A SCOAP Report
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Surgical Care and Outcomes Assessment Program

• Conducts statewide campaigns aimedat practice
  change
• Preop nutritional interventions
• Glycemic control
• Checklist
• Lymph node sampling for colorectal cancer
• Accurate interpretation of imaging for
  appendicitis

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BeforeElective Colorectal Resection, CHARS
2000-2003
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After Elective Colorectal Resection CHARS
2006-2009
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Re-operative ComplicationsElective Colon/Rectal
Resections
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Why the Improvement?Testing Low Rectal
Anastomoses for Leak
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Reducing Unnecessary Appendectomy
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Improving the Use of Dx Imaging Use of US/CT in
Women with Suspected Appendicitis
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Improves SCIP Performance
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SCOAP Glycemic Metrics

• Glucose checked periop (pre-op to recovery)
• Insulin started
• POD 1
• POD 2
• Lowest blood sugar

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Avoiding Hypoglycemia
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SCOAP Data on Perioperative Glucose Levels and
Insulin Use

• 11630 patients from 2005-2010 with
• Bariatric operation (5360)
• Colectomy (6273)
• Who either
• Experienced hyperglycemia glucose gt 180 (3383)
• Or did not (8247)
• During the perioperative period or onPOD 1 or
  POD 2

Kwon. Ann Surg. 2013 257 8-14
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SCOAP Data on Perioperative Glucose Levels and
Insulin Use

• Diabetic pts 4098 (35)
• Hyperglycemic 2369 (58)
• Nondiabetic pts 7532 (65)
• Hyperglycemic 1014 (13)
• 30 of all hyperglycemic patients were not
  diabetic!

Kwon. Ann Surg. 2013 257 8-14
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Composite InfectionHyperglycemia vs No
HyperglycemiaAll Patients
All plt0.01
Kwon. Ann Surg. 2013 257 8-14
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Composite InfectionHyperglycemia vs No
HyperglycemiaDiabetic Patients

plt0.05 plt0.01
Kwon. Ann Surg. 2013 257 8-14
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Composite InfectionHyperglycemia vs No
HyperglycemiaNondiabetic Patients
All plt0.01
Kwon. Ann Surg. 2013 257 8-14
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Composite Infection in Hyperglycemic Patients
With and Without Use of Insulin
Kwon. Ann Surg. 2013 257 8-14
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Operative Reintervention in Hyperglycemic
Patients With and Without Use of Insulin
Kwon. Ann Surg. 2013 257 8-14
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Mortality in Hyperglycemic Patients With and
Without Use of Insulin
Kwon. Ann Surg. 2013 257 8-14
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SCOAP Data on Perioperative Hyperglycemia - Odds
RatiosMultivariate regressions accounting for

• Age
• Sex
• Charlsons comorbidity
• BMI
• Smoking
• Immunosuppression

• Preop antibiotics
• Cancer
• Year
• Surgical Procedure
• Diabetes

SCOAP data courtesy of Sung (Steve) Kwon
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SCOAP Data on Perioperative Hyperglycemia - Odds
RatiosMultivariate regressions

• Death 2.71 (1.724.28)
• Operative intervention 1.80 (1.41-2.30)
• Anastomotic leak 2.43 (1.38-4.28)
• Composite infection 2.00 (1.63-2.44)

SCOAP data courtesy of Sung (Steve) Kwon
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UWMC Glucose Values, 1999 - 2005
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NSQIP Moves to the Private Sector in 2004

• Ann Surg. 2008 Aug 248(2) 329-36.

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Medicare National Coverage Decision for Bariatric
Surgery February 2006

• UWMC cancels 30 scheduled cases
• UWMC completes its planned BSCN certification and
  joins NSQIP
• We get introduced to the infectious enthusiasm of
  a NSQIP meeting

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The Power ofCollaborative Groups ofClinicians
Working Togetherto Achieve High-Quality
Effective Surgical Care for Patients Colorectal
Surgery as an Example
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Literature Search on NSQIP and Colorectal
50 references from 2002 to 2012

• SSI risk 4
• Procedure specific 1
• Lap v. Open 8
• Mortality risk 4
• Indications 7
• UTI risk 1
• VTE risk 2

• Elderly 4
• QI opportunities 5
• Risk calculations 8
• Length of stay 2
• Resident education 2
• Obesity 1
• Anemia/transfusion 2

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Using NSQIP to Demonstrate Improved Outcomes in
Colorectal Surgery
p0.041
Berenguer. Improving SSI Using NSQIP Data. JACS
2010210 737-43
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Multiinstitutional Collaboratives Linked to NSQIP
Focusing on Improving Colorectal Outcomes

• Michigan Surgical Quality Collaborative (MSQC) -
  Colectomy Best Practices Project
• Joint Commission Center for Transforming
  Healthcare - Colorectal Surgical Site Infection
  Collaborative underway initial results
  presented at national NSQIP meeting 2012
• TNACS/TNSQC just getting started
• SUSP/Johns Hopkins/Armstrong Institute/NSQIP

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Bowel Preparation Prior to Elective Colectomy in
Michigan (n1648) Overall SSI Rate in Michigan is
8.0
All patients Get I.V. antibiotics
Englesbe. Ann Surg 2010252 514520
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Surgical Site Infection Rates following Elective
Colectomy The Michigan Surgical Quality
Collaborative
All patients Get I.V. antibiotics
n195
Propensity Matched Analysis(n740)
Englesbe. Ann Surg 2010252 514520
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Oral Antibiotics with a Bowel Preparation A
Propensity Matched Analysis (n740)
All patients Get I.V. antibiotics


Percent of patients

P lt 0.05
Englesbe. Ann Surg 2010252 514520
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Oral Antibiotics with a Bowel Preparation A
Propensity Matched Analysis (n740)
All patients Get I.V. antibiotics
P lt 0.05
Percent of patients
Englesbe. Ann Surg 2010252 514520
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Krapohl, G.L., Bowel preparation for colectomy
and risk of Clostridium difficile infection.Dis
Col Rectum, 2011. 54810-7

• C. diff No C. diff
• No prep (n578) 2.4 97.6
• Prep (n1685) 2.4 97.6
• No Ab (n1001) 2.9 97.1
• Oral Ab (n684) 1.6 98.4
• p0.09

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MSQC/NSQIP Colorectal ProjectProphylactic
Antibiotic Use

• Scheduled Emergency
• (2743) (248)
• SCIP compliant 84 52
• Within 1 hr 93 64
• ------------------------------------------------
  --------------------------
• Weight adjusted dosing (922) 57
• Redosed when indicated (398) 6

Hendren. Am J Surg 2011 201 290-4
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MSQC/NSQIP Colorectal Project

• 2008 2009
• (1387) (1592)
• Ab given 99.8 100
• Within 1 hr 79 93
• SSI 9.4 7.4
• p0.062

Hendren. Am J Surg 2011 201 290-4
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Oral Antibiotics Without Bowel Prep?

• VASQIP, 9940 patients, 112 hospitals
• Incidence SSI
• Bowel prep, no oral Ab 39 20
• No prep at all, no oral Ab 20 18
• Bowel prep oral Ab 34 9
• No prep oral Ab 7 8

Cannon. Dis Col Rectum 2012 55 1160-6
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Oral Antibiotics for Colorectal Operations
Cannon. Dis Col Rectum 2012 55 1160-6
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Bowel Prep Oral AntibioticsVASQIP Data 8180
patients

• Oral antibiotic bowel prep 44
• Mechanical prep alone 39
• No prep at all 17

Hawn. So Surgical Assoc. Palm Beach, FL, 12 Dec
2012
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Bowel Prep Oral AntibioticsVASQIP Data
Hawn. So Surgical Assoc. Palm Beach, FL, 12 Dec
2012
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Bowel Prep Oral AntibioticsVASQIP Data
Hawn. So Surgical Assoc. Palm Beach, FL, 12 Dec
2012
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Antibiotic Choice SSI After Colectomy
Adjuste Odds Ratios
Clinda/Gent
Cipro/Metronid
Cefaz/Metronid
Amp/Sulbact
Ertapenem
Cefazolin
Cefoxitin
Cefotetan
Hendren. Ann Surg 2013257.469
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Surgical Unit-based Safety Program (SUSP)

• Funded by AHRQ
• Sponsored by Johns Hopkins and ACS/NSQIP
• Based on teamwork and the wisdom of the frontline
  staff
• Focused on Colorectal SSI
• Presented in detail at national NSQIP mtg
• All NSQIP hospitals eligible to participate

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Surgical Unit-based Safety Program (SUSP)

• Experience with joining national projects
  previously to kick start a local QI effort and
  realization of the critical importance of
  interdisciplinary teamwork has led us to join
  this important national effort to reduce SSI and
  other postoperative complications, led by Johns
  Hopkins and ACS and funded by AHRQ.

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Normothermia Project Johns Hopkins

• Interventions

• Confirmed that temperature probes were accurate
  (trial comparing foley and esophageal sensors)
• Initiated forced air warming in the pre-operative
  area
• Heightened awareness

• Wick. J Am Coll Surg. 2012 215 193-200

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JHU Colorectal CUSP

• Other changes based on input from frontline
  staff
• Changing instruments after anastomosis
• Weight based dosing for prophylaxis
• Having adequate amounts of antibiotic in the O.R.
• Colorectal specific check list

Wick. J Am Coll Surg. 2012 215 193-200
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JHU Colorectal CUSP
p lt 0.05
Wick. J Am Coll Surg. 2012 215 193-200
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The Effect of Retrospective Review on
Post-Operative Transfusion Rates

• Prior to 2009, UWMC consistently had higher than
  average post-op transfusion rates.
• In 2010, we began a program of regular reporting
  and discussion of post-op transfusion at weekly
  MM conference.
• Here is what has happened since

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Year UWMC Transfusion Rate NSQIP Transfusion Rate UWMC CR Transfusion Rate NSQIP CR Transfusion Rate
2007 6.2 4.2 16.4 11.4
2008 6.3 4.0 18.9 10.6
2009 5.4 3.8 14.8 10.2
2010 3.2 4.5 6.1 12.0
2011 4.0 5.6 5.4 14.8
2012 3.0 4.9 6.9 13.5
43 decrease for all GS cases (95CI 42.5-43.5,
plt0.001) 63 decrease for colorectal cases
(95CI 61-65, plt0.001)
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Year UWMC SCOAP Transfusion Free Rate SCOAP Benchmark Transfusion Free Rate Transfusions with Low Hgb ( 7)
2009 79.9 99.2 NA
2010 86.3 98.5 38.1
2011 87.8 97.8 70
More transfusions with associated low Hgb We are
still not a top-performer among SCOAP hospitals
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Take Aways

• Review and discussion changes practice.
• We didnt just give less transfusions, we gave
  fewer transfusions that were not evidence-based.
• We minimized our patients exposure to
  transfusion-associated risks!
• We are better stewards of a scarce resource.
• We decreased costs.
• We still have room for improvement.

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Final Thoughts

• A surgeon (champion) cant do quality alone.
• Others cant do surgical quality without surgeon
  involvement and commitment.
• Without interdisciplinary teamwork no one can do
  quality.
• Without good data (NSQIP/SCOAP) you dont know
  what you need to work on or if your are
  succeeding.
• Those on the front line have a unique
  perspective.
• The job never stops.

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Slides Gladly Sharedon Request

• patch_at_uw.edu