AMERICAN COLLEGE OF SURGEONS National Surgical Quality Improvement Program

Barbara J. Martin RN MBA CCRNSherree Levering RN

Oscar D. Guillamondegui MD MPH FACS

Local, State, and National Initiatives

National Surgical Quality Improvement Program

• Objective: Describe components of National Surgical Quality Improvement Program (NSQIP)

• In order to receive full contact-hour credit for the CNE activity, you must– Be present no later than five (5) minutes after starting time– Remain until the scheduled ending time– Complete /submit Evaluation form before leaving at the conclusion

• Conflict of Interest: None • Commercial Support: None.• Non-Endorsement of Products: None

– Accredited status does not imply endorsement by Vanderbilt Medical Center, TNA or ANCC of any products that might be displayed in conjunction with this program.

• Off-label Product Use: N/A • Accreditation Statement

– Vanderbilt University Medical Center, Department of Nursing Education and Professional Development is an approved provider of continuing nursing education by the Tennessee Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.

• 1.0 Contact Hour

National Surgical Quality Improvement Program

• Initially developed by the VA to risk-adjust outcomes in response to public concerns

• American College of Surgeons expanded the program to the private sector in 2004

• Currently 408 hospitals enrolled– Community / Private / Academic– Half have fewer than 500 beds; program is

expanding options to include smaller facilities

ACS NSQIP

• Validated, clinically-based data collection• Collects and analyzes clinical outcomes data• Measures quality of systems of care• Quantifies 30-day risk-adjusted surgical

outcomes, including morbidities and mortality• Blinded comparison with national performance• Currently working with CMS to develop

outcomes measures for surgical procedures

We Give NSQIP . . .

• 40 cases every 8 days (minimum 1680 / year)– Random sampling General and Vascular Surgery – Targeted procedure selection: 100% capture

• Colectomy• Proctectomy• Ventral Hernia Repair

– Inpatient and outpatient procedures• Selected by service and CPT code• Age > 17• Trauma / Transplant excluded during that admission

Data Collection• Manual chart review and abstraction• Strict definition of abstracted elements• 150 variables

– Demographics, preoperative factors and labs• Medical and surgical history• Acute and chronic clinical risk factors

– Intraoperative events– Postoperative occurrences, discharge data

• Infectious complications—surgical site, urinary, pneumonia• Technical occurrences—graft failure, bleeding• Other events—reintubation, renal failure, cardiac arrest

Preoperative Risk Factors

• BMI• Smoking• Diabetes• CHF Exacerbation• Ascites• COPD• Weight loss• Functional Status

• Surgery within 30 days• Open wounds• Sepsis / Septic shock• Impaired Sensorium• Acute Renal Failure • Dialysis• Preoperative Steroids• Blood transfusions

• Infectious complications: Surgical Site Infection, UTI, Sepsis

• Respiratory Occurrences: Pneumonia, Unplanned Intubation, On vent > 48 hours

• Cardiac Occurrences: MI, cardiac arrest• Renal Failure• Stroke• Peripheral nerve injury

Postoperative Occurrences

Abstraction Requirements

• All patients are followed for 30 days after surgery • Surveillance definitions are not the same as

clinical definitions• The abstractor’s clinical judgment is valuable, but

not always assignable• All elements of the definitions must be met for

preop risk and postop occurrence– Do the findings meet the purpose of the definition?– Do they meet the letter of the definition?

A Note about Clinical Abstraction

Elements may be consistently “findable”. . .

Or not . . .

SIRS, Sepsis, Septic Shock

• Systemic Inflammatory Response Syndrome: presence of two or more of the following: – Temp >38 C or < 36 C– HR > 90 bpm – RR >20 /min or PaCO2 <32 mmHg – WBC >12,000 , <4000, >10% bands – Anion gap acidosis

• Sepsis– Two of the above AND purulence or positive culture

• Septic Shock– All the above AND evidence of organ dysfunction

SIRS? Sepsis? Septic Shock?

• 72 year old male presents to the ED in distress with severe chest / epigastric / flank pain

• VS T 36.4 BP 118/74 HR 110 RR 24 • PMH Coronary artery disease, insulin

dependent diabetes mellitus, chronic pyelonephritis

• Loses consciousness BP 80/40 HR 116• Taken to CT scan

Septic Shock?

Shock? Yes Septic? NO

30 Day Follow Up

• Many patients are seen in clinic at 30+ days• Minor operations (appendectomy, hernia

repair) may not be seen after two weeks.• If no documentation in StarPanel, patients are

contacted via telephone. No less than three attempts are made.

• Vanderbilt’s fully integrated medical record improves follow-up rates on pateints with and without postoperative occurrences.

NSQIP Gives Us . . .

• Risk-adjusted surgical morbidity and mortality• Semiannual Observed /Expected Ratio reports• Interim reports: ongoing monitoring,

comparison with internal and external peer groups

• Internal data analysis: access to institutional data for report development, integration with other data sets

Semiannual Report

• Reports 12 months of data, with risk adjusted outcomes

• 39 Risk Adjustment Models– Mortality– Overall Morbidity– Cardiac Occurrences– Respiratory Occurrences– Surgical Site Infection– Colon surgery LOS

• Observed / Expected Ratios for each model

Mortality and Morbidity O/E Ratios

• Observed / Expected Outcomes– An O/E of 1 indicates the outcomes were the same as

expected• Less than 1 indicates better than expected • Greater than 1 indicates worse than expected

– High outliers have confidence intervals greater than 1– Low outliers have confidence intervals less than 1

Sample Hospital O/E Report

SAMPLE

High outlier

Low outlier

Risk Factors determine the “Expected”Case

NumberMort

Probability

004377 0.2352%

004378 1.0114%

004379 53.8254%

004380 12.7381%

004381 0.0477%

004382 3.7919%

004383 0.0975%

Occurrences determine the “Observed”

Occurrences by Inpatient vs Post D/C

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

196 10 19 41 45 77 92

SSI PULMONARY EMBOLISM

DVT REQUIRING THERAPY

URINARY TRACT INFECTION

UNPLANNED INTUBATION

PNEUMONIA ON VENTILATOR > 48 HOURS

Pre-discharge

Prior to discharge

•January 1 – December 31, 2010• 258 hospitals• ~375,000 cases

•Vanderbilt: 1,560 cases•1,393 General surgery cases

•168 Colon and rectal surgery (all services)•167 Vascular surgery cases

Semiannual Report StatisticsJuly 2011

Cases by Service

Onc/Endo26%

GI / Lap23%EGS

22%

CRS14%

Vascular11%

Hepatobiliary4%

Procedure Distribution

breast

thyroid

colecto

mych

ole gbp vhr

ex lap

parath

ing herniaappe

hepaticpanc sb

rfundo

cea

closu

re ent

debride /

I&D

proct

gastric

band0

20

40

60

80

100

120

140

160

Risk Adjustment Models

Morbidity• CPT Risk

• ASA Class

• SIRS / Sepsis / Shock

• Inpatient / Outpatient

• Functional Status

• Preop Albumin

• Surgical Specialty

• COPD

• BMI

• Creatinine

• Vent dependence

Mortality• Functional Status

• ASA Class

• CPT Risk

• Age

• SIRS / Sepsis / Shock

• Disseminated Cancer

• SGOT > 40

• Albumin

• Emergency

• Creatinine > 1.2

• Platelets < 150

SSI CPT Risk BMI Inpatient Status Wound Class Current Smoker ASA Class Bilirumin > 1 Steroid Use Work RVU Transfer Status Surgical Specialty

Data Analysis

Onc/Endo27%

GI / Lap25%

EGS17%

Vascular13%

CRS13%

Hepatobiliary5%

VUMC Initiatives • VPEC

– Assessment and documentation of risk elements including smoking history, functional status

• Bariatric Surgery– Early foley discontinuation– Incentive spirometry education and postop monitoring

• Vascular Surgery– Pulmonary assessment pre / postop

• Emergency General Surgery– Documentation of emergent status

Current VUMC Initiatives

• Colorectal surgery – Clinical analysis of NHSN-identified infections with

NSQIP variables

– Evaluation of NHSN / NSQIP case selection variation

• Vascular Surgery analysis of postop respiratory failure and pneumonia

• ICU Database multicenter project

• NSQIP PARS analysis: evaluating correlation between clinical outcomes and provider complaints

NSQIP, NHSN, and Administrative Data• NHSN

– SSI surveillance based on ICD-9, otherwise very little difference– HAI surveillance primarily inpatient

• Device associated infections initially monitored in the critical care setting• Currently monitoring CLABSI in general care; CAUTI soon

• Administrative data (UHC)– Based on provider documentation, coding data’s primary purpose initally

was reimbursement. – Only the index hospitalization is captured.

• NSQIP – Like NHSN, abstraction is from clinical documentation, based on strict

definitions– Follows all patients for 30 days—inpatient, outpatient, discharged– No device associated infection designation

NSQIP UHC

Participants 400 + HospitalsAbout half are academic

369 hospitals114 academic / 255 affiliates

Risk Adjustment Clinical risk factors as documented in medical record

APR-DRG based on coding, other administrative data

Outcomes (Mortality)

30 days post-op Inpatient hospitalization

Service designation

Surgical service for included procedure

Discharge / Major Service

Inclusion By procedure Inpatient / Outpatient

All hospital discharges by attending serviceInpatient only (Outpatient data is now being submitted)

Comparison data

Blinded risk-adjusted data Comparison with peer hospitals

Tennessee Surgical Quality Collaborative

Tennessee Chapter

of American College of Surgeons

Blue Cross Blue

Shield of Tennesse

eTennessee Center for

Patient Safety(THA)

Tennessee

Hospitals

Tennessee Surgical Quality Collaborative

• A consortium of surgeons and hospitals committed to evaluate and improve surgical care by surgeons in the state of Tennessee

• 10 member hospitals with active engagement of surgeon champions, nurse reviewers, and administrators.– Learn from high performers– Develop best-practice recommendations– Identify system variables influencing clinical performance– Non-competitive environment for shared learning

TSQC Mission and Vision

Mission• To improve the care of the surgical patient by

supporting an open discussion and transfer of information through a collaborative team effort.

Vision• To identify best surgical practices, examine how the

surgical team obtains best outcomes and teach other surgical teams how to improve outcomes.

TSQC Development

2007 Partnership model proposed to

Blue Cross

2008 3 year grant awarded to TSQC

2009 Hospitals enrolled, training and

abstraction in progress

July 2010 First O/EJanuary 2011 Draft

Action Plan for Statewide Initiatives

April 2011 AHA NPSF Fellowship

September 2011 Grant Renewal application

submitted

October 2011 Eleven additional hospitals submit applications

21 TSQC Hospitals?

Grant Overview

• 3 year grant May 2008- May 2011• Initial grant to support of 8 hospitals; BCBS

increased funding to support 10 hospitals / surgeon champions

• THA’s TN Center for Patient Safety serves as coordinating center for the collaborative

• Initial grant period extended to October 2011; renewal application has been submitted

Pre-Op Risk Factors*Comparative Data Analysis

VUMC TSQC NSQIPDiabetes:

Insulin 9.8% 9.3% 5.4%Non-Insulin 14.5% 15.4% 7.6%

Dialysis 2.6% 2.8% 1.9%Smoked in last yr 25.3% 28.5% 20.6%COPD 5.6% 8.0% 4.9%Functional Status

Dependent 4.4% 3.5% 1.9%Hypertension 57.3% 60.2% 46.4%

*Not actual data

30 Day Mortality and Post – Op Occurrences*Comparing Tennessee Outcomes to National Performance

ONLY CONFIRMED 30-DAY FOLLOW-UP CASESTSQC NSQIP

Total Number of Cases 10,635 211,930

Outcome

Cases Alive at 30 Days 10,433 98.2% 208,243 98.2%Cases Dead Within 30 Days 191 1.8% 3,687 1.8%

Postop Occurrences

Superficial SSI 240 2.3% 5,206 2.5%

Deep SSI 52 0.50% 833 0.4%

Organ Space SSI 219 2.1% 5,414 2.6%

Wound Disruption 31 0.3% 1,458 0.7%

Pneumonia 198 1.9% 5,206 2.5%

Urinary Tract Infection 209 2.0% 7,289 3.5%

Severe Sepsis 94 0.9% 2,499 1.2%

Mean # of Occurrences 0.2 (+ 0.7) 0.2 (+ 0.7)

*Not actual data

TSQC Members Comparison

Hospital A

Hospital B

Hospital C

Hospital D

Hospital E

Hospital F

Hospital G

Hospital H

Hospital I

Hospital J

0

2

4

6

8

10

12

SSIPneumoniaMortality

*Not actual data

Key Successes: 2009 -2010• Acute Renal Failure –

– Collaborative-wide improvement– Seven of 10 sites showed improvement; one site significantly improved

• Graft/Prosthesis Flap Failure– Collaborative-wide improvement– Eight sites improved; one significantly.

• On Ventilator > 48 hours– Collaborative-wide improvement

• Superficial Incisional SSI– Collaborative-wide improvement– Thirteen procedure groups improved while hernia repair showed significant improvement.– Seven sites improved; one significantly

• Wound Disruption– Collaborative-wide improvement.– Eight sites improved; two significantly.

• Financial Model Shows Positive Results

TSQC Opportunities

• Surgical Site Infections As the First Focus– Colorectal surgery bundle– Evaluation and implementation in 10 hospitals

• Rationale:– High Volume occurrence in TSQC data– 9 of 10 SCNRs identified SSI as opportunity – Aligns with hospital current focus on SSI via CMS

SCIP public reporting– Business case – Length of Stay and Costs significant

TSQC Member Hospitals

NSQIP Hospitals

TSQC Member Hospitals

Future NSQIP hospitals?

NSQIP Hospitals

NSQIP and the Nation

• The Centers for Medicare and Medicaid Services (CMS) is considering five measures from ACS NSQIP for national implementation

• NSQIP – based programs– Bariatric Surgery Center Network– NSQIP-Pediatric– Trauma Quality Improvement Program

• ACS Goal: 1000 member hospitals by 2012

NSQIP Innovations

• 2011 Additional Options– Small and Rural: hospitals with < 1680 cases / year– Essentials: smaller data set– Procedure Targeted: 100% of specific cases– Classic: allows additional variables for research

• Florida Surgical Care Initiative• 2012 Updates

– Procedure targeted variables

Special thanks to

Sherree LeveringOscar Guillamondegui

Naji AbumradChris Clarke Senior VP Tennessee Hospital Association

Joe Cofer Erlanger Medical CenterTSQC Leadership Committee and Membership

TN Chapter American College of SurgeonsBlue Cross - Blue Shield of Tennessee

Tennessee Hospital Association / Tennessee Center for Patient Safety