General Session: Introduction to the ACS NSQIP Online Reports

Max R. Langham Jr., Tim Boswell, Robert Beck, Khadijai Momoh, Maris Brown, Kim Giles, Sandy Grimes, Donna Vickery, James W. Eubanks, Alex Feliz, Elizabeth Paton, Paul Klimo, Eunice Huang, Regan Williams

The LeBonheur Children’s Hospital NSQIP-Peds Work Group:

Disclosures

• Max R. Langham Jr. • Tim Boswell • Robert Beck • Khadijai Momoh • Maris Brown • Kim Giles • Sandy Grimes • Donna Vickery

• James W. Eubanks • Alex Feliz • Elizabeth Paton • Paul Klimo • Eunice Huang • Regan Williams

The following contributors to the content of this talk have no relevant financial relationships with commercial interests to disclose:

Context: NSQIP

• Outcomes-based • Data-driven • Risk-adjusted Goal: Empower surgeons and medical centers to reliably report their outcomes, improve care and lower costs. LeBonheur Children’s Hospital became a beta test site for NSQIP-Pediatrics in 2010.

Compare surgical deaths reported to NSQIP with all surgical deaths at Le Bonheur Children's Hospital • How does this inform our QA projects? • How do we figure out important buckets

for our children’s hospital?

Objective

Setting: Le Bonheur Children’s Hospital

• Free standing 255 bed children’s hospital in Memphis, Tennessee, USA

• 16 operating rooms, ACS Level 1 trauma center • Highest surgical volume of pediatric brain tumor cases

nationwide • Notable neighbors: St. Jude, Semmes-Murphy, Campbell

Clinic

• Neurology and Neurosurgery • Nephrology • Cardiology and Heart Surgery • Urology • Pulmonology

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CPT codes in decreasing frequency

NSQIP Sample 2010-2012: Case type by Frequency with Sum of cases

• 471 different CPT codes • 20 CPT codes contain 50% of all operations

Whisker plots

Whisker plots

Whisker plots

Whisker plots

Study Design

Prospective observational study Main outcome measure: death occurring during the hospital stay in which an operation was performed • NSQIP-Peds 30 day follow up 94.8% • Non NSQIP-Peds sample pulled from administrative extraction from Cerner • No post discharge follow up performed on non NSQIP-Peds patients • Measure is in hospital mortality for both groups

Results: Operative Volume

• 30,383 operative cases in 24,683 patients between 1/1/2010 and 12/31/2012 – 123 deaths identified (0.4%;0.5%)

• 3697 operative cases (12%) in 3,498 patients(15%) included in the NSQIP sample – 20 deaths identified (0.5%;0.6%) – 2 of these deaths occurred after discharge

Service Single operation Multiple operations

Total

General Surgery 36 14 50

CT Surgery 19 12 31

Neurosurgery 14 1 15

ENT 7 2 9

Ortho 1 0 1

Multiple services 0 17 17

Results: Primary surgical service

Results: Comparison of two samples “Mortality Buckets”

Operation NSQIP All Cases

Laparotomy for NEC 8* 23

Craniotomy for tumor/AVM 4* 4

VP shunts 3* 5

RDS/ECMO/FB 1 19*

CDH 1 6

Congenital Heart 32*

Craniotomy trauma 7*

Extracranial trauma 5*

Other 3 22

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Month-Year of Death

NSQIP vs. Le Bonheur Pediatric Mortality, by Month-Year 2010-2012 NSQIP Le Bonheur

Year NSQIP Le Bonheur

2010 3 42

2011 8 33

2012 9 48

Privileged & Confidential T.C.A 68-11-272

Conclusions:

Mortality is uncommon within 30 days of surgery in children Mortality rates were similar between the NSQIP-Peds sample and all in hospital deaths NSQIP-Peds by design misses some types of deaths, and oversamples other causes

Two exemplary outcomes: All Surgeries/All Patients Morbidity Neurosurgery Morbidity As expected outcomes: All others Needs improvement: None

Semi-annual Report 2012

Our QI Goals:

Necrotizing enterocolitis

Goal: Establish a regional NEC collaborative to improve prevention, early recognition, and rapid transport to Le Bonheur Children’s Hospital

Our QI Goals:

• Focus on neonatal cause of death

Respiratory Neurologic

Goal: Improve Neonatal Respiratory Support

Goal: Improve understanding of Neurosurgical deaths