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NSQIP-P Data Driven Improvement Initiatives in Pediatric Surgery

Keith T. Oldham, MDProfessor and Chief

Division of Pediatric SurgeryMedical College of Wisconsin

Marie Z. UihleinChair and Surgeon-in-Chief

Clinical Vice President of SurgeryChildren’s Hospital of Wisconsin

ACS NSQIP National Conference Salt Lake City, Utah July 21 – 24, 2012

Yvonne (Bonnie ) Anderson, RN, MS, CPNPSurgical Clinical ReviewerNational Outcomes Center

Children's Hospital of Wisconsin

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I have no relevant financial relationships with the manufacturer(s) or any commercial product(s) and/or

provider of commercial products or services discussed in this CME activity

I do not intend to discuss unapproved/investigative use of commercial product (s)/device (s)

in my presentation

.

Objective:

Explore potential for local institutional use of ACS-NSQIP-P data

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Presentation Overview

Understand NSQIP-P data and reports, to enhance quality improvement initiatives

Review NSQIP-P occurrence (morbidity) data for trends and opportunities to further investigate improvement at the local and national level

Discuss impact of NSQIP-P Data on Patient Care

Collaboratives and future initiatives

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Objectives

At the end of this session, participants will be able to assess NSQIP-P data reports for trends and perform further data analysis

At the end of this session, participants will be able to identify areas unique to their institutions to develop quality improvement initiatives

At the end of this session, participants will begin to develop plans to participate in collaboratives within the NSQIP-P

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Quality/Outcomes in Pediatric Surgery Administrative efforts…process measures/cost

Federal & State governments Insurers Hospitals(CHCA,NACHRI, N.A.C.H) Joint Commission Industry, labor unions, others

Physician led efforts…medical, patient centered American College of Surgeons(NSQIP,COT) American Pediatric Surgical Association Specialty societies

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‘91

2011 PediatricPhase 2 ends

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ACS NSQIP-P

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Background

In October of 2008, Phase 1 of the ACS NSQIP Pediatric was launched at four tertiary children’s hospitals

Yale New Haven Children’s Hospital

A.I. DuPont Hospital for Children

Children’s Hospital of Wisconsin

Children’s Hospital Colorado

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Results Phase One Data October 2008 to December 2009, 7287 cases Demonstrated an overall mortality rate of 0.3% and a postoperative

occurrence rate of 3.9% Occurrence rates by site range from 3.1% to 5.6% Average sample 17.5% of children’s surgical population Audit Phase 1, data 1.9% disagreement (goal <5.0%) > 95% completeness of data at variable level 87% of patients had full 30-day follow-up Represented a variety of children’s surgery specialties Variability in outcomes was demonstrated across participating sites Supports the potential of the ACS NSQIP Pediatric to identify quality

improvement targets

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ACS NSQIP Pediatric “Beta” phase of the program

One year of data collection completed on 12/31/2010 37,141 patient records from 30 institutions 1644 total CPT codes entered of which 456 accounted for 90%

of the cases

Pediatric Data 10/2008 to Present 106,490 patient records from 47 institutions• CPT codes limited July 2011 491 codes entered of which 160

accounted for for 90% of the cases• Piloting of ACS NSQIP Pediatric ENT Demonstration Project

April 2012 Total 42 CPT Codes

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NSQIP-P The Process

Electronic DataOutcome Sciences

ACS Provides Sites with

Annual ReportsSupport

Performance Process

Improvement

Data to ACSRisk adjustment

Statistical analysis

SCR 30 dayData Collection

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Background

• National Quality Forum• Institute of Medicine • Joint Commission• American Board of Surgery

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Pediatric Databases/RegistryNational Pediatric Databases: 8,100,000 resultsPediatric Surgical Databases: 1,980,000 results

Health Care Cost and Utilization Project (AHRQ) Kids Inpatient Database (KID) Pediatric Health Information System (PHIS) National Database of Nursing Quality Indicators (NDNQI) National Healthcare Safety Network (NHSN) National Research Center (NRC) ORYX Joint Commission NACHRI (National Association Of Children's Hospitals and

of the Related Institutions) NACH National Association of Children's Hospital CHCA (Children's Health Corporation of America)• Case Mix Comparative Data Mix• Quality Measurement System (PQMS)• Quality Transformation Network• Children's Hospital Neonatal Consortium

Trauma – TRISS methodology, Pennsylvania trauma database, NTDB(ACS)

Cardiac Surgery – STS database, others National Cardiovascular Data Registry (NCDR)

• Pediatric Cadiomyopathy• Pediatric Perioperative Cardiac Arrest (POCA)• Prospective Assessment after Pediatric cardiac Ablation

Transplantation – UNOS Scientific Registry of Transplant Recipients (SRTR)

Vermont Oxford Network

VPS

(SPS ) Solutions for Patient Safety

Improve Care Now

Congenital Diaphragmatic Hernia Study Group Registry

Cystic Fibrosis Pediatric Inflammatory Bowel Disease Database Stroke in Infants and Children

Children Oncology Group• Intercontinental Registry for the Treatment of Choriod

Plexus Tumors• International Adrenocortic Tumor Registry Blastoma• Pediatric CML Registry

Juvenile Idiopathic Arthritis Multicenter Registry in Sickle Cell Disease Patients United States Immunodeficiency Network (USIDNET)

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Improving Outcomes Requires Measurement

82%of hospitals decreased complications*

66%of hospitals decreased mortality*

250-500fewer complications per hospital per year*

*Hall BL, et al. “Does Surgical Quality Improve in the American College of Surgeons National Surgical Quality Improvement Program?” Ann Surg. 2009; 250:363-376

Quality: ACS NSQIP - Pediatrics

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Provide reliable and actionable data about a site’s performance

Analyze and interpret results Identify quality improvement opportunities:

• Proactive versus Reactive• Re-engineer workflow – clinical processes of care• Foster and improve internal education• Identify and develop clinical performance

improvement initiatives• Share best practices• Benchmark performance against peers• Conduct research• Re-engineer or eliminate retrospective clinical

databases historically used for quality assurance for The Joint Commission reporting

Pediatric NSQIPPrimary Role – Act on the Data

Assess NSQIP-P DataFocus on:

Occurrences with the highest frequency

Services with the highest occurrences

Specific populations with the highest occurrences

Patients with the highest occurrences

Procedures with the highest occurrences

Every Occurrence is a Patient and a family

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CHW ALL Services Surgical Cases All Services Surgical Cases Comparison HospitalsTotal Cases 1542 37,158Mortality within 30 Days of Surgery 8 (0.5%) 97 (0.3%)

Post Operative Occurrence Rate 6.7% 8.4%Total of Cases with Post‐Op Occurrences 103 3105

Transfusion Intraop/Postop (72h of surgery start time

70 (4.5%) 1682 (4.5%)

Unplanned Intubation 12 (0.8%) 160 (0.4%)Superficial Incisional SSI 12 (0.8%) 449 (1.2%)Urinary Tract Infections 7 (0.5%) 266 (0.7%)Postoperative Systemic Sepsis 5 (0.3%) 223 (0.6%)Wound Disruption 5 (0.3%) 252 (0.7%)Deep Incisional SSI 3 (0.2%) 122 (0.3%)Venous Thrombosis Requiring Therapy 3 (0.2%) 41 (0.1%)Seizure 3 (0.2%) 85 (0.2%)Central‐Line Associated Blood Stream Infection

2 (0.1%) 51 (0.1%)

IVH Grade 1 2 (0.1%) 8 (0.0%)Pneumonia 1 (0.1%) 189 (0.5%)Cardiac Arrest Requiring CPR 1 (0.1%) 46 (0.1%)Organ/Space SSI 1 (0.1%) 189 (0.5%)Nerve Injury 1 (0.0%) 43 (0.1%)Pulmonary Embolism 0 (0.0%) 4 (0.0%)Acute Renal Failure 0 (0.0%) 24 (0.1%)Progressive Renal Insufficiency 0 (0.0%) 19 (0.1%)Coma> 24 hours 0 (0.0%) 3 (0.0%)Cerebral Vascular Accident (CVA) Stroke of Intracranial Hemorrhage

0 (0.0%) 46 (0.1%)

Intraventricular Hemorrhage (IVH) gradeGrade 2 0 (0.0%) 3 (0.0%)Grade 3 0 (0.0%) 1 (0.0%)Grade 4 0 (0.0%) 1 (0.0%)Unknown /Specific grade not documented 0 (0.0%) 5 (0.0%)

Graft/Prosthesis/Flap Failure 0 (0.0%) 21 (0.1%)Sepsis 0 (0.0%) 0 (0.0%)

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Unplanned Intubations Number of Unplanned Intubations

• Surgical Services with most occurrence's of unplanned intubations• Population with most occurrences of Unplanned Intubations

Neonatal Population at Risk • Morbidity (Occurrences) are low in the pediatric surgical populations our highest

number of occurrence were unplanned intubations in the neonatal population• Neonates, defintion changes, with preoperative NSQIP-p risks factors which may

include congenital cardiac disease, congenital malformations, ASA PS class 3-5,Extensive or physiologically-destabilizing surgeries

The need to address the severity grading of occurrences • Not all unplanned intubations are clinically regarded as equal• For example: an unplanned intubation for a cardiac arrest compared to patient

who self extubates

With the low event rate in children • The need to utilize national data to assess if other institutions are seeing the

same occurrence of unplanned intubations To assess the patients who experience unplanned intubations To validate that unplanned intubations are seen in the neonatal surgical

population

Decision to collect all data on the unplanned intubations in the NICU

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Unplanned Intubations An Occurrence Equals a Patient and Family

First Steps in developing a plan to address the issue of unplanned intubations Utilize the NSQIP-P data to understand the problem exists Involve your Surgeon Champion Find the right people to address the concern

• Surgeons• NICU director• Anesthesia• Nursing Staff• Fellows and Residents• Nurse Practitioner and PA’s• Respiratory Therapists

Administration

Case by case analysis to validate the problem and the specific populations Neonatal Patients

Bring the issue to the attention of the NICU Director Do a root cause analysis

• Type of surgery• Length of surgery• Anesthesia given

Assess the preoperative risk factors of patients• Utilizing NSQIP-P variables

Assess post operative risk factors• Weaning protocol for patients• Pain control• Narcotic use• Infection

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Total Counts and Percentages of NSQIP-P Morbidity (occurrences) by Surgical Service: October 7, 2008 –December 31, 2010

Morbidity (Occurrences)Pediatric Surgery

Pediatric Neurosurgery

Pediatric Orthopedic

SurgeryPediatric Urology Plastics

Pediatric Otolaryngology Orthopedics Total

Unplanned Intubation 24 5 1 1 1 2 0 34

Superficial Incision SSI

Postoperative Systemic Sepsis

Urinary Tract Infection

Deep Incision SSI

Central-Line Associated Bloodstream Infection

Organ/Space SSI

Pneumonia

Wound Disruption

Seizure

Venous Thrombosis requiring Therapy

Grade 1

Nerve Injury

Progressive Renal Insufficiency

Acute Renal Failure

Cardiac Arrest Requiring CPR

Cerebral Vascular Accident (CVA)/Stroke or Intracranial Hemorrhage

Graft/Prosthesis/Flap Failure

Unknown/Specific grade not documented

Total Morbidity (Occurrences) 28

Total Counts of NSQIP-P Morbidity (occurrences) by Surgical Service: January 1, 2010–December 31, 2010



Surgery PlasticsPediatric

Neurosurgery Pediatric Urology Pediatric Otolaryngology Total

Transfusion

Unplanned Intubation 9 0 0 2 1 0 12

Unplanned Intubation Neonates 7 0 0 0 1 0 8



Wound Disruption


Deep Incision SSI

IVH



Pneumonia

Acute Renal Failure


Seizure

Organ/Space SSI

Nerve Injury



Coma > 24 Hours


Pulmonary Embolism

Total Morbidity (Occurrences)29

Total Counts of NSQIP-P Morbidity (occurrences) by Surgical Service: January 1, 2011–December 31, 2011



Surgery PlasticsPediatric

Neurosurgery Pediatric Urology Pediatric Otolaryngology Total

Transfusion

Unplanned Intubation 6 0 0 2 0 0 8

Unplanned Intubation Neonates 2 0 0 1 0 0 3



Wound Disruption


Deep Incision SSI

IVH



Pneumonia

Acute Renal Failure


Seizure

Organ/Space SSI

Nerve Injury



Coma > 24 Hours


Pulmonary Embolism

Total Morbidity (Occurrences)30

Unplanned Intubations - ALL

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Unplanned Intubations – Neonatal

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Unplanned Intubations Next StepsVision/Next Steps Assessment of the Data: on Unplanned Intubations Data reported to the NICU director and potential

improvements were identified Goal to change PracticeKey Requirements Neonatal team committed to collecting further data Data will be collected and reported with continued reporting

of ACS NSQIP data Discussion of unplanned intubation at weekly M&M Movement toward understanding and analyzing trends of

occurrences vs. singular events Identify quality improvement opportunities and

interventions

Benchmark Performance 33

NSQIP ROI CALCULATORhttp://site.acsnsqip.org/about/business-case/roi-calculator/

Complication $ Cost Per Case

Averted Events

QI Revenue

Ventilator >48 hrs 27,654 X 17 = $470,118

UTI 12,828 X 12 = $153,936

Pulmonary Embolism

16,644 X 0=

$ 0

Cardiac Arrest 15,079 X 4 = $60,316

Pneumonia 22,097 X 24 = $530,328

Unplanned Intubation

21,025 X 7=

$147,175

Deep SSI 20,012 X 15 = $300,180

$1,662,05336

Potential Cost Savings if U.S. Hospitals Adopt ACS NSQIP

Reducing preventable complications improves care and reduces costs: Reduction in complications: 250-500* Average cost per complication: $11,626 Average savings per hospital: $2,906,500 - $5,813,000 Potential yearly savings across 4,500 hospitals: $13 - $26

billion Estimated total savings over a decade**: $130 - $260

billion

*Per hospital/per year; Hall BL, et al. “Does Surgical Quality Improve in the American College of Surgeons National Surgical Quality Improvement Program?” Ann Surg. 2009; 250:363-376**Length of time used for health reform calculations

Potential for ACS NSQIP-P ROI CALCULATOR for Pediatrics

Complication $ Cost Per Case

Averted Events

QI Revenue

Unplanned Intubation

Cost X Event = Potential Cost Savings

Pneumonia $ X = $

SSI $ X = $

UTI $ X = $


$ X = $

Deep SSI $ X=

$

Wound Disruption & X = $

$

Cost Savings Pediatrics

Number of complications Cost of complication: $ Potential savings per hospital: $ Examples of real NSQIP-P hospitals

• Hospital X reduced SSIs over 2 years for savings of $• Hospital X reduce Unplanned intubation over 2 years

saving of $• Hospital X reduced LOS for annual savings of $

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Anesthesia Initiative

Data reported to Anesthesia

Concern about reliability of ASA classifications

Further breakdown of NSQIP-P Data

ASA data by CPT and ICD-9 codes provided

Discussed ASA class with other anesthesia staff

Discussed ASA class with surgeons during cases

Next step to collect additional data

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ASA-Adjusted Mortality Rate

Average ASA PS class: 2.3; mortality trend decreasing (as patient severity trend increasing)

48H mortality 30D mortality

0.00

2.00

4.0

06.00

8Ad

just

ed R

ate

2006 2007 2008 2009 2010 2011Year

ASA-Adjusted Mortality Rates

Definition: Number of patients who died within 48 hours or 30 days of anesthesia/Number of anesthesia casesData source: ORMIS/ASPIRE database query 12/7/2011 41

Transfusions Number of Transfusions

• Surgical Services with most occurrence's of transfusions• Population with most occurrences of transfusions

Plastics and Pediatric Orthopedic Population at Risk • Morbidity (Occurrences) are low in the pediatric surgical populations high number of occurrence were

transfusion in the plastics and pediatric orthopedic populations• Patients congenital malformations and Extensive or physiologically-destabilizing surgery

The need to address the severity grading of occurrences • Not all transfusions are clinically regarded as equal• For example: transfusion for craniosysnostosis compared to patient with a spinal fusion

With the low event rate in children • The need to utilize national data to assess if other institutions are seeing the same occurrence of transfusions.

To assess the patients who experience transfusion To validate that transfusions are seen in the plastics and pediatric orthopedic populations

Review transfusion practices with Pediatric Orthopedic and Plastic Surgery Attending and Anesthesiologist

Decision to collect more data on transfusion practices

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SPECIFIC Areas for Quality Initiatives

Reduce unplanned intubations

Validate ASA scores across the institution

Reduce intraoperative and post operative transfusions

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Preoperative Cardiac Risk Assessment for Patients Requiring Non-cardiac Surgery

Determine if child is appropriate for a non-cardiac surgery Identify risk factors for surgery which may be surgery related or

patient related Does the NSQIP-P collect the correct preoperative variables and

correct cardiac variables Collaborate with all NSQIP-P hospitals to analyze data for further

revision of cardiac variables Is the collection of cardiac variables valid and reliable Can the NSQIP-P variables become a standardized tool to

stratify surgery risk for pediatric cardiac patients requiring non-cardiac surgery

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How to Utilize Data for Improvement Assess the surgical complications that would be prevented

Assess the revenue that would be realized from preventing complications

Assess the of patient days that would be available to the institution because we were not caring for Children suffering these increased complications

Sharing of Best Practices

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CollaborativesWorking Together to Improve Surgical Care

“National Surgical Quality Improvement Program (ACS NSQIP®) participating hospitals that come together to discuss best practices, quality improvement initiatives and/or to compare their surgical outcomes in a positive learning environment (ACS, 2012).”

“Discuss surgical outcomes, quality improvement opportunities and experiences with hospitals that share similar interests and concerns (ACS, 2012).”

“Group calls and meetings facilitate the exchange of ideas and problem-solving (ACS, 2012).”

“Enhanced data sharing and specialized reports that go beyond the standard semiannual and online benchmarking reports to compare the results of each collaborating site to the collaborative as a whole, and the collaborative as a whole to all sites nationwide (ACS, 2012).”

“Some collaboratives have partnered with payors to offset the cost of collaboration or provide collaborative coordination (ACS, 2012).”

American College of Surgeions (2012). Collaboratives. Retreived from: http://site.acsnsqip.org/participants/collaboratives/ 47

Current Adult Collaboratives Regional Collaboratives:

Connecticut Surgical Quality Collaborative (nine sites) Florida Surgical Care Initiative (67 sites) Illinois Surgical Quality Improvement Collaborative (10 sites) Nebraska Collaborative (four sites) Oregon NSQIP Consortia (seven sites) Pennsylvania Collaborative (10 sites) Tennessee Surgical Quality Collaborative (21 sites) Upstate New York Surgical Quality Initiative (six sites) Virginia Collaborative (five sites)

System-Wide Collaboratives: Clarian Health System (two sites) Department of Defense/Tricare (16 sites) Fraser Health-Canada (three sites) Kaiser Permanente Northern California (six sites) Kaiser Permanente Southern California (four sites) Mayo Clinic Surgical Quality Collaborative (four sites) Partners HealthCare (five sites)

Virtual Collaboratives: ACS NSQIP Colectomy Collaborative ACS NSQIP Glucose Control Collaborative

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Future Direction The ACS NSQIP Pediatric is an opportunity to advance children’s surgery and measure the

quality of care being delivered to children across the United States and internationally

Provides Risk adjusted clinical surgical data and Annual Data Reports with hierarchal modeling, which has never been available

Risk –adjusted data driven quality improvement initiatives to improve outcomes and reduce complications

Local use of this risk-adjusted data to enable participating hospitals to compare their results to others institutions nationally and begin research

Define specific preoperative variables and procedure outcomes based on CPT Codes

Development of surgical specialty service preoperative and outcome variables

The ability to develop risk adjusted standardized tools to stratify surgical risk

Collaboration of hospitals across the country to develop better quality measures and share Best Practices

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NSQIP- Pediatric Data

Translates into Improved Care

Which makes a difference in the life of a

child

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Thank You

Questions?

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