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

Or

How I Got Involved

With NSQIP and What

I Think I’ve Learned

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

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

Initial Focus of SCOAP• Colorectal Surgery• Bariatric Surgery• Appendectomy

Quarterly feedback • Outcomes• process measures

Have now added• Gastrectomies• Pediatric Surgery• Vascular Interventions• Spine Surgery

Surgical Care and Outcomes Assessment

Program

•Voluntary, grassroots clinician collaborative in WA•Surveillance, benchmarking, practice change

interventions

•58 hospitals (~95%)-rural and urban

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

How To Read A SCOAP Report

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

BeforeElective Colorectal Resection, CHARS 2000-2003

17.7±38.2%

After Elective Colorectal Resection CHARS 2006-2009

9.6±29.4%

Re-operative Complications

Elective Colon/Rectal Resections

Why the Improvement?Testing Low Rectal Anastomoses for

Leak

Reducing Unnecessary Appendectomy

Improving the Use of Dx Imaging

Use of US/CT in Women with Suspected Appendicitis

Improves SCIP Performance

SCOAP Glycemic Metrics

• Glucose checked periop (pre-op to recovery)

• Insulin started• POD 1• POD 2• Lowest blood sugar

Avoiding Hypoglycemia

SCOAP Data on Perioperative Glucose Levels and Insulin Use

11630 patients from 2005-2010 withBariatric operation (5360)

Colectomy (6273)

Who eitherExperienced hyperglycemia [glucose > 180] (3383)

Or did not (8247)

During the perioperative period or onPOD 1 or POD 2

Kwon. Ann Surg. 2013; 257: 8-14

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

Composite InfectionHyperglycemia vs No Hyperglycemia

All Patients

02468

10121416

All Pts Bariatric Colectomy

Normal

Gluc>180

All p<0.01

Kwon. Ann Surg. 2013; 257: 8-14

Composite InfectionHyperglycemia vs No Hyperglycemia

Diabetic Patients

0

2

4

6

8

10

12

14

Both Ops Bariatric Colectomy

Normal

Gluc>180**

* p<0.05** p<0.01

*

Kwon. Ann Surg. 2013; 257: 8-14

Composite InfectionHyperglycemia vs No Hyperglycemia

Nondiabetic Patients

0

5

10

15

20

All Pts Bariatric Colectomy

Normal

Gluc>180

All p<0.01

Kwon. Ann Surg. 2013; 257: 8-14

Composite Infection in Hyperglycemic Patients With

and Without Use of Insulin

0

0.5

1

1.5

2

2.5

No Insulin Insulin

Odds Ratios

Kwon. Ann Surg. 2013; 257: 8-14

Operative Reintervention in Hyperglycemic Patients With

and Without Use of Insulin

0

0.5

1

1.5

2

2.5

No Insulin Insulin

Odds Ratios

Kwon. Ann Surg. 2013; 257: 8-14

Mortality in Hyperglycemic Patients With and Without Use

of Insulin

00.5

11.5

22.5

33.5

No Insulin Insulin

Odds Ratios

Kwon. Ann Surg. 2013; 257: 8-14

SCOAP Data on Perioperative Hyperglycemia - Odds Ratios

Multivariate regressions accounting for

Age

Sex

Charlson’s comorbidity

BMI

Smoking

Immunosuppression

Preop antibiotics

Cancer

Year

Surgical Procedure

Diabetes

SCOAP data courtesy of Sung (Steve) Kwon

SCOAP Data on Perioperative Hyperglycemia - Odds Ratios

Multivariate regressions

Death 2.71 (1.72–4.28)

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

UWMC Glucose Values, 1999 - 2005

NSQIP Moves to the “Private” Sector in 2004

Ann Surg. 2008 Aug; 248(2): 329-36.

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

The Power of

Collaborative Groups of

Clinicians Working Together

to Achieve High-Quality Effective

Surgical Care for Patients:

Colorectal Surgery as an Example

Literature Search on NSQIP and Colorectal

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

50 references from 2002 to 2012

Using NSQIP to Demonstrate Improved Outcomes in

Colorectal Surgery

Berenguer. Improving SSI Using NSQIP Data. JACS 2010;210: 737-43

*p=0.041

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

Bowel Preparation Prior to Elective Colectomy in Michigan (n=1648)

Overall SSI Rate in Michigan is 8.0%

Englesbe. Ann Surg 2010;252: 514–520

All patientsGet I.V. antibiotics

Surgical Site Infection Rates following Elective Colectomy

The Michigan Surgical Quality Collaborative

Propensity Matched Analysis(n=740)

Englesbe. Ann Surg 2010;252: 514–520

n=195

All patientsGet I.V. antibiotics

0%

5%

10%

15%

DeepIncisional

OrganSpace

SuperficialIncisional

Overall SSI

No Oral Antibiotics

Oral Antibiotics

Per

cent

of

patie

nts

* P < 0.05

*

*

Oral Antibiotics with a Bowel Preparation

A Propensity Matched Analysis (n=740)

*

Englesbe. Ann Surg 2010;252: 514–520

All patientsGet I.V. antibiotics

0%

5%

10%

15%

C.difficile colitis Prolonged Ileus

No Oral Antibiotics

Oral Antibiotics

Pe

rce

nt o

f pa

tient

s

* P < 0.05

Oral Antibiotics with a Bowel Preparation

A Propensity Matched Analysis (n=740)

Englesbe. Ann Surg 2010;252: 514–520

All patientsGet I.V. antibiotics

Krapohl, G.L., Bowel preparation for colectomy and risk of Clostridium difficile

infection.Dis Col Rectum, 2011. 54:810-7

C. diff No C. diff

No prep (n=578) 2.4% 97.6%

Prep (n=1685) 2.4% 97.6%

No Ab (n=1001)* 2.9% 97.1%

Oral Ab (n=684)* 1.6% 98.4%

* p=0.09

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

MSQC/NSQIP Colorectal Project

2008 2009

(1387) (1592)

Ab given 99.8% 100%

Within 1 hr 79% 93%

SSI* 9.4% 7.4% p=0.062

Hendren. Am J Surg 2011; 201: 290-4

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

Oral Antibiotics for Colorectal Operations

Cannon. Dis Col Rectum 2012; 55: 1160-6

Bowel Prep & Oral AntibioticsVASQIP Data – 8180 patients

Hawn. So Surgical Assoc. Palm Beach, FL, 12 Dec 2012

Oral antibiotic bowel prep 44%

Mechanical prep alone 39%

No prep at all 17%

Bowel Prep & Oral AntibioticsVASQIP Data

Hawn. So Surgical Assoc. Palm Beach, FL, 12 Dec 2012

Bowel Prep & Oral AntibioticsVASQIP Data

Hawn. So Surgical Assoc. Palm Beach, FL, 12 Dec 2012

Antibiotic Choice & SSI After Colectomy

Hendren. Ann Surg 2013;257.469

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

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.

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

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

JHU Colorectal CUSP

*p < 0.05 Wick. J Am Coll Surg. 2012; 215: 193-200

The Effect of Retrospective Review on Post-Operative Transfusion RatesPrior 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 M&M conference.

Here is what has happened since…

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 (95%CI 42.5%-43.5%, p=<0.001)

63% decrease for colorectal cases (95%CI 61-65%, p=<0.001)

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

Take AwaysReview and discussion changes practice.We didn’t just give less transfusions, we gave

fewer transfusions that were not evidence-based.

We minimized our patient’s exposure to transfusion-associated risks!

We are better stewards of a scarce resource.We decreased costs.We still have room for improvement.

Final Thoughts• A surgeon (champion) can’t do “quality” alone.

• Others can’t do surgical quality without surgeon involvement and commitment.

• Without interdisciplinary teamwork no one can do quality.

• Without good data (NSQIP/SCOAP) you don’t 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.

Slides Gladly Sharedon Request

patch@uw.edu