808H_6_PROV.ppt

Surgical Care Improvement Project

Surgical Care Improvement Project

Mark A. Wilson, MD, PhDVice-President, Surgery

VA Pittsburgh Healthcare System

Mark A. Wilson, MD, PhDVice-President, Surgery

VA Pittsburgh Healthcare System

2

ObjectivesObjectives

• Define goals and organization of SCIP

• Discuss conceptual basis for SCIP elements

• Review performance measures and current data

• Explore the relevance of process measures to quality improvement in surgery

3

What is SCIP?What is SCIP?

• American College of Surgeons• American Hospital Association• American Society of Anesthesiologists• Association of peri-Operative Registered Nurses• Agency for Healthcare Research and Quality• Centers for Medicare & Medicaid Services• Centers for Disease Control and Prevention• Department of Veteran’s Affairs• Institute for Healthcare Improvement• Joint Commission on Accreditation of Healthcare

Organizations

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Why SCIP?Why SCIP?

• 69% of adverse events and deaths in healthcare are related to “errors” and are thus potentially preventable. (IOM)

• 2.6% of ~ 30 million operations in the US -> SSI; significant impact on LOS, finances, etc. http://www.ihi.org/ihi/Topics/PatientSafety/SurgicalSiteInfections/SurgicalSiteInfectionsCaseForImprovement

• 7-8 million operated patients per year with significant cardiac risk factors and at least 1 million cardiac events annually

• Significant risks for perioperative venous thromboembolism

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SCIP GoalSCIP Goal

To reduce preventable surgical morbidity and mortality by 25% by 2010

SCIP constituents believe that Medicare could annually prevent up to 13,027 perioperative deaths and 271,055 surgical complications in major surgical cases by a high level of compliance with evidence-based processes for surgical care.

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Voluntary Reporting Hospitals

0

500

1000

1500

2000

2500

3000

3500

4000

# H

osp

ital

s

2002 2003 2004 2005 2006 2007

Number of Reporting Hospitals

Deficit Reduction Act of 2005

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SCIP ModulesSCIP Modules

Complication prevention groups:

• Surgical infection prevention• Cardiovascular complication prevention• Venous thromboembolism prevention• Respiratory complication prevention

Specifications Manual: http://www.qualitynet.org/dcs/ContentServer?cid=1142976368240&pagename=QnetPublic%2FPage%2FQnetTier3&c=Page

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Surgical Infection PreventionSurgical Infection Prevention

SCIP INF 1: Prophylactic antibiotic received within one hour prior to surgical incision

SCIP INF 2: Prophylactic antibiotic selection for surgical patients

SCIP INF 3: Prophylactic antibiotics discontinued within 24 hours after surgery end time (48 hours for cardiac patients)

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Surgical Infection Prevention - 2Surgical Infection Prevention - 2

SCIP INF 4: Cardiac surgery patients with controlled 6 a.m. postoperative serum glucose

SCIP INF 5: Postoperative wound infection diagnosed during index hospitalization (Outcome)

SCIP INF 6: Surgery patients with appropriate hair removal

SCIP INF 7: Colorectal surgery patients with immediate postoperative normothermia

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RationaleRationale

• Reduction of SSI when tissue levels of antibiotics are appropriate at time of surgery

• No demonstrated benefit to prophylaxis postoperatively, and higher infection rates if antibiotics are continued beyond 24 hours

• Hyperglycemia contributes to SSI risk• Shaving pre-operatively increases SSI• Data to support a reduction of SSI rates

when normothermia is maintained are controversial.

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SCIP 1-3SCIP 1-3

7 case types that are included:• CABG• Other cardiac• Colon surgery• Hip arthroplasty• Knee arthroplasty• Hysterectomy• Vascular surgery

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Evolution of National PerformanceEvolution of National Performance

89.3

55.7

94.192.6

84.6

40.730

40

50

60

70

80

90

100

2001* Q12005

Q22005

Q32005

Q42005

Q12006

Q22006

Q32006

Q42006

Q12007

Q22007

Q32007

Pe

rce

nt

Abx 60 min Guideline Abx Abx discontinued

//

*National sample of 39,000 Medicare patients undergoing surgery in US hospitals during 2001. Bratzler DW, Houck PM, et al. Arch Surg. 2005;140:174-182.

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National Performance Q3 2007National Performance Q3 2007

0

20

40

60

80

100

Antibioticsw/i 1 hour

CorrectAntibiotic

Antibiotic DC’dw/i 24 hours

Per

cen

t

National Average BenchmarkLow 10%

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Correct Prophylactic Antibiotic Selection

Note: Nationwide Average among all JC-accredited healthcare organizations for the July 06-June 07 period: 93%

Jun 06 through Nov 07

0%

20%

40%

60%

80%

100%

Jun-06 Jul-06 Aug-06 Mar-07 Apr-07 May-07 Jun-07 Jul-07 Aug-07 Oct-07 Nov-07

Score Average Target

FY08 Target = 95%National Average (VA/non-VA) = 94.2%

National VA Data

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Prophylactic Antibiotic Started TimelyProphylactic Antibiotic Started Timely

SIP – Inpt – Prophylactic Antibiotics Started Timely (sip 1a)


0%

20%

40%

60%

80%

100%

Jan 05 Jan 06 Mar 07 Nov 07

FY08 Target = 95%

Average = 85.2%


National VA Data

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Prophylactic Antibiotics DC’d Timely



91.0%

0%

20%

40%

60%

80%

100%

Oct 05 Jan 06 Mar 07 Nov 07

Average = 75.8%

FY08 Target = 88%


National VA Data

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National Performance Q3 2007National Performance Q3 2007

0

20

40

60

80

100

Pe

rce

nt

Glucose Control(cardiac)

No Razor Normothermia

National Average BenchmarkLow 10%

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Glucose Levels – Cardiac Surgery

93.2%

0%

20%

40%

60%

80%

100%

Oct 05 Jan 06 Jan 07 Nov 07

FY08 Target = 95.0%

Average = 87.0%


National VA Data

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Hair Removal By Acceptable Method

National VA Data


99.9%

0%

20%

40%

60%

80%

100%

Oct 06 Jan 07 Nov 07

FY08 Target = 95%

Average = 99.2%


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First Temp in Range – Colon SurgeryNational VA Data


82.3%

0%

20%

40%

60%

80%

100%

Oct 05 Jan 06 Jan 07M

ar-0

7

Apr-07

May

-07

Jun-0

7

Jul-0

7

Aug-07

Oct-0

7

Nov-07

66.8% = Average


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Cardiovascular Complication PreventionCardiovascular Complication Prevention

SCIP Card 1: Non-cardiac vascular surgery patients with evidence of coronary artery disease who received beta-blockers during the perioperative period

SCIP Card 2: Surgery patients on a beta-blocker prior to arrival that received a beta-blocker during the perioperative period

SCIP Card 3: Intra- or postoperative acute myocardial infarction (AMI) diagnosed during index hospitalization and within 30 days of surgery (Outcome)

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Beta Blocker Usage

90.8%

0%

20%

40%

60%

80%

100%

Oct 06 Jan 07 Nov 07

FY08 Target = 92%

Average = 84.7%


Surgery Pts on Beta-Blocker Therapy Prior to Admission Who Received a Beta-Blocker During

the Perioperative Period

National VA Data

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Role of Beta Blockers ???Role of Beta Blockers ???

The Lancet 2008; 371:1839-1847 Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial POISE Study Group

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POISE TrialPOISE Trial

• 190 hospitals, 23 countries• 8351 patients with, or at risk of ASHD

undergoing non-cardiac surgery• Randomized to double-blinded receipt of

extended release metoprolol or placebo• Started 2-4 hours preop and continued for

30 days postop• No dosage adjustment

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POISE Trial - ResultsPOISE Trial - Results

MI findings are consistent with prior trials

Hypotension was more common in metoprolol group….? contributor to stroke and death

Would titration by experienced clinicians decrease CVA and/or death rates for beta blockers?

Patient criteria for beta blockers and time of initiation continue to be discussed

0.00530.5%1.0%CVA

0.03172.3%3.1%Death

0.00175.7%4.2%MI

pPlaceboMetoprolol

0.00530.5%1.0%CVA

0.03172.3%3.1%Death

0.00175.7%4.2%MI

pPlaceboMetoprolol

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Venous ThromboembolismVenous Thromboembolism

• Leapfrog: VTE is “the most common preventable cause of hospital death in the United States.”

• AHRQ: “Thromboprophylaxis is the number one patient safety practice.”

• American Public Health Association: VTE prophylaxis is a “public health crisis.”

• Guidelines: – American College of Chest Physicians– Intervention must be tied to risk assessment– Evolving Joint Commission patient safety goal

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Thromboembolism PreventionThromboembolism Prevention

SCIP VTE 1: Surgery patients with recommended venous thromboembolism prophylaxis ordered

SCIP VTE 2: Surgery patients who received appropriate venous thromboembolism prophylaxis within 24 hours prior to surgery to 24 hours after surgery

SCIP VTE 3: Intra- or postoperative pulmonary embolism (PE) diagnosed during index hospitalization and within 30 days of surgery (Outcome)

SCIP VTE 4: Intra- or postoperative deep vein thrombosis (DVT) diagnosed during index hospitalization and within 30 days of surgery (Outcome)

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Evolution in National PerformanceEvolution in National Performance

National Data for All Hospitals

//

82.484.1 84.8

86.3

77.879.6 80.5

82.1

71.9

69.7

60

70

80

90

100

Q1, 2005* Q2 2006 Q3 2006 Q4 2006 Q1 2007 Q2 2007 Q3 2007

Per

cen

t

Recommended VTE prophylaxis VTE prophylaxis received

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Appropriate VTE Prophylaxis Ordered

National VA Data

95.1%

0%

20%

40%

60%

80%

100%

Oct 06 Jan 07 Nov-07

FY08 Target = 92%

Average = 86.8%


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Received Appropriate VTE Prophylaxis

92.4%

0%

20%

40%

60%

80%

100%

Oct 0

6

Nov 06

Dec 0

6

Jan 0

7

Feb 0

7

Mar

-07

Apr-07

May

-07

Jun-0

7

Jul-0

7

Aug-07

Oct-0

7

Nov-07

FY08 Target = 90%

Average = 83.4%


National VA Data

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VHA “Report Card” on SCIPVHA “Report Card” on SCIP

“We concluded that all facilities evaluated during the CAP reviews implemented strategies to prevent or reduce the incidence of surgical infections. ….For those measures that were below VHA’s established goals, managers implemented appropriate action plans to improve performance.

We made no recommendations. “

VHA OIG, Healthcare Inspection, Surgical Quality Improvement Program, March 2008

http://www.va.gov/oig/54/reports/VAOIG-07-00773-106.pdf

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SCIP ImpactsSCIP Impacts

Outcomes from SIP…

Overall surgical infection rate decreased 27%, from 2.28% in the first 3 months to 1.65% in the last 3 reporting months.

Dellinger EP, et al. Am J Surg. 2005;190:9–15.

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SCIP ImpactsSCIP Impacts

National 30-day All Cause MortalityNon-cardiac surgery

Limited to all Medicare patients undergoing those operations included in SCIP.

3.89 3.783.52

3.88

0

1

2

3

4

5

2004 2005 2006 2007

30-d

ay m

ort

alit

y % 75,940 deaths

1,951,669 operations

75,167 deaths1,938,962 operations

71,312 deaths 61,577 deaths1,748,860 operations

1,887,105operations

GOAL

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Self AnalysisSelf Analysis

Association of timely administration of prophylactic antibiotics for major surgical

procedures and surgical site infection.

Hawn MT, Itani KM, Gray SH, et al.

Patients with EPRP SCIP-1 and NSQIP data were studied

Patient and facility level analyses comparing SCIP-1 and SSI were performed

Adjustment for clustering effects within hospitals, validation of SSI risk score and procedure type (percentage of colon, vascular, orthopedic)

9,195 elective procedures (5,981 orthopedic, 1,966 colon, and 1,248 vascular) in 95 VA hospitals.

J Am Coll Surg. 2008 May;206(5):814-9

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Timely antibiotic administration occurred in 86.4% of patients who had an SSI rate of 4.6%; untimely administration was associated with SSI rate of 5.8% in unadjusted analysis

Patient level risk-adjusted multivariable generalized estimating equation modeling found the SSI risk score was predictive of SSI (p < 0.001) and SIP-1 was not associated with SSI.

Hospital level multivariable linear modeling found procedure mix (p < 0.0001), but not SIP-1 rate or facility volume, to be associated with facility SSI rate.

The study had 80% power to detect a 1.75% difference for patient level SSI rates.

Timely antibiotic administration did not markedly contribute to overall patient or facility SSI rates.

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ObservationsObservations

• Focus on surgical outcomes will continue – driven largely by financial issues (payer cost

and provider compensation)– the right thing for all of us anyway

• Surgical process measures are increasingly accepted….data to assess efficacy are needed.

• Implications regarding P4P are significant!• Definition of the processes that are of

sufficient clinical importance to warrant resource commitment for standardization is critical

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Some helps…Some helps…

An excellent summary of the background for SCIP elements:

http://vaww.visn1.med.va.gov/Estrada.config?resource=52620

VA SCIP data:http://vaww.oqp.med.va.gov

SCIP sites:http://www.qualitynet.orghttp://www.medqic.org/scip/

Special thanks to Dale Bratzler, DO; Chair, SCIP Steering Committee, Oklahoma OIFO for sharing national SCIP data

808H_6_PROV.ppt

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