Leap and SCIP Your Way to Better Outcomes

Jennifer Joiner, MSN, RN, CCRN-CSC

Clinical Nurse Educator, Cardiac Surgery

Robert Wood Johnson University Hospital

SCIP

Surgical Care Improvement Project Goals:

Decrease the incidence of surgical complications by 25% by 2010

Decrease mortality and morbidity through collaborative efforts

In 2003:

Post-op complications accounted for ~22% of preventable deaths

Focused on 18 types of medical injuries related to 2.4 million additional hospital days and $9.3 billion in extra costs

Surgical Site Infections (SSI’s)

Account for 14-16% of all hospital acquired infections

BUT- 40% of surgical patients’ infections are related to SSI’s

Several Organizations Contribute to Better Outcomes National Surgical Quality Improvement Program

(NSQIP)- decreased mortality rate at the VA by 27%

National Nosocomial Infections Surveillance (NNIS) System of the CDC- decreased up to 44% in device-associated complications and infection rates

Medicare’s Quality Improvement Organizations (QIO’s)- Decreased SSI’s by 27% at 56 centers in the US (** contracts with CMS)

Main Focus Areas of SCIP Infection

Antibiotics given within 1 hr of incision time (91.2%)

Right Antibiotic ordered (100%)Antibiotic discontinued within 24/48hr (83.8%)6am Blood Sugar (cardiac surgery patients)

less than 200* (92%)Post-op wound infections (0% Deep SWI)Appropriate hair removal (100%)

Adverse Cardiac Events

Occurs in 2-5% of non-cardiac surgery patients 34% of vascular surgery patients

BUT- Perioperative MI is related to a 40-70% mortality rate plus Increased LOS, costs and morbidity

Nearly ½ of fatal cardiac events could have been prevented with Beta Blocker therapy during the perioperative period (by decreasing cardiac ischemia)

CardiacBeta Blocker given during the perioperative

period if on one pre-op (100%)

Acute MI within 30 days of surgery

Venous Thromboembolism (VTE’s)

For all major surgeries without prophylaxis ordered: 25% DVT rate 7% PE rate

High risk: Orthopedic surgery without prophylaxis ordered: Over 50% DVT rate 30% PE rate

Problem: Underused or inappropriate treatment used for prophylaxis

VTE (Venous Thromboembolism)

VTE Prophylaxis (95.3%)VTE Prophylaxis from 24hr before surgery to

24 hr after surgery (94.6%)PE within 30 days of surgeryDVT within 30 days of surgery

Respiratory Complications

Post-op pneumonia-- 9-40% incidence rate

Pneumonia is associated with a 30-45% mortality rate as a complication after surgery

Data Collection to be added at a later date

Respiratory# of days vent patient had HOB documented

through POD #7VAP rate# of days PUD prophylaxis ordered through

POD #7# of patients with vent weaning orders

documented

Mortality Rate within 30 days of surgery (1.49% vs. 3.4% expected rate)

Readmission Rate within 30 days of surgery

The Leap Frog Group

Late 1990’s, a number of large US health care purchasers formed the Leap Frog Group to develop breakthroughs in safety and value of health care to US consumers.

Long-term goal: to reward hospitals and MDs on the basis of excellence in quality and quality improvement. Inadequate IT systems and public reporting is not

consistent to benchmark against; thus, group is focusing on patient safety

Leap Frog Group

Offers valuable benchmarking capabilities to hospitals

Provide consumers and purchasers of health care with information on the quality and safety of their hospitals

Increases health care transparency by encouraging adoption of health IT standards, provision of options that promote quality and efficiency in health, and makes pricing and quality information publicly available

RWJUH Named One of Top 33 Hospitals in Quality and Safety by the 2008 Leap Frog Group Survey

RWJUH is one of 2 hospitals in NJ 33 hospitals chosen out of 1200+

nationwide26 hospitals, 7 children’s hospitals

Leap Frog Patient Safety Standards Computer Physician Order Entry

* costs r/t startup, equipment, training, maintanence* decreased med errors and adverse drug events- $180-900K/year* decreased repeated tests, lab, radiology, history, losing paper charts; increased efficiency

ICU Physician Staffing*costs r/t salary; decreased LOS, inappropriate ICU admissions, inappropriate testing and consults, complications- $800K-$3.4 million

Evidenced-Based Hospital Referral for high risk surgeries and neonatal intensive care* Idea is the more you do, the better you are at it* costs r/t administrative, moving patients, redundancy in testing and evaluation, more costly care in academic centers; smaller hospitals would suffer

Never Events 28 serious reportable events by NQF

Leaving foreign objects in patients after surgery/procedure Death or serious injury related to:

Med error ABO/HLA incompatible blood or blood product causing a hemolytic reaction Electric shock or electric cardioversion Fall Hypoglycemia Air embolism Use or function of a device in a manner other than intended

Wrong patient, site, or procedure performed Intra-operative or immediate post-op death in an ASA Class 1 patient Stage 3 or 4 hospital-acquired pressure ulcer

Surgeon Mortality Rates

National Quality Forum Safe Practices (NQF-SP)

Resource Utilization Measures (“Core Measures”)

CABG PCI AMI Pneumonia AAA Repair NICU

Cardiac Surgery Measures

ASA/Plavix at discharge- 99.3% Use of IMA- 99.3% Beta Blocker w/in 24h of sx 73.9% Beta Blocker at discharge 94% Anti-Lipid meds at discharge 95.5%

Percutaneous Coronary Intervention (PCI) PCI within 90 min of arrival- AMI 88.2% ASA on arrival 98.4% ASA at discharge 99.1%

Acute Myocardial Infarction (AMI)

ASA on arrival 98.4% ASA at discharge 99.1% ACE-I or ARB for LVSD 95% Adult Smoking Cessation Advice/Counseling

100% Beta Blocker at discharge 100% Beta Blocker on arrival 97.9% PCI within 90min 88.2%

Pneumonia Oxygenation assessment-ABG within 24hr 100% Pneumococcal vaccine for all with pneumonia

(and all 65+) given prior to discharge 54.8% Blood cultures within 24hr of admission to the

ICU 100% Smoking cessation advice/counseling 100% Initial Antibiotic within 6hr of arrival 94.6% Flu vaccine given prior to discharge (n/a for 2nd

qtr)

Hospital Acquired Conditions

Pressure Ulcers Injuries

In addition-Severity adjusted average LOS inflated by a

14day all-cause readmission rate

How Can The RN Impact Outcomes? Perioperative RN:

Abx within 1hr of incision time Right Abx ordered/given Appropriate hair removal Beta Blocker prior to surgery VTE prophylaxis Peridex given prior to intubation DOCUMENTATION!!! Don’t be afraid to speak up!!!

ICU RN: Antibiotics stopped within the right time period? (cardiac sugery

up to 48hr; all others 24hr) 6am blood sugar under control (cardiac surgery) Post-op wound infection- incision care and assessments VTE prophylaxis? VAP prevention bundle Pulmonary toileting, ambulation Vent weaning documentation (yes/no/why) ASA/plavix, Beta Blocker, and Anti-Lipid on transfer out of ICU?

(For AMI, ACE-I and/or ARB?) Vaccine status/orders for discharge dose ABG, blood cultures within 24hr and antibiotic given within 6hr

for pneumonia? Smoking cessation counseling for all smokers Prevention of pressure ulcers and injuries “Get the Red Out”!!! DOCUMENTATION AND ADVOCACY!!!

Med-Surg and Telemetry RN: Antibiotics stopped within right time period? 6am blood sugar under control? (cardiac surgery) PUD, VTE prophylaxis ordered through POD #7 Pulmonary toileting, ambulation ASA/Plavix, Beta Blocker, Anti-Lipid, (ACE-I and ARB

for AMI) at discharge? Smoking cessation counseling ABG, blood cultures within 24hr, antibiotic given

within 6hr of arrival? Vaccine status addressed and orders entered for day

of discharge Prevention of pressure ulcers and injuries “Get the Red Out”!!! DOCUMENTATION AND ADVOCACY!!!

Resources

www.leapfroggroup.org www.pronj.org www.medqic.org www.sts.org www.va.gov www.ihi.org www.jcaho.org www.ahrq.gov www.cms.hhs.gov www.hospitalcompare.hhs.gov