AMERICAN COLLEGE OF SURGEONS National Surgical Quality Improvement Program
Barbara J. Martin RN MBA CCRNSherree Levering RN
Oscar D. Guillamondegui MD MPH FACS
Local, State, and National Initiatives
National Surgical Quality Improvement Program
• Objective: Describe components of National Surgical Quality Improvement Program (NSQIP)
• In order to receive full contact-hour credit for the CNE activity, you must– Be present no later than five (5) minutes after starting time– Remain until the scheduled ending time– Complete /submit Evaluation form before leaving at the conclusion
• Conflict of Interest: None • Commercial Support: None.• Non-Endorsement of Products: None
– Accredited status does not imply endorsement by Vanderbilt Medical Center, TNA or ANCC of any products that might be displayed in conjunction with this program.
• Off-label Product Use: N/A • Accreditation Statement
– Vanderbilt University Medical Center, Department of Nursing Education and Professional Development is an approved provider of continuing nursing education by the Tennessee Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.
• 1.0 Contact Hour
National Surgical Quality Improvement Program
• Initially developed by the VA to risk-adjust outcomes in response to public concerns
• American College of Surgeons expanded the program to the private sector in 2004
• Currently 408 hospitals enrolled– Community / Private / Academic– Half have fewer than 500 beds; program is
expanding options to include smaller facilities
ACS NSQIP
• Validated, clinically-based data collection• Collects and analyzes clinical outcomes data• Measures quality of systems of care• Quantifies 30-day risk-adjusted surgical
outcomes, including morbidities and mortality• Blinded comparison with national performance• Currently working with CMS to develop
outcomes measures for surgical procedures
We Give NSQIP . . .
• 40 cases every 8 days (minimum 1680 / year)– Random sampling General and Vascular Surgery – Targeted procedure selection: 100% capture
• Colectomy• Proctectomy• Ventral Hernia Repair
– Inpatient and outpatient procedures• Selected by service and CPT code• Age > 17• Trauma / Transplant excluded during that admission
Data Collection• Manual chart review and abstraction• Strict definition of abstracted elements• 150 variables
– Demographics, preoperative factors and labs• Medical and surgical history• Acute and chronic clinical risk factors
– Intraoperative events– Postoperative occurrences, discharge data
• Infectious complications—surgical site, urinary, pneumonia• Technical occurrences—graft failure, bleeding• Other events—reintubation, renal failure, cardiac arrest
Preoperative Risk Factors
• BMI• Smoking• Diabetes• CHF Exacerbation• Ascites• COPD• Weight loss• Functional Status
• Surgery within 30 days• Open wounds• Sepsis / Septic shock• Impaired Sensorium• Acute Renal Failure • Dialysis• Preoperative Steroids• Blood transfusions
• Infectious complications: Surgical Site Infection, UTI, Sepsis
• Respiratory Occurrences: Pneumonia, Unplanned Intubation, On vent > 48 hours
• Cardiac Occurrences: MI, cardiac arrest• Renal Failure• Stroke• Peripheral nerve injury
Postoperative Occurrences
Abstraction Requirements
• All patients are followed for 30 days after surgery • Surveillance definitions are not the same as
clinical definitions• The abstractor’s clinical judgment is valuable, but
not always assignable• All elements of the definitions must be met for
preop risk and postop occurrence– Do the findings meet the purpose of the definition?– Do they meet the letter of the definition?
A Note about Clinical Abstraction
Elements may be consistently “findable”. . .
Or not . . .
SIRS, Sepsis, Septic Shock
• Systemic Inflammatory Response Syndrome: presence of two or more of the following: – Temp >38 C or < 36 C– HR > 90 bpm – RR >20 /min or PaCO2 <32 mmHg – WBC >12,000 , <4000, >10% bands – Anion gap acidosis
• Sepsis– Two of the above AND purulence or positive culture
• Septic Shock– All the above AND evidence of organ dysfunction
SIRS? Sepsis? Septic Shock?
• 72 year old male presents to the ED in distress with severe chest / epigastric / flank pain
• VS T 36.4 BP 118/74 HR 110 RR 24 • PMH Coronary artery disease, insulin
dependent diabetes mellitus, chronic pyelonephritis
• Loses consciousness BP 80/40 HR 116• Taken to CT scan
Septic Shock?
Shock? Yes Septic? NO
30 Day Follow Up
• Many patients are seen in clinic at 30+ days• Minor operations (appendectomy, hernia
repair) may not be seen after two weeks.• If no documentation in StarPanel, patients are
contacted via telephone. No less than three attempts are made.
• Vanderbilt’s fully integrated medical record improves follow-up rates on pateints with and without postoperative occurrences.
NSQIP Gives Us . . .
• Risk-adjusted surgical morbidity and mortality• Semiannual Observed /Expected Ratio reports• Interim reports: ongoing monitoring,
comparison with internal and external peer groups
• Internal data analysis: access to institutional data for report development, integration with other data sets
Semiannual Report
• Reports 12 months of data, with risk adjusted outcomes
• 39 Risk Adjustment Models– Mortality– Overall Morbidity– Cardiac Occurrences– Respiratory Occurrences– Surgical Site Infection– Colon surgery LOS
• Observed / Expected Ratios for each model
Mortality and Morbidity O/E Ratios
• Observed / Expected Outcomes– An O/E of 1 indicates the outcomes were the same as
expected• Less than 1 indicates better than expected • Greater than 1 indicates worse than expected
– High outliers have confidence intervals greater than 1– Low outliers have confidence intervals less than 1
Sample Hospital O/E Report
SAMPLE
High outlier
Low outlier
Risk Factors determine the “Expected”Case
NumberMort
Probability
004377 0.2352%
004378 1.0114%
004379 53.8254%
004380 12.7381%
004381 0.0477%
004382 3.7919%
004383 0.0975%
Occurrences determine the “Observed”
Occurrences by Inpatient vs Post D/C
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
196 10 19 41 45 77 92
SSI PULMONARY EMBOLISM
DVT REQUIRING THERAPY
URINARY TRACT INFECTION
UNPLANNED INTUBATION
PNEUMONIA ON VENTILATOR > 48 HOURS
Pre-discharge
Prior to discharge
•January 1 – December 31, 2010• 258 hospitals• ~375,000 cases
•Vanderbilt: 1,560 cases•1,393 General surgery cases
•168 Colon and rectal surgery (all services)•167 Vascular surgery cases
Semiannual Report StatisticsJuly 2011
Cases by Service
Onc/Endo26%
GI / Lap23%EGS
22%
CRS14%
Vascular11%
Hepatobiliary4%
Procedure Distribution
breast
thyroid
colecto
mych
ole gbp vhr
ex lap
parath
ing herniaappe
hepaticpanc sb
rfundo
cea
closu
re ent
debride /
I&D
proct
gastric
band0
20
40
60
80
100
120
140
160
Risk Adjustment Models
Morbidity• CPT Risk
• ASA Class
• SIRS / Sepsis / Shock
• Inpatient / Outpatient
• Functional Status
• Preop Albumin
• Surgical Specialty
• COPD
• BMI
• Creatinine
• Vent dependence
Mortality• Functional Status
• ASA Class
• CPT Risk
• Age
• SIRS / Sepsis / Shock
• Disseminated Cancer
• SGOT > 40
• Albumin
• Emergency
• Creatinine > 1.2
• Platelets < 150
SSI CPT Risk BMI Inpatient Status Wound Class Current Smoker ASA Class Bilirumin > 1 Steroid Use Work RVU Transfer Status Surgical Specialty
Data Analysis
Onc/Endo27%
GI / Lap25%
EGS17%
Vascular13%
CRS13%
Hepatobiliary5%
VUMC Initiatives • VPEC
– Assessment and documentation of risk elements including smoking history, functional status
• Bariatric Surgery– Early foley discontinuation– Incentive spirometry education and postop monitoring
• Vascular Surgery– Pulmonary assessment pre / postop
• Emergency General Surgery– Documentation of emergent status
Current VUMC Initiatives
• Colorectal surgery – Clinical analysis of NHSN-identified infections with
NSQIP variables
– Evaluation of NHSN / NSQIP case selection variation
• Vascular Surgery analysis of postop respiratory failure and pneumonia
• ICU Database multicenter project
• NSQIP PARS analysis: evaluating correlation between clinical outcomes and provider complaints
NSQIP, NHSN, and Administrative Data• NHSN
– SSI surveillance based on ICD-9, otherwise very little difference– HAI surveillance primarily inpatient
• Device associated infections initially monitored in the critical care setting• Currently monitoring CLABSI in general care; CAUTI soon
• Administrative data (UHC)– Based on provider documentation, coding data’s primary purpose initally
was reimbursement. – Only the index hospitalization is captured.
• NSQIP – Like NHSN, abstraction is from clinical documentation, based on strict
definitions– Follows all patients for 30 days—inpatient, outpatient, discharged– No device associated infection designation
NSQIP UHC
Participants 400 + HospitalsAbout half are academic
369 hospitals114 academic / 255 affiliates
Risk Adjustment Clinical risk factors as documented in medical record
APR-DRG based on coding, other administrative data
Outcomes (Mortality)
30 days post-op Inpatient hospitalization
Service designation
Surgical service for included procedure
Discharge / Major Service
Inclusion By procedure Inpatient / Outpatient
All hospital discharges by attending serviceInpatient only (Outpatient data is now being submitted)
Comparison data
Blinded risk-adjusted data Comparison with peer hospitals
Tennessee Surgical Quality Collaborative
Tennessee Chapter
of American College of Surgeons
Blue Cross Blue
Shield of Tennesse
eTennessee Center for
Patient Safety(THA)
Tennessee
Hospitals
Tennessee Surgical Quality Collaborative
• A consortium of surgeons and hospitals committed to evaluate and improve surgical care by surgeons in the state of Tennessee
• 10 member hospitals with active engagement of surgeon champions, nurse reviewers, and administrators.– Learn from high performers– Develop best-practice recommendations– Identify system variables influencing clinical performance– Non-competitive environment for shared learning
TSQC Mission and Vision
Mission• To improve the care of the surgical patient by
supporting an open discussion and transfer of information through a collaborative team effort.
Vision• To identify best surgical practices, examine how the
surgical team obtains best outcomes and teach other surgical teams how to improve outcomes.
TSQC Development
2007 Partnership model proposed to
Blue Cross
2008 3 year grant awarded to TSQC
2009 Hospitals enrolled, training and
abstraction in progress
July 2010 First O/EJanuary 2011 Draft
Action Plan for Statewide Initiatives
April 2011 AHA NPSF Fellowship
September 2011 Grant Renewal application
submitted
October 2011 Eleven additional hospitals submit applications
21 TSQC Hospitals?
Grant Overview
• 3 year grant May 2008- May 2011• Initial grant to support of 8 hospitals; BCBS
increased funding to support 10 hospitals / surgeon champions
• THA’s TN Center for Patient Safety serves as coordinating center for the collaborative
• Initial grant period extended to October 2011; renewal application has been submitted
Pre-Op Risk Factors*Comparative Data Analysis
VUMC TSQC NSQIPDiabetes:
Insulin 9.8% 9.3% 5.4%Non-Insulin 14.5% 15.4% 7.6%
Dialysis 2.6% 2.8% 1.9%Smoked in last yr 25.3% 28.5% 20.6%COPD 5.6% 8.0% 4.9%Functional Status
Dependent 4.4% 3.5% 1.9%Hypertension 57.3% 60.2% 46.4%
*Not actual data
30 Day Mortality and Post – Op Occurrences*Comparing Tennessee Outcomes to National Performance
ONLY CONFIRMED 30-DAY FOLLOW-UP CASESTSQC NSQIP
Total Number of Cases 10,635 211,930
Outcome
Cases Alive at 30 Days 10,433 98.2% 208,243 98.2%Cases Dead Within 30 Days 191 1.8% 3,687 1.8%
Postop Occurrences
Superficial SSI 240 2.3% 5,206 2.5%
Deep SSI 52 0.50% 833 0.4%
Organ Space SSI 219 2.1% 5,414 2.6%
Wound Disruption 31 0.3% 1,458 0.7%
Pneumonia 198 1.9% 5,206 2.5%
Urinary Tract Infection 209 2.0% 7,289 3.5%
Severe Sepsis 94 0.9% 2,499 1.2%
Mean # of Occurrences 0.2 (+ 0.7) 0.2 (+ 0.7)
*Not actual data
TSQC Members Comparison
Hospital A
Hospital B
Hospital C
Hospital D
Hospital E
Hospital F
Hospital G
Hospital H
Hospital I
Hospital J
0
2
4
6
8
10
12
SSIPneumoniaMortality
*Not actual data
Key Successes: 2009 -2010• Acute Renal Failure –
– Collaborative-wide improvement– Seven of 10 sites showed improvement; one site significantly improved
• Graft/Prosthesis Flap Failure– Collaborative-wide improvement– Eight sites improved; one significantly.
• On Ventilator > 48 hours– Collaborative-wide improvement
• Superficial Incisional SSI– Collaborative-wide improvement– Thirteen procedure groups improved while hernia repair showed significant improvement.– Seven sites improved; one significantly
• Wound Disruption– Collaborative-wide improvement.– Eight sites improved; two significantly.
• Financial Model Shows Positive Results
TSQC Opportunities
• Surgical Site Infections As the First Focus– Colorectal surgery bundle– Evaluation and implementation in 10 hospitals
• Rationale:– High Volume occurrence in TSQC data– 9 of 10 SCNRs identified SSI as opportunity – Aligns with hospital current focus on SSI via CMS
SCIP public reporting– Business case – Length of Stay and Costs significant
TSQC Member Hospitals
NSQIP Hospitals
TSQC Member Hospitals
Future NSQIP hospitals?
NSQIP Hospitals
NSQIP and the Nation
• The Centers for Medicare and Medicaid Services (CMS) is considering five measures from ACS NSQIP for national implementation
• NSQIP – based programs– Bariatric Surgery Center Network– NSQIP-Pediatric– Trauma Quality Improvement Program
• ACS Goal: 1000 member hospitals by 2012
NSQIP Innovations
• 2011 Additional Options– Small and Rural: hospitals with < 1680 cases / year– Essentials: smaller data set– Procedure Targeted: 100% of specific cases– Classic: allows additional variables for research
• Florida Surgical Care Initiative• 2012 Updates
– Procedure targeted variables
Special thanks to
Sherree LeveringOscar Guillamondegui
Naji AbumradChris Clarke Senior VP Tennessee Hospital Association
Joe Cofer Erlanger Medical CenterTSQC Leadership Committee and Membership
TN Chapter American College of SurgeonsBlue Cross - Blue Shield of Tennessee
Tennessee Hospital Association / Tennessee Center for Patient Safety
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