1. HAI at FHA: NSQIP Data Tells the Story November 2010

2. NSQIP at FHA Rates – SSI, UTI and Sepsis O/E – SSI and UTI Process + Outcomes Measure How NSQIP can help your team Future of NSQIP at FHA

3. NSQIP *National Surgical Quality Improvement Program *Data-driven, risk-adjusted, outcomes-based surgical quality improvement program -systematic sampling process -30-day outcome -robust data collection -data validity -report flexibility

4. NSQIP at FHA 2006Royal Columbian Hospital Surgeon Champion: Dr. Peter Blair SCR: Betty Allan Surrey Memorial Hospital Surgeon Champion: Dr. Peter Doris SCR: Angela Tecson 2009Burnaby Hospital Surgeon Champion: Dr. JeanNoel Mahy SCR: Darlene Jager NSQIP Director: Lorraine Gillespie FHQC- Fraser Health Quality Collaborative Can-NSQIP – Canadian NSQIP Collaborative

5. HAI Rates Surgical Site Infection

6. HAI Rates Urinary Tract Infection

7. HAI Rates Pneumonia

8. Sepsis/Septic Shock HAI Rates

9. O/E Ratio Observed to Expected Ratio “O” = number of observed events “E” = number of expected events on the basis of risks and complexity Risk Adjustment – “levels the playing field” Outlier – statistically “better” or statistically “worse” than expected

10. Overall Surgical Site Infections RCH and SMH – GS and VS BH – Multispecialty (Initial Year) 2007 2009 SMH Reduction Rate: 49% RCH Reduction Rate: 29% SMH RCH BH

11. Overall Urinary Tract Infections RCH and SMH – GS and VS BH – Multispecialty (Initial Year) 2007 2009 SMH Reduction Rate: 54% RCH Reduction Rate: 24% SMH RCH BH

12. NSQIP Data at FHA 30-day outcomes collected – phone calls, letters and surgeons office visits Preoperative data is limited to chart and EMR information No risk-adjusted report on postoperative sepsis/septic shock O/E reports – twice a year

13. Are we really doing what we said we are doing? Is what we are doing creating an impact? Example: Dec 2009-Jan 2010 176 Cases General and Vascular Surgery Process and Outcomes Measure

14. Example: SSI Infection Reduction Strategies Preop Antibiotic Compliance – 87.5% No SSISSI No Preop Antiobiotics 14 (8%) 8 (4.5%) Preop Antibiotics Given 141 (80%) 13 (7.4%) P-value:.001 Odds Ratio: 6.1 No SSISSI No Preop Antiobiotics 24 (13.6%) 12 (6.8%) Preop Antibiotics Given within 1hr 131 (74.4%) 9 (5.1%) P-value:.00008 Odds Ratio: 7.2

15. How can NSQIP help? Data Definition Support– SSI, UTI and Sepsis Reports: –Monthly rates –Benchmark –Risk-adjusted data – Semiannual Report –SPC Charts – specific cause variation

16. NSQIP’s SPC Chart Example

17. Future of NSQIP at FHA Multispecialty Targeted Procedure Module Risk calculators – pre-admission Partnership with UBC statisticians Partnership with BCPSQC Increase site enrollment Continue to share evidence-based practices

18. Thank you! Email:.FHA surgical clinical reviewer Website: www.acsnsqip.org