1. AMERICAN COLLEGE OF SURGEONS National Surgical Quality Improvement Program Barbara J. Martin RN MBA CCRN Sherree Levering RN Oscar D. Guillamondegui MD MPH FACS Local, State, and National Initiatives

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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?

10. A Note about Clinical Abstraction Elements may be consistently “findable”... Or not...

11. 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, 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

12. 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

13. Septic Shock? Shock? Yes Septic? NO

14. 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.

15. 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

16. 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

17. 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

18. Sample Hospital O/E Report High outlier Low outlier

19. Risk Factors determine the “Expected” Case Number Mort Probability 0043770.2352% 0043781.0114% 00437953.8254% 00438012.7381% 0043810.0477% 0043823.7919% 0043830.0975%

20. Occurrences determine the “Observed”

21. 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 Statistics July 2011

22. Cases by Service

23. Procedure Distribution

24. 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

25. Data Analysis

27. 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

28. 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

29. 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

30. NSQIPUHC Participants400 + Hospitals About half are academic 369 hospitals 114 academic / 255 affiliates Risk AdjustmentClinical risk factors as documented in medical record APR-DRG based on coding, other administrative data Outcomes (Mortality) 30 days post-opInpatient hospitalization Service designation Surgical service for included procedure Discharge / Major Service InclusionBy procedure Inpatient / Outpatient All hospital discharges by attending service Inpatient only (Outpatient data is now being submitted) Comparison data Blinded risk-adjusted dataComparison with peer hospitals

31. Tennessee Surgical Quality Collaborative

32. 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

33. 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.

34. TSQC Development 21 TSQC Hospitals?

35. 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

36. Pre-Op Risk Factors* Comparative Data Analysis VUMCTSQCNSQIP Diabetes: Insulin 9.8% 9.3%5.4% Non-Insulin14.5% 15.4%7.6% Dialysis2.6% 2.8% 1.9% Smoked in last yr25.3%28.5%20.6% COPD 5.6%8.0% 4.9% Functional Status Dependent 4.4% 3.5% 1.9% Hypertension57.3%60.2%46.4% *Not actual data

37. 30 Day Mortality and Post – Op Occurrences* Comparing Tennessee Outcomes to National Performance ONLY CONFIRMED 30-DAY FOLLOW-UP CASES TSQCNSQIP Total Number of Cases10,635211,930 Outcome Cases Alive at 30 Days 10,43398.2%208,24398.2% Cases Dead Within 30 Days 1911.8%3,6871.8% Postop Occurrences Superficial SSI 2402.3%5,2062.5% Deep SSI 520.50%8330.4% Organ Space SSI 2192.1%5,4142.6% Wound Disruption 310.3%1,4580.7% Pneumonia 1981.9%5,2062.5% Urinary Tract Infection 2092.0%7,2893.5% Severe Sepsis 940.9%2,4991.2% Mean # of Occurrences0.2 (+ 0.7) *Not actual data

38. TSQC Members Comparison *Not actual data

39. 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

40. 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

41. TSQC Member Hospitals NSQIP Hospitals

42. TSQC Member Hospitals Future NSQIP hospitals? NSQIP Hospitals

43. 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

44. 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

45. Special thanks to Sherree Levering Oscar Guillamondegui Naji Abumrad Chris Clarke Senior VP Tennessee Hospital Association Joe Cofer Erlanger Medical Center TSQC Leadership Committee and Membership TN Chapter American College of Surgeons Blue Cross - Blue Shield of Tennessee Tennessee Hospital Association / Tennessee Center for Patient Safety