1 Beyond SCIP Stanford Hospital and Clinics John Morton, MD, MPH, FACS
2 To Err is Human STANFORD BOARD DIRECTIVE
3 Surgical Safety A serious public health issue n Globally, 234 million operations/yr n With a mortality rate of % and 3-16% complications rate: 1 million deaths 7 million disabling complications
4 SF Chronicle
5 Department of Surgery Quality Plan Preview n Imperative from SHC Board n Areas of Focus n Measurement n Goals n Communication n Education n Accountability n Leadership
6 n Rounding Policy Persistent Pursuit of Excellence n Dedicated Monthly Grand Rounds on Quality n NSQIP based Morbidity and Mortality Conference n Resident Award for Quality Improvement n Novel Quality Improvement/Patient Safety Resident Curriculum n Documentation Improvement Program n Peer Review/OR Checklist/Leadership n Surgery Quality Council n Quality Initiatives
7 Update: FY 2010 SCIP CORE MEASURES
8 Surgical care improvement project n SCIP is one of four categories of Core Measures n The Surgical Care Improvement Project (SCIP) is a national quality partnership of organizations interested in improving surgical care by significantly reducing surgical complications. n Each of the SCIP target areas are advised by a technical expert panel and supported by evidence-based research.
9 FY2010 SCIP CORE measures n SCIP INF 1: Patient receives prophylactic antibiotic within 60 minutes prior to surgical incision. n SCIP INF 2: Patient receives prophylactic antibiotics consistent with current recommendations identified in published guidelines. n SCIP INF 3: Prophylactic antibiotics are discontinued within 24 hours of surgery end time (48 hours for cardiac surgery). n SCIP INF 4: Glucose control in cardiac surgery patients. n SCIP INF 6: Surgery patients with appropriate hair removal.
10 FY2010 SCIP CORE measures n SCIP CARD 2: Beta Blocker therapy prior to Admission who Received a Beta Blocker During the Perioperative Period n SCIP VTE 1: Surgery patients with recommended VTE prophylaxis ordered n SCIP VTE 2: Surgery patients who received appropriate VTE prophylaxis within 24 hours prior to surgery to 24 hours after surger 48 hours for CABG and other cardiac surgery. NEW NEW n SCIP-INF-9: Urinary Catheter Removed on Postoperative Day 1 (POD 1) or by midnight on Postoperative Day 2 (POD 2). n SCIP-Inf-10 Surgery Patients with Perioperative Temperature Management.
11 n Exceptions to removing catheter: Urological, GYN, Perineal procedures Planned return to OR Suprapubic catheter SCIP Infection Measure - 9 n Measure: Indwelling Urinary Catheter Removed on POD 1 or by midnight on POD 2 n Science-based rationale: Studies have shown that the longer indwelling urinary catheters remain in patients the greater risk of UTI. n Inclusion criteria: Indwelling catheters: Foley catheter 3-Way catheter, Coude catheter, Council tip catheter Intermittent catheters: in and out catheterization, Texas catheter, prn catheterization for residual urine, self-catheterization, straight catheterization, spot catheterization n Exclusion criteria: External catheter
12 Potential Exclusion Criterion n Urological, gynecological or perineal procedure performed n ICU bed and documentation of receiving diuretics n Other surgical procedures that occurred within 3 days (4 days for CABG) prior to or after the procedure of interest n Physician documented infection prior to surgical procedure n Length of stay < two days postoperatively n Suprapubic catheter or had intermittent catheterization preoperatively n No catheter in place postoperatively n Physician documentation of a reason for not removing the urinary catheter postoperatively Example: Foley retained to monitor accurate input and output
13 SCIP INFECTION MEASURE - 9 Documentation that the catheter was removed on POD 1 or POD 2 with Anesthesia End Date being POD 0 (POD 2 ends at midnight on the second post-op day) Role of Surgeons: Documentation of the reason why urinary catheter needs to stay in longer than midnight on POD 2. An order to just continue catheter will not suffice. Example: The patient required ICU care AND receiving diuretics. Role of RNs: Check physicians orders to discontinue catheter and then discontinue catheter asap and document removal.
14 SCIP Infection Measure - 10 n Measure: Surgery Patients with Perioperative Temperature Management n Science-based rationale: Studies have shown that hypothermia has been associated with adverse outcomes, including impaired wound healing, adverse cardiac events, altered drug metabolism, increased infection and coagulopathies. n Documentation of at least one body temperature greater than or equal to 36 C within the 30 minutes immediately prior to or 15 minutes immediately after Anesthesia End Time (i.e. time associated with the anesthesia providers signoff after principal procedure).
15 SCIP Infection Measure - 10 n Anesthesiologists: Temperature must be 36 degrees or higher by end of surgery, unless Intentional Hypothermia is documented in medical record. Document core temperature on anesthesia record 30 minutes before patient is transferred. Physicians/CRNAs need to document intentional hypothermia during perioperative period. n PACU and ICU RNs: Obtain and document temperature within first 15 minutes after patient arrives in unit.
16 Potential Exclusion Criterion Patients whose length of anesthesia was less than 60 minutes Patients who did not have general or neuraxial anesthesia Patients who received Intentional Hypothermia for the procedure performed.
17 NEW Focus on outstanding surgical care Remove urinary catheters by POD 2 SCIP Measure effective NOW Surgeons: Document reason catheter needs to stay in longer Example: Foley retained to monitor accurate urine output Exceptions to removing catheter: þ Urological, GYN, and Perineal procedures þ Planned return to OR þ In ICU and receiving diuretic on POD1 or POD2 RNs: Check MD orders for the DC Catheter order Ask MD to document any exceptions
18 NEW Focus on outstanding surgical care Perioperative Temperature Management SCIP Measure effective NOW Anesthesiologists: þ Temperature must be 36º C /96.8ºF degrees or higher at handoff to PACU/ICU RNs, unless Intentional Hypothermia is documented þ Document End of Anesthesia time & Linal temperature þ Document use of Bair Hugger PACU and ICU RNs: þ Temp must be taken and documented within 15 minutes of handoff by Anesthesiologist
19 Action Plan n Educate all OR clinicians and staff on the two new SCIP measures by September 15. n Review and monitor performance of two new SCIP measures monthly with OR personnel to ensure 95% compliance. n Include performance of new SCIP measures on SHC Quality Alert dashboard and detail reasons for inadequate performance. n Drill down on cases of noncompliance and reinforce individual clinician education.
20 Surgical Care Improvement Project (SCIP) n SHC Goal: Increase compliance for the following measures to 90%: SCIP Inf 1 Antibiotic received with one hour prior to incision SCIP Inf 2 Antibiotic selection SCIP Inf 3 Antibiotic discontinued within 24 hours after surgery time SCIP VTE 1 Surgery patients with recommended VTE prophylaxis ordered SCIP VTE 2 Surgery patients who received appropriate VTE prophylaxis within 24 hours prior to surgery to 24 hours after surgery
22 Does a Surgical Safety Checklist Improve Short-Term Patient Safety Culture and Outcomes? Thomas C. Tsai, MD, MPH, 1 Tina Hernandez- Broussard, MPH, PhD, 2 Mark L. Welton, MD, FACS, 2 John M. Morton, MD, MPH, FACS 2 1 Brigham and Women s Hospital 2 Stanford University School of Medicine ACS Clinical Congress October 6, 2010
24 Results: OR Time Mean Start to Incision Time Mean Total Elapsed Time Before Checklist (minutes) A5er Checklist (minutes) P- value <
27 How did we get here? 1 YEAR MORTALITY RATE 4.6%
28 BARIATRIC SURGERY: AMERICAN SURGICAL SUCCESS STORY
29 Accreditation in Bariatric Surgery CMS National Coverage Determination February, 2006 CMS will approve and reimburse procedures at a program accredited by one of the two programs: ASBS/ Surgical Review Corporation. American College of Surgeons Bariatric Surgery Centers
30 37% 24% 21% 21%
31 NEJM LABS DATA
32 ident, lue f chief of ofessor urgery, in Ann the, ment f he n the of the ne, Coral is for d Arbor. ment f to 2.3 value partnerships, at Blue physicians in particular regions of the country have led to improve Cross and Blue Because Shield of the Michigan Bariatric Surgery Collaborative and collaborations. the National We reviewsurgical one, the Michigan Quality regional Im- collaborative ment p pating Michigan, in Detroit. in the quality of care. Even so, there have not been many of these Darrell A. Campbell is chief of clinical affairs provement and a professor improvement Program program, rely onwhich separate was paidregistries for by a large private inginsur ho in the Department of Surgery, with different yieldedoutcome improvements measures for a range ofand clinicaldefini- tions, improvements costs in several important in complication areas. In general rates and vascular in surgery ticipat a conditions, and compl has r University of Michigan, in Ann Arbor. Michigan cannot complications be from assessed surgery dropped against almost that 2.6 percent national benchmark. participatinghowever, Michigan hospitals a we did change compare that translatesthose into 2,5 among Nancy Birkmeyer is cent, associate professor in the Department of Surgery, University of Michigan. fewer Michigan patients with surgical complications each year. Est therea annual savings from this one collaborative are approximately Richard L. Prager is a up to professor in the Department $20 million, far exceeding the cost of administering the program. Exhibit 3 of Surgery, University of Regional collaborative improvement programs should become Car Michigan. increasingly attractive to hospitals and physicians, as wellgraft as to na Thirty-Day Mortality After Bariatric Hitinder S. Gurm is Surgery: an policy Hospitals makers, In as Michigan they seek Versus to improve Hospitals health care qualityprovem and red assistant professor in the Outside Of Michigan, Department of Internal costs. in ter Medicine, University of measu Michigan. ity; com Mauro Moscucci is a Non-Michigan hospitals professor of medicine in the mamm The need to improve quality of care Background On Hospital Qu Cardiovascular Division of the Michigan hospitals breast Miller School of Medicine, in US hospitals is widely recognized. Potentially avoidable ad- Despite increasing attention Improvement University of Miami, in Coral proces from pa Gables, Florida. verse events are common among makers, and professional organizat hospitalized patients, and wide scale efforts to improve hospital Surger qual Marianne Udow-Phillips is director of the Center for variation in hospital performance outcomes suggests that there is ample room for improve- ing of performance data may motiva little effect on patient outcomes. geons. Pu Healthcare Research and dinatin Transformation, in Ann Arbor. ment. 1 4 The business case for improving hospital quality is also apparent. In surgery, for programs such as the Centers thefor Mi M to improve. 7 However, there remain John D. Birkmeyer is a professor in the Department example, the true cost associated with treating Medicaid Services Hospital lar Compar rep Background On Hospital Quality of Surgery, University of complications exceeds $10,000 per patient, the the Leapfrog Group s selective referr in US hospitals is widely recognized. Potentially Improvement perfor Michigan. avoidable adverse events are common among andmakers, purchasers. and 5 Additional professional payments fororganizations, com- patients to hospitals large- that have Dur de large Despite majorityincreasing of which is passed attention on to payers fromwill payers, be successful policy in redirecting large hospitalized patients, and wide scale efforts to improve hospital quality have had plicated littlehospital effectstays on(outlier patient payments), outcomes. unplanneing of readmissions, performance and caredata following maydis- motivate demonstrated hospitals that patients will ac superior Public results report- Simply and put, it2 to improve. Michig 7 However, there remain doubts that charge for patients with complications account going to hospitals that achieve p programs such as the Centers for Medicare and formedicaid approximately Services 20 percent Hospital of the total costs Compare and start website going to hospitals or indisti that ach associated the Leapfrog with manygroup s inpatient procedures, selective ac-referracording to national Medicare data. 6 these referral patterns could be ter ones. initiative Even if practical will be successful in redirecting large numbers of accord barriers t patients to hospitals that have demonstrated Thora superior results Simply put, such it hasn t efficient been transfer 2 of patien demonstrated that patients will actually stop igan h SOURCE Michigan Surgical Quality Collaborative andgoing National to Surgical hospitals Quality thatimprovement achieve poor Program results 636 Health Affairsand April start 2011going 30:4 to hospitals achieve far better Downloaded ones. from Even content.healthaffairs.org if practical by Health barriers Affairs on to February changing 6, 2012 registries, NOTES Thirty-day mortality rates declined faster in Michigan hospitals than in star ra other hospitals participating in the National Surgical these Quality referralat Improvement patterns STANFORD UNIV Program could MED CTRbe (p ¼addressed 0:045). aggreg Quality Profiles By David A. Share, Darrell A. Campbell, Nancy Birkmeyer, Richard L. Prager, Hitinder S. Gurm, Mauro Moscucci, Marianne Udow-Phillips, and John D. Birkmeyer How A Regional Collaborative Of Hospitals And Physicians In Michigan Cut Costs And Improved The Quality Of Care ABSTRACT There is evidence that collaborations between hospitals and physicians in particular regions of the country have led to improvements in the quality of care. Even so, there have not been many of these collaborations. We review one, the Michigan regional collaborative improvement program, which was paid for by a large private insurer, has yielded improvements for a range of clinical conditions, and has reduced costs in several important areas. In general and vascular surgery alone, complications from surgery dropped almost 2.6 percent among participating Michigan hospitals a change that translates into 2,500 fewer Michigan patients with surgical complications each year. Estimated annual savings from this one collaborative are approximately $20 million, far exceeding the cost of administering the program. Regional collaborative improvement programs should become increasingly attractive to hospitals and physicians, as well as to national policy makers, as they seek to improve health care quality and reduce costs. Percent The need to improve quality of care variation in hospital performance outcomes suggests that there is ample room for improvement. 1 4 The business case for improving hospital quality is also apparent. In surgery, for example, the true cost associated with treating 7000 complications cases exceeds $10,000 per patient, the large majority of which is passed on to payers and purchasers. 5 Additional payments for complicated hospital stays (outlier payments), unplanned readmissions, and care following discharge for patients with complications account? mortalities for approximately 20 percent of the total costs associated with many inpatient procedures, according to national Medicare data. 6 such as efficient transfer of patients medical
33 American College of Surgeons National Surgical Quality Improvement Program Semiannual Report, July 2009 Dates of Surgery: January 1, 2008 December 31, 2008 Stanford Hospital and Clinics
34 New Data Collection Paradigms C L A S S I C L I T E S M A L L / C A H PROCEDURE TARGETED ACS NSQIP PRINCIPLES Focus on high value procedures Reduce low value procedures Higher sampling rates Reduce existing data burden New, procedure-specific data (can include process) Cover the procedures relevant to the hospital, flexible Across specialties Voluntary (self-select) 34
35 Why the Change? Focused Modules n For instance, in General Surgery (the largest set): CORE Colectomy Gastric bypass Cholecystectomy (acute cholecystitis) Ventral hernia repair Pancreatectomy Appendectomy OPTIONAL Thyroidectomy Proctectomy for cancer Cholecystectomy (all cases) Esophagectomy Hepatectomy Carotid (CEA or stent) Abdominal Aortic Aneurysm (open or endo) Aortoiliac Bypass (open or endo) Lower Extremity Bypass (open or endo) n Vascular Surgery (developed in conjunction with SVS)
36 Why the Change? Focused Modules n For instance, a specific set for colectomy might include: Primary indication for surgery cancer, cancer w obstr, polyps, acute tics, chronic tics, bleeding, etc If inflammatory bowel disease, use of preoperative steroids / immunosuppressive agents yes/no Preoperative mechanical bowel prep yes/no Preoperative Oral Antibiotic prep / Oral bowel prep yes/no Operative approach open, lap, hand assisted, unplanned conversion to Anastomotic leak no, yes w/o intervention, yes w/perc intervention, yes w/reoperation Postoperative ileus yes/no (Postoperative placement of nasogastric tube or NPO for >72 hours) n This set was developed with Dr. Anthony Senagore
37 Why the Change? Focused Modules n To Re-emphasize: Focused sets should allow- Site by site decisions on procedure focus Reduction of low impact cases Higher sampling rates (more robust performance assessments) Specific risk factors (ie- bowell prep) Can be process measures Potential reduction in data burden (fewer adjusters needed) Focused outcomes- (ie- colectomy anastamotic leak) Can be process related Improved risk adjustment, improved comparability across cases/sites. Focused QI interventions- aligned with institutional desires Improved individual reporting
38 A Means For Improvement Stanford Cedars Sinai Mayo Clinic University of MN Saint Francis OSF North Shore LIJ Cleveland Clinic Northwestern American College of Surgeons Targeted Solutions Tool Share solutions with 16,000 accredited institutions
39 Joint Commission Center for Transforming Healthcare - American College of Surgeons Surgical Site Infection Project n Participating Hospitals Cedars-Sinai, Cleveland Clinic, Mayo Clinic, Northwestern North Shore Long Island Jewish, OSF Saint Francis, Stanford n In August 2010, CTH launched its fourth project in collaboration with ACS on SSI NSQIP data on outcomes of surgery are widely regarded as highly reliable, with exemplary riskadjusted outcomes
40 Project Summary Project Problem Statement: n The incidence of Surgical Site Infections in colorectal surgery is high, variable, and represents opportunity for improvement. Project Goal: Reduce colorectal surgical site infections by 50% (Observed & O/E) Project Scope: n Process Begins: Pre-Operative Processes (Pre-Op Clinic with Surgeon) n Process Ends: 30 Days Post-Surgery Includes: All emergent & elective surgical procedures Excludes: Trauma and Transplant patients & Patients under 18 years of age
41 Joint Commission Center for Transforming Healthcare - American College of Surgeons Surgical Site Infection Project n Looked for a procedure/outcome that: Is common across different types of hospitals Complications have significant, adverse clinical impact High variability in performance across hospitals n Ideal Candidate = SSI in colorectal surgery
46 It Doesn t Work. 63% Reduction ICU Catheter Infections
47 Motivation Needed?
48 Change Management
49 New Rules n Dialogue is almost always a signpost on the road to quality improvement n Quality is not a personal virtue; it is an performance expectation that is accountable and rewarded. n If you knock one down, you got to put up another one n CAN NOT KEEP DOING THE SAME
51 COLECTOMY IS A COST AND DEFECT MULTIPLIER
52 Pareto Curve
54 BMI: Modifiable? 2009 Colorectal Cases (All NSQIP Hospitals) Class I obesity ( ): 21.69% Class II obesity ( ): 10.19% Class III obesity ( 40): 8.00% 40% of Total Population with BMI > % of Total Population with Cancer 1/3 of our patients could benefit from pre-op surgical weight loss
58 Impact of SSI n Year 2008: SSIs generate an average of $28,211 in extra costs per case and comprise 38% of all morbidities. (ACS NSQIP, Business case, 2008) n SSI s add an additional 7-9 excess hospital days per case. (Infection Control Today, 2002)
59 Science of SSI ( The development of an SSI is a multifactorial and not dependent on perioperative antibiotic administration alone. n Prophylactic Antibiotics n Wound Oxygen Tension ( O2 = SSI risk) n Normothermia Mild hypothermia, 1-2 C, increases wound infection rate. (Kurz, NEJM, 1996) n Glucose Control ( Hyperglycemia = SSI risk)
60 What can be the following step? n Further multivariate analysis of SSI risk factors Diabetes* Poor nutritional status* Medications* Body habitus Age Emergent surgery Post discharge follow up and care
61 What can be the following step? n Identify pathogen n Pattern recognition n OR traffic n Redosing
62 Surgical Site Infection Prevention Strategies Standardized OR Preps þ Preps w/highest efficacy (Chloraprep / Duraprep) Surgery Chlorhexidine Guidelines þ Outpatient Clinics: Provide patient with (4%) CHG EZ scrub sponges for Baths/Showers for pre-op skin prep night before surgery þ Pre Operative Units: If patient does not use (4%) CHG scrub RN to provide (2%) CHG wipes for use day of surgery þ Inpatient Units Nurses: Provide pre-operative antimicrobial skin prep using (2%) CHG Cloths night before or morning of surgery
63 Scrubs Outside of the OR-Evidence Needed? n n We have a tremendous image problem in the medical industry anyway, Barone told me. Because of the perceived prevalence of medical errors, people are amazed that anyone can get through the ordeal of being in the hospital. So just for the sake of improving our image, we should probably leave the scrubs at home. A few said that Martin was proposing a draconian solution to a relatively minor problem without EVIDENCE and that, should the health care field start clamping down on scrubs, they might as well prevent health care workers from carrying cell phones, laptops and all kinds of other objects that can ferry pathogens from the hospital to the home and everywhere in between DATA Don t demonstrate If we can t be perfect why try?
64 n Three trials of 1443 n Participants compared bar soap with chlorhexidine; when combined there was no difference in the risk of SSIs (RR 1.02, 95% CI 0.57 to 1.84). Three trials of 1192 patients compared bathing with chlorhexidine with no washing, one large study found a statistically significant difference in favour of bathing with chlorhexidine (RR 0.36, 95%CI 0.17 to 0.79). ITS SOAP!!!!
65 Blood Utilization: Quality Improvement- Why and How? John M. Morton, MD, MPH, FACS Associate Professor Director of Surgical Quality Stanford University Medical Center
67 Blood Transfusion Methods n Nation-wide Inpatient Sample n 7 million annual discharges/1000 Hospitals n All-Payor n Blood Transfusion ICD 9 Procedure Codes 99.XX or V58.2 n Regression Analyses Controlled for Age, Gender, Race, Charlson Comorbidity, Admission Type, Payor
70 Blood Transfusion Prevalence How Are Patients Different?
71 Blood Transfusion Prevalence How Are Patients Different? ALL Tx No TX
72 Blood Transfusion Prevalence Outcomes
73 Blood Transfusion Prevalence Outcomes ALL Tx No TX
74 Predictors of Postoperative Bleeding 1) Advanced age 2) Small body size or preoperative anemia (low RBC volume) 3) Anti-platelet & anti-thrombotic drugs. 4) Prolonged operation (CPB time) high correlation with OR type. 5) Emergency operation 6) Other co-morbidities (CHF, COPD, HTN, PVD, renal failure, etc.)
75 Causes of Postoperative Bleeding & Blood Transfusion n Patient-related Age Red blood cell volume Co-morbidities CHF Renal failure COPD n Procedure-related Prolonged operation Emergency operation Surgical site bleeding ( hole in the artery )
76 Guidelines & Aspirin the Dilemma n Aspirin causes increased bleeding. Amount of bleeding is small (0.5 units/patient) n Aspirin important for better outcome in acute coronary syndromes Nothing more important than aspirin including heparin, thrombolytics, 2b/3a, & PCI. n STS recommendation stop aspirin for a few days in very low risk patients, continue in all others. Ferraris VA, et al. STS Guidelines. Ann Thorac Surg. 2005;79:
77 Do Thienopyridines Cause Postoperative Bleeding? n Evidence is more compelling than for aspirin n 11 studies with clopidogrel & CABG. n All studies show increased bleeding when clopidogrel given within 5 days of CABG some with increased mortality. n AHA/ACC & STS guidelines recommend stop clopidogrel for 5 days before operation, if possible. Ferraris VA, et al. STS Guidelines. Ann Thorac Surg. 2005;79: ; Accessed Jan
78 Thienopyridines (Plavix ) & Postoperative Bleeding Study Pts. Outcome in clopidogrel-treated patients. CURE Investigators. NEJM, 2005; 345:492. van der Linden, Circulation. 2005;112:I Akowuah, ATS. 2005;80: Von Heymann, CCM; 2005:33:2241. Increased major bleeding if plavix-treated within 5 days of CABG in UA/NSTEMI patients. 37 Increased bleeding & re-exploration aprotinin used in one group Increased mortality, transfusion, and re-exploration in placebo - aprotinin & EACA used in one group. 36 Increased chest tube drainage & non-heme. Lindvall, ATS. 2005;80: Increased transfusion (heme & non-heme), & re-exploration Ascione, ATS. 2005;79: Increased mortality, transfusion and re-exploration. Chu, ATS. 2004;78: Increased transfusion (heme & non-heme) Chen, JTCVS. 2004;128: Increased transfusion (heme & non-heme) Gansera, Thorac Cardiovasc Surg.2003;51:185. Ray, BMC Cardiovasc Disord, 2003;3:3. 64 Increased transfusion (heme and non-heme), & re-exploration 57 Increased re-exploration & transfusion Yende, CCM. 2002;29: Increased transfusion (heme & non-heme) & re-exploration. Hongo, JACC. 2002:40: Increased morbidity, transfusion, & re-exploration.
79 What Works for Blood Conservation? n Multiple interventions are better than a few favorite interventions. n TQM approach Measurement & Management. n Outcome greater than sum of parts Examples Normovolumic hemodilution Anti-fibrinolytic drugs
80 Normovolemic Hemodilution Class IIb Recommendation n 5 prospective studies 3 showed no benefit 2 showed benefit Not possible to do meta-analysis. n Contraindications Urgent operation Anemia Sepsis n May be beneficial when used as part of a multimodality approach.
81 Most of Patients Received One Unit PRBC! Transfusions for Carotid Endarterectomy Number of patients > 6 Number of PRBC transfused
82 Transfusion Profile 4445 patients having cardiac procedures w/ CPB over 4 years Legend Frequency Cumulative % 100% 80% 60% 40% 20% Cumulative percent n More than 50% do not get transfusion. n Patients who receive > 10 units of blood are in 90 th percentile n 10-20% of patients consume 80% of blood products. Number of patients receiving transfusion 0 0% Units of blood products transfused Ferraris, Int. J. Angiology, 2006.
83 Transfusion & Serious Morbidity n Serious morbidity and mortality increase with the amount transfused Fraction with serious morbidity thru 5 6 thru thru thru thru thru thru thru thru 45 Donor units transfused >45
84 What About Small Amounts of Blood Transfusion Study Mortality without transfusion Mortality from Transfusion of 1-2 U PRBC Mortality from Transfusion of 3 or more U PRBC Relative Risk for Transfusion of 1-2 U PRBC Carotid Endarterectomy Non-cardiac Chest Operations Lower Extremity Revascularization 0.8% 6.1% 8.0% 2.74 (p < 0.001) 2.4% 7.2% 13.9% 2.01 (p < 0.001) 1.9% 6.2% 2.48 (p < 0.001) Ferraris, STSA, 2009
85 Bleeding After PCI Is a Risk for 1-year Mortality (5,384 patients) n Independent predictors of 1-year mortality. Variable Hazard Ratio (95% CI) Bleeding w/in 30 days 2.96 ( ) MI w/in 30 days 2.29 ( ) Urgent revascularization w/in 30d 2.49 ( ) Age (years) 2.27 ( ) Diabetes 1.47 ( ) Multivessel CAD 2.72 ( ) Elevated troponin 1.77 ( ) LV ejection fraction 0.71 ( ) Creatinine 1.10 ( ) Ndrepepa, 2008
86 Variability in Transfusion Practices n Physician & institution practices are hard to manage (control is a bad word!). n Accurate & timely information is not available ( lab takes too long). Stover, Anesthesiology. 1998;88:327.
87 Problems with Interventions - Consensus Guidelines for RBC Transfusion Transfusion indicated Hgb 6.0 on CPB Hgb 8.0 in high risk (age > 65, and/or comorbidity). Acute blood loss (30% of blood volume). Rapid blood loss without immediate control. Hgb 10 g/dl in certain patients with critical end-organ ischemia. Transfusion not indicated Hgb 10 after CPB without critical end-organ ischemia. Uncertain benefit of transfusion Hgb between 8-10g/ dl in a stable patient benefit is unclear.
88 Guidelines for Transfusion of Non-red Cell Hemostatic Factors n No evidence base! n Transfuse for clinical bleeding only. Can be guided by accurate & timely point-of-care tests (e.g. Platelet count, PFA-100, TEG, POC PT/PTT, etc.). Ferraris VA, et al. STS Guidelines on blood conservation. Ann Thorac Surg, 2007.
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Last Updated: Version 4.3b NQF-ENDORSED VOLUNTARY CONSENSUS STANDARDS FOR HOSPITAL CARE Measure Information Form CMS/The Joint Commission: Suspended (Effective immediately beginning with July 1, 2014 discharges)
Round Table: Antithrombotic therapy beyond ACS Antiplatelet and anticoagulation treatment of patients undergoing carotid and peripheral artery angioplasty M. Matsagkas, MD, PhD, EBSQ-Vasc Associate Professor
Using Medicare Hospitalization Information and the MedPAR Beth Virnig, Ph.D. Associate Dean for Research and Professor University of Minnesota MedPAR Medicare Provider Analysis and Review Includes information
Patient Experience The Cleveland Clinic Journey American Medical Group Association Orlando, Florida March 14, 2013 James Merlino, MD Chief Experience Officer Overview How did Cleveland Clinic change their
Appendix 1. Description of the OECD Health Care Quality Indicators as well as indicator-specific information The numbers after the indicator name refer to the report(s) by OECD and/or THL where the data
Blue Distinction Centers for Bariatric Surgery Clinical Program Requirements for 2010 Mid-Point Designations Evaluation is based primarily on the facilities responses to the Blue Distinction Centers for
Perioperative Cardiac Evaluation Caroline McKillop Advisor: Dr. Tam Psenka 10-3-2007 Importance of Cardiac Guidelines -Used multiple times every day -Patient Safety -Part of Surgical Care Improvement Project
Kidney Transplant Candidate Informed Consent Education Here are educational materials about Kidney Transplant. Please review and read these before your evaluation visit. The RN Transplant Coordinator will
Building an ASC Surgical Site Infection Surveillance Program Lori Groven, MSPHN, RN, CIC Mary Haugen, RN, MA Lori Groven, MSPHN, RN, CIC Mary Haugen, RN, MA Objectives 1. Describe the process of starting
The Impact of Regional Anesthesia on Perioperative Outcomes By Dr. David Nelson As a private practice anesthesiologist, I am often asked: What are the potential benefits of regional anesthesia (RA)? My
Emerging Topics in Healthcare Reform Preventing Readmissions Janssen Pharmaceuticals, Inc. Preventing Readmissions The Patient Protection and Affordable Care Act (ACA) contains several provisions intended
Anesthesia & Perioperative Medicine 167 Ashley Avenue, Suite 301 MSC 912 Charleston, SC 29425-9120 Tel 843 792 2322 Fax 843 792 9314 Department of Anesthesia & Perioperative Medicine 5-Year Strategic Plan
THE ROLE OF LONG TERM ACUTE CARE HOSPITALS IN THE ACUTE CARE CONTINUUM Wednesday, June 02, 2010 As A Provider Of Continuing Nursing Education, Triumph Healthcare Is Required By Texas Nurses Association
National Provider Call: Hospital Value-Based Purchasing (VBP) Program Fiscal Year 2016 Overview for Beneficiaries, Providers and Stakeholders Cindy Tourison, MSHI Lead, Hospital Inpatient Quality Reporting
U.S. Department of Health & Human Services May 7, 2014 New HHS Data Shows Major Strides Made in Patient Safety, Leading to Improved Care and Savings The data in this report shows a substantial nine percent
VUMC Guidelines for Management of Indwelling Urinary Catheters UC Insertion Preparation & Procedure Indications for insertion and continued use of indwelling urinary catheters include: Urinary retention
(NQF) Title Description Numerator 122v2 1 0059 Diabetes: Hemoglobin A1c Poor Control N/A 21 0268 Perioperative Care: Selection of Prophylactic Antibiotic First OR Second Generation Cephalosporin Percentage
Catheter Associated Urinary Tract Infection (CAUTI) Prevention System CAUTI Prevention Team 1 Objectives At the end of this module, the participant will be able to: Identify risk factors for CAUTI Explain
January 2012 Purpose of the Project The human and financial costs of cardiovascular disease are enormous. Heart disease is the leading cause of death for men and women in the United States and was estimated
eappendix A. Summary for Preoperative ECG American College of Cardiology/ American Heart Association, 2007 A1 2002 A2 European Society of Cardiology and European Society of Anaesthesiology, 2009 A3 Improvement,
What is Vascular Surgery Worth to a Health Care System? Peter Gloviczki, MD Robert Zwolak, MD Sean Roddy, MD Conflict of Interest NONE Mayo Clinic, Rochester, MN, Dartmouth-Hitchcock Medical Center, Lebanon,
Perioperative Management of Diabetes S Rajbhandari (Nepal/UK) Diabetes in Nepal 19.0% above the age of 40 have diabetes in urban area Shrestha Diabet Med 23 (2006)1130 25.9% above the age of 60 have diabetes
MN Community Measurement Total Knee Replacement Impact and Recommendation Document June 2010 Degree of Impact Relevance to Consumers, Employers and Payers Annually there are over 500,000 total knee replacement
1 IDENTIFYING CLINICAL RESEARCH QUESTIONS THAT FIT PRACTICE PRIORITIES Module I: Identifying Good Questions Objective Describe how to find good clinical questions for research. 2 ntifying good clinical
BLOOD CONSERVATION STRATEGIES IN CARDIAC SURGERY: MORE IS BETTER GUIDELINES IN ANTIPLATELET AND ANTICOAGULATION RX IN CARDIAC SURGERY DIMITRIOS V. AVGERINOS MD, PhD, FACS, FACC Department of Cardiac Surgery,
Office of Rural Health Policy MEDICARE BENEFICIARY QUALITY IMPROVEMENT PROJECT Paul Moore, DPh Senior Health Policy Advisor Office of Rural Health Policy Health Resources and Services Administration Department
Stroke/VTE Quality Measure Build for Meaningful Use Stage 1 Presented by Susan Haviland, BSN RN Senior Consult, Santa Rosa Consulting Meaningful Use Quality Measures Centers for Medicare and Medicaid Services
Demographics *LMRN: *DOB: / / *Gender: Male Female *Race: White Native Hawaiian/Other Pacific Islander Black or African American Asian American Indian or Alaska Native Unknown *Hispanic Ethnicity: Unknown
Three-Star Composite Rating Method CheckPoint uses three-star composite ratings to enable consumers to more quickly and easily interpret information about hospital quality measures. Composite ratings combine
Getting smart about dyspnea and life saving drug therapy in ACS patients Kobi George Kaplan Medical Center Rehovot 78 year old female Case description Presented with resting chest pain and dyspnea Co morbidities:
MAKING DOLLAR$ AND $ENSE FROM A CARDIAC ANESTHESIA PRACTICE Christopher A. Troianos, MD Professor and Chair of Anesthesiology Western Pennsylvania Hospital West Penn Allegheny Health System Western Campus
Patient Optimization Improves Outcomes, Lowers Cost of Care > Consistent preoperative processes ensure better care for orthopedic patients The demand for primary total joint arthroplasty is projected to
Cilostazol versus Clopidogrel after Coronary Stenting Seong-Wook Park, MD, PhD, FACC Division of Cardiology, Asan Medical Center University of Ulsan College of Medicine Seoul, Korea AMC, 2004 Background
Sepsis: Identification and Treatment Daniel Z. Uslan, MD Associate Clinical Professor Division of Infectious Diseases Medical Director, UCLA Sepsis Task Force Severe Sepsis: A Significant Healthcare Challenge
NQF-Endorsed Measures for Surgical Procedures TECHNICAL REPORT February 13, 2015 This report is funded by the Department of Health and Human Services under contract HHSM-500-2012-00009I Task Order HHSM-500-T0008
Specialty Excellence Award and America s 100 Best Hospitals for Specialty Care 2013-2014 Methodology Contents Introduction... 2 Specialty Excellence Award Determination... 3 America s 100 Best Hospitals
Objectives HCAHPS, Value-Based Purchasing and A Culture of Always Karen Cook, RN BSN www.studergroup.com 1. Describe the history and current usage of the CAHPS family of surveys and other relevant outpatient
THE 2015 QUALIS HEALTH AWARDS OF EXCELLENCE IN HEALTHCARE QUALITY Since 2002, Qualis Health has presented the annual Awards of Excellence in Healthcare Quality to outstanding organizations in Idaho and
NURSE DRIVEN FOLEY CATHETER PROTOCOL BACKGROUND There are over 1.7 million hospital-acquired infections in US hospitals annually, 40% of which are urinary tract infections. 80% of hospital-acquired UTIs
September 12, 2011 Janet M. Corrigan, PhD, MBA President and Chief Executive Officer National Quality Forum 601 13th Street, NW Suite 500 North Washington, D.C. 20005 Re: Measure Applications Partnership
Using CDS (Clinical Decision Support) for Quality Initiatives at a Community Hospital Jonathan Sykes MD, CMIO Jacalyn Liebowitz RN, MBA,NEA-BCFACHE VP Care Continuum Allegiance Health - Jackson, MI DISCLAIMER:
Navigating the Regulatory Issues of Blood Management Bob Dyga RN, CCP, LP, CPBMT Vice President, Perfusion Operations UPMC/Procirca History of Transfusion Medicine Blundell s Blood Gravitator h2p://bloodjournal.hematologylibrary.org/content/112/7/2617/f5.large.jpg
Accountable Care Organization April 13, 2011 The Indianapolis Association of Health Underwriters Drivers of Payment Reform Increased attention to regional variation in costs and quality Payment for care
ACO 1-7 Patient Satisfaction Survey Consumer Assessment of HealthCare Providers Survey (CAHPS) 1. Getting Timely Care, Appointments, Information 2. How well Your Providers Communicate 3. Patient Rating
CMS-0033-P 153 convey the clinical quality measure's title, number, owner/developer and contact information, and a link to existing electronic specifications where applicable. TABLE 20: Proposed Clinical
Medical School Center for Healthcare Outcomes & Policy Bldg 520, Room 31658 2800 Plymouth Rd, SPC 2800 Ann Arbor, Ml48109 (734) 998-7470 (734) 998-7473 fax January 18, 2013 Jyme H. Schafer, MD, MPH Director,
Strategies to reduce postoperative wound infections Dr Ann Bull Operations Director VICNISS Coordinating Centre London 2012 final medal tally: Australia s consolation prize Eventing results Surgical site
The New Complex Patient as Seen Through the Lens of Diabetes Clinical Programming 1 Valerie Garrett, M.D. Medical Director, Diabetes Center at Mission Health System Nov 6, 2014 Diabetes Health Burden High
How We Rate Hospitals June 2014 1. Overview....................................................................... 2 2. Patient Outcomes 2.1 Avoiding infections.......................................................