Leap and SCIP Your Way to Better Outcomes


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  • SCIP is a national quality partnership of organizations committed to improving the safety of surgical care by decreasing postop complications Involves surgeon, anesthesiologists, perioperative RN, ICU/med surg RNs, pharmacy, infection control
  • Pre-op cardiac clearance is important; prophylaxis and cardioprotective measures equally as important
  • Low dose unfractionated heparin (LDUH) as effective and costs ½ of Low molecular weight heparin (LMWH) What is prophylaxis? SCD’s and lovenox/heparin or therapeutic coumadin levels… NOT ASA, plavix, or aggrenox or TEDS!!!
  • (80% goal for all measures) Urgent/Emergent cases may skew beta blocker within 24hr of surgery data
  • For AAA repair, beta blocker before admission and at discharge
  • Leap and SCIP Your Way to Better Outcomes

    1. 1. Leap and SCIP Your Way to Better Outcomes Jennifer Joiner, MSN, RN, CCRN-CSC Clinical Nurse Educator, Cardiac Surgery Robert Wood Johnson University Hospital
    2. 2. SCIP <ul><li>Surgical Care Improvement Project </li></ul><ul><li>Goals: </li></ul><ul><ul><li>Decrease the incidence of surgical complications by 25% by 2010 </li></ul></ul><ul><ul><li>Decrease mortality and morbidity through collaborative efforts </li></ul></ul>
    3. 3. In 2003: <ul><li>Post-op complications accounted for ~22% of preventable deaths </li></ul><ul><li>Focused on 18 types of medical injuries related to 2.4 million additional hospital days and $9.3 billion in extra costs </li></ul>
    4. 4. Surgical Site Infections (SSI’s) <ul><li>Account for 14-16% of all hospital acquired infections </li></ul><ul><li>BUT- 40% of surgical patients’ infections are related to SSI’s </li></ul>
    5. 5. Several Organizations Contribute to Better Outcomes <ul><li>National Surgical Quality Improvement Program (NSQIP)- decreased mortality rate at the VA by 27% </li></ul><ul><li>National Nosocomial Infections Surveillance (NNIS) System of the CDC- decreased up to 44% in device-associated complications and infection rates </li></ul><ul><li>Medicare’s Quality Improvement Organizations (QIO’s)- Decreased SSI’s by 27% at 56 centers in the US (** contracts with CMS) </li></ul>
    6. 6. Main Focus Areas of SCIP <ul><li>Infection </li></ul><ul><ul><li>Antibiotics given within 1 hr of incision time (91.2%) </li></ul></ul><ul><ul><li>Right Antibiotic ordered (100%) </li></ul></ul><ul><ul><li>Antibiotic discontinued within 24/48hr (83.8%) </li></ul></ul><ul><ul><li>6am Blood Sugar (cardiac surgery patients) less than 200* (92%) </li></ul></ul><ul><ul><li>Post-op wound infections (0% Deep SWI) </li></ul></ul><ul><ul><li>Appropriate hair removal (100%) </li></ul></ul>
    7. 7. Adverse Cardiac Events <ul><li>Occurs in </li></ul><ul><ul><li>2-5% of non-cardiac surgery patients </li></ul></ul><ul><ul><li>34% of vascular surgery patients </li></ul></ul><ul><li>BUT- Perioperative MI is related to a 40-70% mortality rate plus </li></ul><ul><ul><li>Increased LOS, costs and morbidity </li></ul></ul><ul><li>Nearly ½ of fatal cardiac events could have been prevented with Beta Blocker therapy during the perioperative period (by decreasing cardiac ischemia) </li></ul>
    8. 8. <ul><li>Cardiac </li></ul><ul><ul><li>Beta Blocker given during the perioperative period if on one pre-op (100%) </li></ul></ul><ul><ul><li>Acute MI within 30 days of surgery </li></ul></ul>
    9. 9. Venous Thromboembolism (VTE’s) <ul><li>For all major surgeries without prophylaxis ordered: </li></ul><ul><ul><li>25% DVT rate </li></ul></ul><ul><ul><li>7% PE rate </li></ul></ul><ul><li>High risk: Orthopedic surgery without prophylaxis ordered: </li></ul><ul><ul><li>Over 50% DVT rate </li></ul></ul><ul><ul><li>30% PE rate </li></ul></ul><ul><li>Problem: Underused or inappropriate treatment used for prophylaxis </li></ul>
    10. 10. VTE (Venous Thromboembolism) <ul><ul><li>VTE Prophylaxis (95.3%) </li></ul></ul><ul><ul><li>VTE Prophylaxis from 24hr before surgery to 24 hr after surgery (94.6%) </li></ul></ul><ul><ul><li>PE within 30 days of surgery </li></ul></ul><ul><ul><li>DVT within 30 days of surgery </li></ul></ul>
    11. 11. Respiratory Complications <ul><li>Post-op pneumonia-- 9-40% incidence rate </li></ul><ul><li>Pneumonia is associated with a 30-45% mortality rate as a complication after surgery </li></ul>
    12. 12. Data Collection to be added at a later date <ul><li>Respiratory </li></ul><ul><ul><li># of days vent patient had HOB documented through POD #7 </li></ul></ul><ul><ul><li>VAP rate </li></ul></ul><ul><ul><li># of days PUD prophylaxis ordered through POD #7 </li></ul></ul><ul><ul><li># of patients with vent weaning orders documented </li></ul></ul>
    13. 13. <ul><li>Mortality Rate within 30 days of surgery (1.49% vs. 3.4% expected rate) </li></ul><ul><li>Readmission Rate within 30 days of surgery </li></ul>
    14. 14. The Leap Frog Group <ul><li>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. </li></ul><ul><li>Long-term goal: to reward hospitals and MDs on the basis of excellence in quality and quality improvement. </li></ul><ul><ul><li>Inadequate IT systems and public reporting is not consistent to benchmark against; thus, group is focusing on patient safety </li></ul></ul>
    15. 15. Leap Frog Group <ul><li>Offers valuable benchmarking capabilities to hospitals </li></ul><ul><li>Provide consumers and purchasers of health care with information on the quality and safety of their hospitals </li></ul><ul><li>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 </li></ul>
    16. 16. RWJUH Named One of Top 33 Hospitals in Quality and Safety by the 2008 Leap Frog Group Survey <ul><li>RWJUH is one of 2 hospitals in NJ </li></ul><ul><li>33 hospitals chosen out of 1200+ nationwide </li></ul><ul><ul><li>26 hospitals, 7 children’s hospitals </li></ul></ul>
    17. 17. Leap Frog Patient Safety Standards <ul><li>Computer Physician Order Entry </li></ul><ul><li>* costs r/t startup, equipment, training, maintanence </li></ul><ul><li>* decreased med errors and adverse drug events- $180-900K/year </li></ul><ul><li>* decreased repeated tests, lab, radiology, history, losing paper charts; increased efficiency </li></ul><ul><li>ICU Physician Staffing </li></ul><ul><li>*costs r/t salary; decreased LOS, inappropriate ICU admissions, inappropriate testing and consults, complications- $800K-$3.4 million </li></ul><ul><li>Evidenced-Based Hospital Referral for high risk surgeries and neonatal intensive care </li></ul><ul><li>* Idea is the more you do, the better you are at it </li></ul><ul><li>* costs r/t administrative, moving patients, redundancy in testing and evaluation, more costly care in academic centers; smaller hospitals would suffer </li></ul>
    18. 18. <ul><li>Never Events </li></ul><ul><ul><li>28 serious reportable events by NQF </li></ul></ul><ul><ul><ul><li>Leaving foreign objects in patients after surgery/procedure </li></ul></ul></ul><ul><ul><ul><li>Death or serious injury related to: </li></ul></ul></ul><ul><ul><ul><ul><li>Med error </li></ul></ul></ul></ul><ul><ul><ul><ul><li>ABO/HLA incompatible blood or blood product causing a hemolytic reaction </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Electric shock or electric cardioversion </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Fall </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Hypoglycemia </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Air embolism </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Use or function of a device in a manner other than intended </li></ul></ul></ul></ul><ul><ul><ul><li>Wrong patient, site, or procedure performed </li></ul></ul></ul><ul><ul><ul><li>Intra-operative or immediate post-op death in an ASA Class 1 patient </li></ul></ul></ul><ul><ul><ul><li>Stage 3 or 4 hospital-acquired pressure ulcer </li></ul></ul></ul><ul><li>Surgeon Mortality Rates </li></ul>
    19. 19. <ul><li>National Quality Forum Safe Practices (NQF-SP) </li></ul><ul><ul><li>Resource Utilization Measures (“Core Measures”) </li></ul></ul><ul><ul><ul><li>CABG </li></ul></ul></ul><ul><ul><ul><li>PCI </li></ul></ul></ul><ul><ul><ul><li>AMI </li></ul></ul></ul><ul><ul><ul><li>Pneumonia </li></ul></ul></ul><ul><ul><ul><li>AAA Repair </li></ul></ul></ul><ul><ul><ul><li>NICU </li></ul></ul></ul>
    20. 20. Cardiac Surgery Measures <ul><li>ASA/Plavix at discharge- 99.3% </li></ul><ul><li>Use of IMA- 99.3% </li></ul><ul><li>Beta Blocker w/in 24h of sx 73.9% </li></ul><ul><li>Beta Blocker at discharge 94% </li></ul><ul><li>Anti-Lipid meds at discharge 95.5% </li></ul>
    21. 21. Percutaneous Coronary Intervention (PCI) <ul><li>PCI within 90 min of arrival- AMI 88.2% </li></ul><ul><li>ASA on arrival 98.4% </li></ul><ul><li>ASA at discharge 99.1% </li></ul>
    22. 22. Acute Myocardial Infarction (AMI) <ul><li>ASA on arrival 98.4% </li></ul><ul><li>ASA at discharge 99.1% </li></ul><ul><li>ACE-I or ARB for LVSD 95% </li></ul><ul><li>Adult Smoking Cessation Advice/Counseling 100% </li></ul><ul><li>Beta Blocker at discharge 100% </li></ul><ul><li>Beta Blocker on arrival 97.9% </li></ul><ul><li>PCI within 90min 88.2% </li></ul>
    23. 23. Pneumonia <ul><li>Oxygenation assessment-ABG within 24hr 100% </li></ul><ul><li>Pneumococcal vaccine for all with pneumonia (and all 65+) given prior to discharge 54.8% </li></ul><ul><li>Blood cultures within 24hr of admission to the ICU 100% </li></ul><ul><li>Smoking cessation advice/counseling 100% </li></ul><ul><li>Initial Antibiotic within 6hr of arrival 94.6% </li></ul><ul><li>Flu vaccine given prior to discharge (n/a for 2 nd qtr) </li></ul>
    24. 24. Hospital Acquired Conditions <ul><li>Pressure Ulcers </li></ul><ul><li>Injuries </li></ul><ul><li>In addition- </li></ul><ul><ul><li>Severity adjusted average LOS inflated by a 14day all-cause readmission rate </li></ul></ul>
    25. 25. How Can The RN Impact Outcomes? <ul><li>Perioperative RN: </li></ul><ul><ul><li>Abx within 1hr of incision time </li></ul></ul><ul><ul><li>Right Abx ordered/given </li></ul></ul><ul><ul><li>Appropriate hair removal </li></ul></ul><ul><ul><li>Beta Blocker prior to surgery </li></ul></ul><ul><ul><li>VTE prophylaxis </li></ul></ul><ul><ul><li>Peridex given prior to intubation </li></ul></ul><ul><ul><li>DOCUMENTATION!!! </li></ul></ul><ul><ul><li>Don’t be afraid to speak up!!! </li></ul></ul>
    26. 26. <ul><li>ICU RN: </li></ul><ul><ul><li>Antibiotics stopped within the right time period? (cardiac sugery up to 48hr; all others 24hr) </li></ul></ul><ul><ul><li>6am blood sugar under control (cardiac surgery) </li></ul></ul><ul><ul><li>Post-op wound infection- incision care and assessments </li></ul></ul><ul><ul><li>VTE prophylaxis? </li></ul></ul><ul><ul><li>VAP prevention bundle </li></ul></ul><ul><ul><li>Pulmonary toileting, ambulation </li></ul></ul><ul><ul><li>Vent weaning documentation (yes/no/why) </li></ul></ul><ul><ul><li>ASA/plavix, Beta Blocker, and Anti-Lipid on transfer out of ICU? (For AMI, ACE-I and/or ARB?) </li></ul></ul><ul><ul><li>Vaccine status/orders for discharge dose </li></ul></ul><ul><ul><li>ABG, blood cultures within 24hr and antibiotic given within 6hr for pneumonia? </li></ul></ul><ul><ul><li>Smoking cessation counseling for all smokers </li></ul></ul><ul><ul><li>Prevention of pressure ulcers and injuries </li></ul></ul><ul><ul><li>“ Get the Red Out”!!! </li></ul></ul><ul><ul><li>DOCUMENTATION AND ADVOCACY!!! </li></ul></ul>
    27. 27. Med-Surg and Telemetry RN: <ul><ul><li>Antibiotics stopped within right time period? </li></ul></ul><ul><ul><li>6am blood sugar under control? (cardiac surgery) </li></ul></ul><ul><ul><li>PUD, VTE prophylaxis ordered through POD #7 </li></ul></ul><ul><ul><li>Pulmonary toileting, ambulation </li></ul></ul><ul><ul><li>ASA/Plavix, Beta Blocker, Anti-Lipid, (ACE-I and ARB for AMI) at discharge? </li></ul></ul><ul><ul><li>Smoking cessation counseling </li></ul></ul><ul><ul><li>ABG, blood cultures within 24hr, antibiotic given within 6hr of arrival? </li></ul></ul><ul><ul><li>Vaccine status addressed and orders entered for day of discharge </li></ul></ul><ul><ul><li>Prevention of pressure ulcers and injuries </li></ul></ul><ul><ul><li>“ Get the Red Out”!!! </li></ul></ul><ul><ul><li>DOCUMENTATION AND ADVOCACY!!! </li></ul></ul>
    28. 28. Resources <ul><li>www.leapfroggroup.org </li></ul><ul><li>www.pronj.org </li></ul><ul><li>www.medqic.org </li></ul><ul><li>www.sts.org </li></ul><ul><li>www.va.gov </li></ul><ul><li>www.ihi.org </li></ul><ul><li>www.jcaho.org </li></ul><ul><li>www.ahrq.gov </li></ul><ul><li>www.cms.hhs.gov </li></ul><ul><li>www.hospitalcompare.hhs.gov </li></ul>