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The Surgical Care Improvement Project  A National Initiative to Improve Outcomes for Patients having Surgery Dale W. Bratz...
Surgical Care Improvement Project National Goal To reduce preventable surgical morbidity and mortality by 25% by 2010
SCIP Steering Committee <ul><li>American College of Surgeons </li></ul><ul><li>American Hospital Association </li></ul><ul...
Surgical Care Improvement Project (SCIP) <ul><li>Preventable Complication Modules </li></ul><ul><ul><li>Surgical infection...
Surgical Infection Prevention
Surgical Site Infections (SSI) <ul><li>2-5% of operated patients will develop SSI  </li></ul><ul><ul><li>40 million operat...
Surgical Care Improvement Project Performance measures - Process <ul><li>Surgical infection prevention </li></ul><ul><ul><...
Efficacy Of Prophylaxis Is Independent Of The Specific Antibiotic Age of Lesion at Antibiotic Injection (Hours) Lesion Siz...
Timing of Antibiotic Prophylaxis GI Operations Stone HH et al.  Ann Surg . 1976;184:443-452.
Perioperative Antibiotics Timing of Administration Classen, et al.  N Engl J Med . 1992;328:281. Hours From Incision 14/36...
Antibiotic Recommendation Sources <ul><li>American Society of Health System Pharmacists  </li></ul><ul><li>Infectious Dise...
 
Single vs Multiple Dose Surgical Prophylaxis: Systematic Review McDonald. Aust NZ J Surg 1998;68:388 Favors single dose Fa...
Impact of Prolonged Antibiotic Prophylaxis <ul><li>2,641 CABG patients </li></ul><ul><ul><li>Grp 1 -  <  48 hours of antib...
Antibiotic Timing Related to Incision Bratzler DW, Houck PM, et al.  Arch Surg . 2005; 140:174-182 .
Discontinuation of Antibiotics Patients were excluded from the denominator of this performance measure if there was any do...
Surgical Infection Prevention Performance Stratified by Surgery 1 1  All results are weighted to reflect adjustment based ...
Surgical Infection Prevention Performance Stratified by Surgery 1 1  All results are weighted to reflect adjustment based ...
Surgical Infection Prevention Performance Stratified by Surgery 1 1  All results are weighted to reflect adjustment based ...
Latham R, et al.  Infect Control Hosp Epidemiol . 2001.
Perioperative Glucose Control <ul><li>1,000 cardiothoracic surgery patients </li></ul><ul><li>Diabetics and non-diabetics ...
Furnary et al. Ann Thorac Surg 1999:67:352
Pre-operative shaving <ul><li>Shaving the surgical site with a razor induces small skin lacerations </li></ul><ul><ul><li>...
Temperature Control <ul><li>200 colorectal surgery patients </li></ul><ul><ul><li>control - routine intraoperative thermal...
Cardiovascular Complication Prevention
Prevention of Cardiac Events Introduction <ul><li>As many as 7-8 million Americans that undergo major noncardiac surgery h...
Surgical Care Improvement Project Performance measures - Process <ul><li>Perioperative cardiac events </li></ul><ul><ul><u...
Prevention of Cardiac Events Introduction <ul><li>Neurohormonal stress </li></ul><ul><ul><li>Increased heart rate </li></u...
Prevention of Cardiac Events Introduction <ul><li>Perioperatively administered beta blockers have the potential to: </li><...
Prevention of Cardiac Events A Sample of Some of the Studies Decreased myocardial ischemia Esmolol Total knee 60 PR Urban,...
Prevention of Cardiac Events Mangano DT, et al. N Engl J Med. 1996;335:1713-1720. <ul><li>Randomized, placebo controlled t...
Postoperative Survival <ul><li>6-month survival 100% vs 92% (P<0.001) </li></ul><ul><li>2-yr survival 90% vs 79% (P=0.019)...
How often is postoperative myocardial infarction  potentially  preventable?  <ul><li>72 Patients identified with postopera...
72 Patients with PMI 70 at high risk 58 ideal candidates 12 with BB contraindications 2 not high risk 30/58 Rx with BB (5 ...
Perioperative Beta blockers ACC/AHA Guideline <ul><ul><li>Class I recommendation </li></ul></ul><ul><ul><ul><li>Beta block...
Venous Thromboembolism Prevention
Prevention of Venous Thromboembolism Introduction <ul><li>VTE Remains a major health problem in the US </li></ul><ul><ul><...
Prevention of Venous Thromboembolism <ul><li>Despite the well known risk of VTE and the publication of evidence-based guid...
Surgical Care Improvement Project Performance measures - Process <ul><li>Prevention of venous thromboembolism </li></ul><u...
Published Audits of VTE Prophylaxis General Surgery <ul><li>Anderson, et al. </li></ul><ul><ul><li>1986 audit of 16 Massac...
Published Audits of VTE Prophylaxis General Surgery Use of any form of prophylaxis based on level of risk for venous throm...
Published Audits of VTE Prophylaxis General Surgery <ul><li>Stratton, et al </li></ul><ul><ul><li>Audit in 10 teaching or ...
VTE Prophylaxis in General Surgery National SIP Project - Results * Prophylaxis was considered appropriate if the patient ...
ACCP Guidelines for VTE Prevention Geerts WH, et al.  CHEST . 2004;126:338S-400S.
Respiratory Complication Prevention
Prevention of Ventilator-associated Pneumonia <ul><li>Hospital-acquired pneumonia (HAP) occurs 48 hours or more after admi...
Complications of Ventilator-associated Pneumonia <ul><li>“ Attributable mortality” estimated to be between 33 and 50% </li...
Surgical Care Improvement Project Performance measures - Process <ul><li>Prevention of ventilator-associated pneumonia </l...
Outcomes Measures <ul><li>Useful for internal quality improvement efforts only </li></ul><ul><li>Useful for public reporti...
SCIP Outcomes Measures <ul><li>Measures useful for  QI only </li></ul><ul><ul><li>SSI rates during index hospitalization <...
Surgical Care Improvement Project: Why? <ul><li>Medicare could prevent* up to: </li></ul><ul><ul><li>13,027 perioperative ...
Potential to Reduce Perioperative Complications in SCIP Based on the goal of achieving near-complete guideline compliance ...
Preliminary Results – CMS Three State Pilot
Surgical Care Improvement Preliminary Results – CMS Pilot Surgical Infection Module
Surgical Care Improvement Preliminary Results – CMS Pilot Cardiac Complications Module
Surgical Care Improvement Preliminary Results – CMS Pilot VTE Prevention Module
Surgical Care Improvement Preliminary Results – CMS Pilot Respiratory Complications Module
Summary <ul><li>There remain substantial opportunities to improve outcomes from surgery </li></ul><ul><li>There is a natio...
Project overview available at:  www.medqic.org/scip
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  • SSI account for about 14-16% pf all hospital acquired infections. Up to 5% ,or 1 out of every 20 patients undergoing surgical procedures, are likely to develop a surgical site infection. In the United States, that means about 500,000 patients every year will develop a SSI. Reports indicate that SSI adds an average of one week to hospitalization . The excess costs associated with SSIs can be over $8 million / year, and much of that cost is not reimbursable through insurance companies. Hospitals, depending on the type of reimbursement contracts they have, can lose money when patients become infected. But for the patient and family, the cost is much more serious.
  • Historical diabetic got q 4 hr slining scale sqi to keep bg &lt; 200.; after 1991, dibetics got insulin drip titrated to keep glucose levels between 150 and 200. Here there deep sternal infect rate declines.
  • Transcript of "The Surgical Care Improvement Project"

    1. 1. The Surgical Care Improvement Project A National Initiative to Improve Outcomes for Patients having Surgery Dale W. Bratzler, DO, MPH QIOSC Medical Director Oklahoma Foundation for Medical Quality, Inc.
    2. 2. Surgical Care Improvement Project National Goal To reduce preventable surgical morbidity and mortality by 25% by 2010
    3. 3. SCIP Steering Committee <ul><li>American College of Surgeons </li></ul><ul><li>American Hospital Association </li></ul><ul><li>American Society of Anesthesiologists </li></ul><ul><li>Association of peri-Operative Registered Nurses </li></ul><ul><li>Agency for Healthcare Research and Quality </li></ul><ul><li>Centers for Medicare & Medicaid Services </li></ul><ul><li>Centers for Disease Control and Prevention </li></ul><ul><li>Department of Veteran’s Affairs </li></ul><ul><li>Institute for Healthcare Improvement </li></ul><ul><li>Joint Commission on Accreditation of Healthcare Organizations </li></ul>
    4. 4. Surgical Care Improvement Project (SCIP) <ul><li>Preventable Complication Modules </li></ul><ul><ul><li>Surgical infection prevention </li></ul></ul><ul><ul><li>Cardiovascular complication prevention </li></ul></ul><ul><ul><li>Venous thromboembolism prevention </li></ul></ul><ul><ul><li>Respiratory complication prevention </li></ul></ul>
    5. 5. Surgical Infection Prevention
    6. 6. Surgical Site Infections (SSI) <ul><li>2-5% of operated patients will develop SSI </li></ul><ul><ul><li>40 million operations annually in the U.S. </li></ul></ul><ul><ul><li>0.8 - 2 million SSI’s occur annually in the U.S. </li></ul></ul><ul><li>SSI increases LOS in hospital </li></ul><ul><ul><li>average 7.5 days </li></ul></ul><ul><li>Excess cost per SSI: </li></ul><ul><ul><li>*$2,734-26,019 (1985, US$) </li></ul></ul><ul><ul><li>US national costs: $130-845 million/year </li></ul></ul>* Jarvis, Infect Control HospEpidemiol. 1996;17.
    7. 7. Surgical Care Improvement Project Performance measures - Process <ul><li>Surgical infection prevention </li></ul><ul><ul><ul><li>Antibiotics </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Administration within one hour before incision </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Use of antimicrobial recommended in guideline </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Discontinuation within 24 hours of surgery end </li></ul></ul></ul></ul></ul><ul><ul><ul><li>Glucose control in cardiac surgery patients </li></ul></ul></ul><ul><ul><ul><li>Proper hair removal </li></ul></ul></ul><ul><ul><ul><li>Normothermia in colorectal surgery patients </li></ul></ul></ul>
    8. 8. Efficacy Of Prophylaxis Is Independent Of The Specific Antibiotic Age of Lesion at Antibiotic Injection (Hours) Lesion Size, mm (24 Hours) Penicillin, 40,000 U Staph + Penicillin Control Chloramphenicol, 0.1 mg/Kg Erythromycin, 0.1 mg/Kg Tetracycline, 0.1 mg/Kg Control Control Control Staph + Erythromycin Staph + Tetracycline Staph + Chloramphenicol Burke JF. Surgery . 1961;50:161. 0 5 10 0 2 4 6 -2 0 2 4 6 -2 0 5 10 0 5 10 0 5 10
    9. 9. Timing of Antibiotic Prophylaxis GI Operations Stone HH et al. Ann Surg . 1976;184:443-452.
    10. 10. Perioperative Antibiotics Timing of Administration Classen, et al. N Engl J Med . 1992;328:281. Hours From Incision 14/369 5/699 5/1009 2/180 1/81 1/41 1/47 15/441
    11. 11. Antibiotic Recommendation Sources <ul><li>American Society of Health System Pharmacists </li></ul><ul><li>Infectious Diseases Society of America </li></ul><ul><li>The Hospital Infection Control Practices Advisory Committee </li></ul><ul><li>Medical Letter </li></ul><ul><li>Surgical Infection Society </li></ul><ul><li>Sanford Guide to Antimicrobial Therapy </li></ul>
    12. 13. Single vs Multiple Dose Surgical Prophylaxis: Systematic Review McDonald. Aust NZ J Surg 1998;68:388 Favors single dose Favors multiple dose All studies, fixed All studies, random Multi > 24h Multi < 24h
    13. 14. Impact of Prolonged Antibiotic Prophylaxis <ul><li>2,641 CABG patients </li></ul><ul><ul><li>Grp 1 - < 48 hours of antibiotics </li></ul></ul><ul><ul><li>Grp 2 - > 48 hours of antibiotics </li></ul></ul><ul><li>SSI Rates </li></ul><ul><ul><li>Grp 1 - 8.7% (131/1502) </li></ul></ul><ul><ul><li>Grp 2 - 8.8 % (100/1139) </li></ul></ul><ul><li>Antibiotic resistant pathogen - Grp 2 </li></ul><ul><ul><li>Odds Ratio 1.6 (95% CI: 1.1-2.6) </li></ul></ul>Harbarth S, et al. Circulation . 2000.
    14. 15. Antibiotic Timing Related to Incision Bratzler DW, Houck PM, et al. Arch Surg . 2005; 140:174-182 .
    15. 16. Discontinuation of Antibiotics Patients were excluded from the denominator of this performance measure if there was any documentation of an infection during surgery or in the first 48 hours after surgery. Bratzler DW, Houck PM, et al. Arch Surg . 2005; 140:174-182 .
    16. 17. Surgical Infection Prevention Performance Stratified by Surgery 1 1 All results are weighted to reflect adjustment based on the state-specific sampling scheme. 2 Reflects data for only 11 220 cases that had an explicitly documented incision time. These results include patients who received vancomycin between one and two hours before the incision (N=213). Cases were excluded from this performance measure if there was insufficient data to determine the time interval between prophylactic antimicrobial dose and surgical incision (N=22,902). In addition, patients undergoing colon surgery who received oral antimicrobials only for prophylaxis were excluded from the denominator (N=11). Bratzler DW, Houck PM, et al. Arch Surg . 2005; 140:174-182 . 55.7 (54.8-56.6) All Surgeries (11,220) 54.8 (51.4-58.3) Hysterectomy (432) 46.0 (43.5-48.4) Colon (732) 59.7 (58.3-61.2) Hip/knee (2,694) 47.0 (44.0-49.9) Vascular (1,116) 58.5 (56.8-60.2) Cardiac (3,287) Antibiotic within 1 hour 2 % (95% CI) Surgery (N)
    17. 18. Surgical Infection Prevention Performance Stratified by Surgery 1 1 All results are weighted to reflect adjustment based on the state-specific sampling scheme. Antimicrobials were considered “prophylactic” if they were given before surgery, given intraoperatively, or given within 24 hours after the end of surgery. Cases were excluded from this performance measure if no antimicrobials were administered, if no antimicrobials administered were considered “prophylactic,” or if there was insufficient data to make the determination on timing (N=336). In addition, because there are no published guidelines for antimicrobial selection for beta-lactam allergic patients undergoing colon surgery or hysterectomy, cases with a documented beta-lactam allergy that did not pass the performance measure for these two operations were excluded from the denominator (N=568). Bratzler DW, Houck PM, et al. Arch Surg . 2005; 140:174-182 . 92.6 (92.3-92.8) All Surgeries (33,229) 90.2 (89.0-91.3 Hysterectomy (2,395) 75.8 (74.6-77.0) Colon (4,855) 97.2 (96.7-97.5) Hip/knee (14,996) 91.5 (90.5-92.5) Vascular (3,140) 95.1 (94.7-95.6) Cardiac (7,843) Correct Antibiotic % (95% CI) Surgery (N)
    18. 19. Surgical Infection Prevention Performance Stratified by Surgery 1 1 All results are weighted to reflect adjustment based on the state-specific sampling scheme. Antimicrobials were considered “prophylactic” if they were given before surgery, given intraoperatively, or given within 24 hours after the end of surgery. Cases were excluded from this performance measure if no antimicrobials were administered, if no antimicrobials administered were considered “prophylactic,” or if there was insufficient data to make the determination of timing (N=344). Any patient with documentation in the medical record of an infection during surgery or within 48 hours after the end of surgery was excluded from the denominator (N=634). In addition, patients who underwent more than one surgical procedure of interest during the hospitalization were excluded from the denominator (N=552). Bratzler DW, Houck PM, et al. Arch Surg . 2005; 140:174-182 . 40.7 (40.2-41.2) 77.9 (76.3-79.5) 40.8 (39.5-42.2) 36.7 (35.9-37.4) 45.2 (43.4-47.0) 34.4 (33.4-35.5) Antibiotic Stopped within 24 hours % (95% CI) 40.4 21.4 57.0 39.0 42.7 40.9 Median Time to Discontinuation (Hours) All Surgeries (32,603) Hysterectomy (2,569) Colon (4,911) Hip/knee (14,575) Vascular (2,913) Cardiac (7,635) Surgery (N)
    19. 20. Latham R, et al. Infect Control Hosp Epidemiol . 2001.
    20. 21. Perioperative Glucose Control <ul><li>1,000 cardiothoracic surgery patients </li></ul><ul><li>Diabetics and non-diabetics with hyperglycemia </li></ul>Patients with a blood sugar > 300 mg/dL during or within 48 hours of surgery had more than 3X the likelihood of a wound infection! Latham R, et al. Infect Control Hosp Epidemiol . 2001.
    21. 22. Furnary et al. Ann Thorac Surg 1999:67:352
    22. 23. Pre-operative shaving <ul><li>Shaving the surgical site with a razor induces small skin lacerations </li></ul><ul><ul><li>potential sites for infection </li></ul></ul><ul><ul><li>disturbs hair follicles which are often colonized with S. aureus </li></ul></ul><ul><ul><li>Risk greatest when done the night before </li></ul></ul><ul><ul><li>Patient education </li></ul></ul><ul><ul><ul><li>be sure patients know that they should not do you a favor and shave before they come to the hospital! </li></ul></ul></ul>
    23. 24. Temperature Control <ul><li>200 colorectal surgery patients </li></ul><ul><ul><li>control - routine intraoperative thermal care (mean temp 34.7 ° C) </li></ul></ul><ul><ul><li>treatment - active warming (mean temp on arrival to recovery 36.6 ° C) </li></ul></ul><ul><li>Results </li></ul><ul><ul><li>control - 19% SSI (18/96) </li></ul></ul><ul><ul><li>treatment - 6% SSI (6/104), P=0.009 </li></ul></ul>Kurz A, et al. N Engl J Med . 1996. Also: Melling AC, et al. Lancet . 2001. (preop warming)
    24. 25. Cardiovascular Complication Prevention
    25. 26. Prevention of Cardiac Events Introduction <ul><li>As many as 7-8 million Americans that undergo major noncardiac surgery have multiple cardiac risk factors or established coronary artery disease </li></ul><ul><ul><li>More than 1 million cardiac events annually </li></ul></ul><ul><li>Myocardial ischemia either clinically occult or overt confers a 9-fold increase in risk of unstable angina, nonfatal myocardial infarction, and cardiac death </li></ul>Schmidt M, et al. Arch Intern Med . 2002;162:63-69. Mangano DT, et al. N Engl J Med . 1996;335:1713-1720. Selzman CH, et al. Arch Surg . 2001;136:286-290.
    26. 27. Surgical Care Improvement Project Performance measures - Process <ul><li>Perioperative cardiac events </li></ul><ul><ul><ul><li>Perioperative beta blockers in patients with known coronary artery disease undergoing non-cardiac vascular surgery </li></ul></ul></ul><ul><ul><ul><li>Perioperative beta blockers in patients who are on beta blockers before surgery </li></ul></ul></ul>Perioperative is defined as preoperatively on the day of surgery or intraoperatively prior to extubation.
    27. 28. Prevention of Cardiac Events Introduction <ul><li>Neurohormonal stress </li></ul><ul><ul><li>Increased heart rate </li></ul></ul><ul><ul><li>Increased myocardial contractility </li></ul></ul><ul><ul><li>Increased myocardial oxygen demand </li></ul></ul>Selzman CH, et al. Arch Surg . 2001;136:286-290.
    28. 29. Prevention of Cardiac Events Introduction <ul><li>Perioperatively administered beta blockers have the potential to: </li></ul><ul><ul><li>Decrease myocardial oxygen demand </li></ul></ul><ul><ul><ul><li>Reduced heart rate </li></ul></ul></ul><ul><ul><ul><li>Reduced wall tension </li></ul></ul></ul><ul><ul><ul><li>Reduced contractility </li></ul></ul></ul><ul><ul><li>Decrease myocardial ischemia and adverse cardiac events </li></ul></ul>
    29. 30. Prevention of Cardiac Events A Sample of Some of the Studies Decreased myocardial ischemia Esmolol Total knee 60 PR Urban, 2000 Decreased cardiac events from 34% to 3.4% at 30-days Bisoprolol Major vascular 59 PR Poldermans, 1999 Decreased cardiac events from 21% to 10% at two years Atenolol Noncardiac 99 PR Mangano, 1996 50% decreased MI Unknown General vascular 53 CC Yeager, 1995 Decreases silent myocardial ischemia Metroprolol Peripheral vascular 48 CC Pasternack, 1989 Decreased myocardial oxygen demand, infarction, and arrhythmias Propranolol CABG 50 PR Hammon, 1984 No perioperative cardiac events Propranolol Gen. Abdominal 13 CC Smulyan, 1982 Findings Drug Surgery N Study Type Study, y
    30. 31. Prevention of Cardiac Events Mangano DT, et al. N Engl J Med. 1996;335:1713-1720. <ul><li>Randomized, placebo controlled trial of perioperative atenolol on overall survival and cardiovascular mortality in patients with or at risk of cardiovascular disease. </li></ul><ul><ul><li>200 patients (99 atenolol) </li></ul></ul><ul><ul><li>Atenolol or placebo before anesthesia induction, immediately after surgery, and for seven days postoperatively </li></ul></ul><ul><ul><ul><li>Heart rate maintained > 55 bpm, BP maintained > 100 mm Hg </li></ul></ul></ul>
    31. 32. Postoperative Survival <ul><li>6-month survival 100% vs 92% (P<0.001) </li></ul><ul><li>2-yr survival 90% vs 79% (P=0.019) </li></ul>Mangano DT, et al. N Engl J Med . 1996;335:1713-20.
    32. 33. How often is postoperative myocardial infarction potentially preventable? <ul><li>72 Patients identified with postoperative MI using 2º dx </li></ul><ul><ul><li>Charts reviewed by trained nurse abstractors </li></ul></ul><ul><ul><li>Diagnosis of MI required both laboratory physician confirmation </li></ul></ul><ul><li>Demographic characteristics </li></ul><ul><ul><li>Mean age 70 </li></ul></ul><ul><ul><li>53% Female </li></ul></ul><ul><ul><li>Race </li></ul></ul><ul><ul><ul><li>81% White, 7% Black, 1% Latino, 10% unknown </li></ul></ul></ul><ul><ul><li>Surgery Type </li></ul></ul><ul><ul><ul><li>35% Vascular, 28% General, 17% Ortho, 10% Ob-Gyn, 11% other </li></ul></ul></ul><ul><li>25% in-hospital mortality rate </li></ul>Lindenauer PK, et al. Arch Intern Med . 2004;164:762-766.
    33. 34. 72 Patients with PMI 70 at high risk 58 ideal candidates 12 with BB contraindications 2 not high risk 30/58 Rx with BB (5 optimal Rx) 28/58 Not Rx with BB 22 Previously treated 8 initiated in hospital 26 previously untreated 2 discontinued <ul><li>48 % of postoperative myocardial infarction potentially preventable </li></ul><ul><li>Only 9% of patients received optimal beta blocker therapy </li></ul>Perioperative Beta Blocker Use in Patients with Postoperative MI Lindenauer PK, et al. Arch Intern Med . 2004;164:762-766.
    34. 35. Perioperative Beta blockers ACC/AHA Guideline <ul><ul><li>Class I recommendation </li></ul></ul><ul><ul><ul><li>Beta blockers required in the recent past to control symptoms of angina, symptomatic arrhythmias, or hypertension </li></ul></ul></ul><ul><ul><ul><li>Patients at high cardiac risk owing to the finding of ischemia on preoperative testing who are undergoing vascular surgery </li></ul></ul></ul><ul><ul><li>Class IIa </li></ul></ul><ul><ul><ul><li>Patients with known coronary artery disease or major risk factors for coronary disease </li></ul></ul></ul>Eagle KA, et al. ACC/AHA. http://www.acc.org/clinical/guidelines.perio/dirIndex.htm.
    35. 36. Venous Thromboembolism Prevention
    36. 37. Prevention of Venous Thromboembolism Introduction <ul><li>VTE Remains a major health problem in the US </li></ul><ul><ul><li>200,000 new cases annually </li></ul></ul><ul><ul><li>In addition to the risk of sudden death </li></ul></ul><ul><ul><ul><li>30% of survivors develop recurrent VTE within 10 years </li></ul></ul></ul><ul><ul><ul><li>28% of survivors develop venous stasis syndrome within 20 years </li></ul></ul></ul><ul><ul><li>The incidence of VTE is more than 100 times greater for patients who have been hospitalized than among community dwelling </li></ul></ul><ul><ul><li>Incidence increases with age </li></ul></ul>Goldhaber SZ. N Engl J Med . 1998;339:93-104. Silverstein MD, et al. Arch Intern Med . 1998;158:585-593. Heit JA, et al. Thromb Haemost . 2001;86:452-463. Heit JA. Clin Geriatr Med. 2001 ;17:71-92. Heit JA, et al. Mayo Clin Proc . 2001;76:1102-1110.
    37. 38. Prevention of Venous Thromboembolism <ul><li>Despite the well known risk of VTE and the publication of evidence-based guidelines for prevention, previous medical record audits have demonstrated underuse of prophylaxis </li></ul>Anderson FA Jr, et al. Ann Intern Med . 1991;115:591-595. Anderson FA Jr, et al. J Thromb Thrombolysis . 1998; 5 (1 Suppl):7S-11S. Bratzler DW, et al. Arch Intern Med . 1998;158:1909-1912. Stratton MA, et al. Arch Intern Med . 2000;160:334-340.
    38. 39. Surgical Care Improvement Project Performance measures - Process <ul><li>Prevention of venous thromboembolism </li></ul><ul><ul><ul><li>Proportion who receive recommended VTE prophylaxis </li></ul></ul></ul><ul><ul><ul><li>Proportion who receive appropriate form of VTE prophylaxis (based on ACCP Consensus Recommendations) </li></ul></ul></ul>
    39. 40. Published Audits of VTE Prophylaxis General Surgery <ul><li>Anderson, et al. </li></ul><ul><ul><li>1986 audit of 16 Massachusetts hospitals </li></ul></ul><ul><ul><ul><li>Approximately 1/3 received prophylaxis </li></ul></ul></ul><ul><li>Anderson, et al. </li></ul><ul><ul><li>1994 audit, statewide in Massachusetts </li></ul></ul><ul><ul><ul><li>84% of colectomy patients received prophylaxis </li></ul></ul></ul><ul><ul><ul><li>regional variation 57-93% </li></ul></ul></ul>Anderson FA Jr, et al. Physician practices in the prevention of venous thromboembolism. Ann Intern Med . 1991;115:591-595. Anderson FA Jr, et al. Practices in the prevention of venous thromboembolism. J Thromb Thrombolysis . 1998; 5 (1 Suppl):7S-11S.
    40. 41. Published Audits of VTE Prophylaxis General Surgery Use of any form of prophylaxis based on level of risk for venous thromboembolism among 419 Medicare patients from 20 hospitals undergoing major abdominothoracic surgery. Measures were implemented for patients at moderate risk (35%; 95% CI, 25-46%), at high risk (40%; 95% CI, 29-51%), and at very high risk (39%; 95% CI, 33-45%). Overall utilization rate for prophylaxis was 38% (95% CI, 33-43%). Bratzler DW, et al. Arch Intern Med . 1998;158:1909-1912.
    41. 42. Published Audits of VTE Prophylaxis General Surgery <ul><li>Stratton, et al </li></ul><ul><ul><li>Audit in 10 teaching or community university-affiliated hospitals (size ranged from 350-747 beds) </li></ul></ul><ul><ul><ul><li>495 major abdominal surgery patients </li></ul></ul></ul><ul><ul><ul><li>372 (75.2%) received prophylaxis </li></ul></ul></ul><ul><ul><ul><ul><li>249/495 (50.3%) received grade A therapy </li></ul></ul></ul></ul>Stratton MA, et al. Prevention of venous thromboembolism: adherence to the 1995 American College of Chest Physicians Consensus Guidelines for surgical patients. Arch Intern Med . 2000;160:334-340.
    42. 43. VTE Prophylaxis in General Surgery National SIP Project - Results * Prophylaxis was considered appropriate if the patient received IPC, LDUH, or LMWH with or without other modalities (American College of Chest Physicians’ grade 1A recommendation). † This column is limited to the subset of patients who had a principal diagnosis of malignancy. Prophylaxis was considered appropriate if the patient received a combination of LDUH or LMWH with IPC or ES with or without other interventions (American College of Chest Physicians’ grade 1C recommendation), or warfarin with or without other interventions (American College of Chest Physicians’ grade 2C recommendation). Bratzler DW, et al. (in review). 53.0 47.9 41.3 66 73 63 94.4 91.3 88.5 96.8 94.4 94.3 125 160 122 Highest performance District of Columbia Connecticut Michigan 16.1 25.3 25.9 87 79 54 54.4 65.0 69.9 59.8 75.9 77.0 169 137 113 Lowest performance Puerto Rico Mississippi Texas 31.4 3533 80.6 86.7 6896 All Recommended Prophylaxis † % Cases (N) Recommended Prophylaxis* % Any Prophylaxis % Cases (N) State/territory Very-high-risk High-risk
    43. 44. ACCP Guidelines for VTE Prevention Geerts WH, et al. CHEST . 2004;126:338S-400S.
    44. 45. Respiratory Complication Prevention
    45. 46. Prevention of Ventilator-associated Pneumonia <ul><li>Hospital-acquired pneumonia (HAP) occurs 48 hours or more after admission </li></ul><ul><ul><li>Ventilator-associated pneumonia (VAP) arises more than 48 hours after endotracheal intubation </li></ul></ul><ul><ul><ul><li>6-20 fold increased incidence of HAP in patients on the ventilator (9-27% of all intubated patients) </li></ul></ul></ul><ul><ul><ul><li>Approximately half of all VAP cases occur within the first four days of intubation </li></ul></ul></ul>Niederman MS, Craven DE, et al. Am J Respir Crit Care Med. 2005;171:388-416.
    46. 47. Complications of Ventilator-associated Pneumonia <ul><li>“ Attributable mortality” estimated to be between 33 and 50% </li></ul><ul><ul><li>Mortality greater for medical illness, bacteremia with Pseudomonas aeruginosa or Acinetobacter species, and with ineffective antibiotic treatment </li></ul></ul><ul><ul><li>Patients often at risk for multi-drug resistant pathogens </li></ul></ul><ul><ul><li>Increased risk of stress ulceration and bleeding within 48 hours of mechanical ventilation </li></ul></ul><ul><li>Dramatic increase in costs of care </li></ul><ul><ul><li>Increases hospital stay 7-9 days on average </li></ul></ul><ul><ul><li>Excess costs of $40,000 </li></ul></ul>Niederman MS, Craven DE, et al. Am J Respir Crit Care Med. 2005;171:388-416.
    47. 48. Surgical Care Improvement Project Performance measures - Process <ul><li>Prevention of ventilator-associated pneumonia </li></ul><ul><ul><ul><li>Proportion of patients on ventilator with head of bed elevated 30 degrees </li></ul></ul></ul><ul><ul><ul><li>Proportion of ventilator patients put on a rapid weaning protocol (daily sedation vacations and assessments of readiness to extubate) </li></ul></ul></ul><ul><ul><ul><li>Proportion of ventilator patients who receive peptic ulcer disease prophylaxis </li></ul></ul></ul>
    48. 49. Outcomes Measures <ul><li>Useful for internal quality improvement efforts only </li></ul><ul><li>Useful for public reporting </li></ul><ul><li>Useful for pay-for-performance </li></ul>
    49. 50. SCIP Outcomes Measures <ul><li>Measures useful for QI only </li></ul><ul><ul><li>SSI rates during index hospitalization </li></ul></ul><ul><ul><li>In-hospital cardiac event rates </li></ul></ul><ul><ul><li>Rates of DVT/PE diagnosed during index hospitalization </li></ul></ul><ul><ul><li>Rate of postoperative pneumonia cases that are diagnosed during index hospitalization </li></ul></ul><ul><li>Measures that may be useful for public reporting </li></ul><ul><ul><li>Risk-adjusted 30-day readmission rate (Medicare only) </li></ul></ul><ul><ul><li>Risk-adjusted 30-day mortality rate (Medicare only) </li></ul></ul>
    50. 51. Surgical Care Improvement Project: Why? <ul><li>Medicare could prevent* up to: </li></ul><ul><ul><li>13,027 perioperative deaths </li></ul></ul><ul><ul><li>271,055 surgical complications </li></ul></ul>* Major surgical cases
    51. 52. Potential to Reduce Perioperative Complications in SCIP Based on the goal of achieving near-complete guideline compliance to prevent each of these complications as compared to current national rates of guideline compliance for each complication.
    52. 53. Preliminary Results – CMS Three State Pilot
    53. 54. Surgical Care Improvement Preliminary Results – CMS Pilot Surgical Infection Module
    54. 55. Surgical Care Improvement Preliminary Results – CMS Pilot Cardiac Complications Module
    55. 56. Surgical Care Improvement Preliminary Results – CMS Pilot VTE Prevention Module
    56. 57. Surgical Care Improvement Preliminary Results – CMS Pilot Respiratory Complications Module
    57. 58. Summary <ul><li>There remain substantial opportunities to improve outcomes from surgery </li></ul><ul><li>There is a national commitment to performance measurement and improvement of surgical outcomes </li></ul><ul><li>Through a broad national partnership hospitals across the nation will be encouraged to participate in activities to reduce the complications of surgery in the US </li></ul>
    58. 59. Project overview available at: www.medqic.org/scip
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