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© A
mer
ican
Col
lege
of S
urge
ons 2
013.
Al
l rig
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TQIP Basics for TMDs and TPMs: Orientation to reports & drill down tools Avery Nathens, MD, PhD, FACS
© A
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ican
Col
lege
of S
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ons 2
013.
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Objectives • How to get the most out of your reports • When and how to drill down to get more
information • How to use TQIP to complement your PI
program • More details in “Reading between the
lines”
© A
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Col
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of S
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Report contents
• Facility characteristics • Aggregate patient/injury
characteristics • Risk adjusted analysis
• Mortality • LOS
• Contextual analysis on patient cohorts
© A
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Col
lege
of S
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Contextual analysis • Informative data presented by center to understand
how care is delivered for specific types of patients
TBI ICP monitoring
Tracheostomy timing Timing of death (withdrawal of care)
Elderly Timing to OR for Rx of hip fractures Timing of death (withdrawal of care)
Pelvic fractures Use of angiography
Shock (Time to hemorrhage control) (Transfusion practices)
Isolated blunt splenic injury Splenic preservation Angiography LOS – ICU, hospital
© A
mer
ican
Col
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of S
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013.
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Obs
erve
d to
exp
ecte
d m
orta
lity
ratio
expected line
point
Confidence interval
O/E < 1
Better than expected
O/E > 1
Worse than expected
Caterpillar graphs Risk-adjusted outcomes
© A
mer
ican
Col
lege
of S
urge
ons 2
013.
Al
l rig
hts r
eser
ved
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ldw
ide .
Caterpillar graphs Risk adjusted outcomes
Odd centers
Even centers
© A
mer
ican
Col
lege
of S
urge
ons 2
013.
Al
l rig
hts r
eser
ved
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ldw
ide .
Use the data to tell a story TBI Mortality
© A
mer
ican
Col
lege
of S
urge
ons 2
013.
Al
l rig
hts r
eser
ved
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ide .
Excess length of stay
© A
mer
ican
Col
lege
of S
urge
ons 2
013.
Al
l rig
hts r
eser
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ICP monitoring
© A
mer
ican
Col
lege
of S
urge
ons 2
013.
Al
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hts r
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Time to death
Are we providing futile care?
© A
mer
ican
Col
lege
of S
urge
ons 2
013.
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hts r
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Tracheostomy practices in TBI
Disposition after Tracheostomy
Do we have a problem with end of life care?
© A
mer
ican
Col
lege
of S
urge
ons 2
013.
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l rig
hts r
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TQIP Online • Secure site for data drill down • Patient lists for investigation of patients in TQIP
to help explain outcomes and TQIP results
© A
mer
ican
Col
lege
of S
urge
ons 2
013.
Al
l rig
hts r
eser
ved
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ide .
TQIP participant portal www.acstqip.org
© A
mer
ican
Col
lege
of S
urge
ons 2
013.
Al
l rig
hts r
eser
ved
Wor
ldw
ide .
© A
mer
ican
Col
lege
of S
urge
ons 2
013.
Al
l rig
hts r
eser
ved
Wor
ldw
ide .
TQIP Online Patient Lists
© A
mer
ican
Col
lege
of S
urge
ons 2
013.
Al
l rig
hts r
eser
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TQIP Patient Lists • Every patient record submitted to TQIP
• Patient/injury characteristics • Ensure the data we have is what you have
• Discharge status • Alive/dead • TQIP probability of survival
• Identifies unexpected survivors or deaths • Guides your PI process
© A
mer
ican
Col
lege
of S
urge
ons 2
013.
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l rig
hts r
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ldw
ide .
Accessing your patient lists
Click on a patient ID to see more
© A
mer
ican
Col
lege
of S
urge
ons 2
013.
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hts r
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Patient details
© A
mer
ican
Col
lege
of S
urge
ons 2
013.
Al
l rig
hts r
eser
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Individual patient
© A
mer
ican
Col
lege
of S
urge
ons 2
013.
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l rig
hts r
eser
ved
Wor
ldw
ide .
© A
mer
ican
Col
lege
of S
urge
ons 2
013.
Al
l rig
hts r
eser
ved
Wor
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ide .
Export data for further analysis
© A
mer
ican
Col
lege
of S
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ons 2
013.
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TBI report Patient ID Age Lived / Died Estimated probability
of death (%)
15476 17 LIVED 0.19 23645 17 LIVED 0.21 55555 21 LIVED 0.22 32112 32 LIVED 0.24 12421 21 LIVED 0.49 15734 31 LIVED 0.64 42157 43 LIVED 0.65 24125 45 LIVED 0.66 34512 51 LIVED 0.67 11221 45 LIVED 0.67 12412 46 LIVED 0.68 21453 64 LIVED 0.73 12345 45 DIED 0.8 54781 26 LIVED 0.8 63521 47 LIVED 0.81
© A
mer
ican
Col
lege
of S
urge
ons 2
013.
Al
l rig
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Unexpected death
• 45 yo male, transferred in after a fall • No trauma team activation • SBP 134, HR 110, RR 18, T 37, GCSm 6 • Small subdural, small contusion and
subgaleal hematoma • Awaiting disposition • Cardiac arrest without return of cardiac
function
© A
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ican
Col
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of S
urge
ons 2
013.
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TBI report
Patient ID
Age Lived / Died
Probability of Death TBI
12999 78 LIVED 10.07 21125 74 LIVED 10.12 32115 83 LIVED 10.23 12451 56 LIVED 10.26 21212 17 DIED 10.8 13178 79 LIVED 11.17 11182 78 LIVED 11.21 27531 27 LIVED 11.24 23755 83 LIVED 11.33
© A
mer
ican
Col
lege
of S
urge
ons 2
013.
Al
l rig
hts r
eser
ved
Wor
ldw
ide .
Unexpected death • 17 yo, fell hit head, transferred in from
elsewhere • SBP 135, HR 45, T 34.5, GCSm 3 • No trauma team activation • CT ~45 min after arrival – blew pupil
• Epidural hematoma • Evacuated • Large PCA infarct postop
• Care withdrawn
© A
mer
ican
Col
lege
of S
urge
ons 2
013.
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l rig
hts r
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Shock report Patient ID Age Lived /
Died Probability of Death
Shock 13331 34 LIVED 22.53 13214 20 LIVED 45.8 21341 28 DIED 48.57 15423 28 DIED 56.22 25252 54 LIVED 57.46 23232 55 DIED 61.85 32324 41 DIED 74.89 12129 39 LIVED 78.38 19874 27 DIED 79.61 19751 82 DIED 85.91 17922 83 DIED 91.25 18678 62 DIED 95.36 54218 62 DIED 95.6
© A
mer
ican
Col
lege
of S
urge
ons 2
013.
Al
l rig
hts r
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ldw
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Unexpected survivor • 39 yo male, run over by garbage truck, transported
by land with an ED SBP of 58 on a Monday morning
• Bilateral pneumo, pulmonary contusions • Sternocostal dissociation, multiple rib fractures, • Splenic & liver laceration - laparotomy, packed • Pelvic fracture, extraperitoneal packing + angio • Extraperitoneal bladder rupture • Extensive degloving abdominal wall, left groin,
lower extremity • Traumatic AKA
© A
mer
ican
Col
lege
of S
urge
ons 2
013.
Al
l rig
hts r
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ved
Wor
ldw
ide .
Unexpected survivor
• Massive transfusion protocol activated • Within a few hours: 32u RBC’s, 24 u FFP’s,
cryo, platelets • Guided by frequent labs & input from
transfusion medicine
• Why did he survive? • Transfusion medicine is a weekday service
© A
mer
ican
Col
lege
of S
urge
ons 2
013.
Al
l rig
hts r
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ved
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ldw
ide .
Process evaluation • Virtually impossible to compare practices
across institutions without data • Challenging to effect change without
knowledge of where you stand • Timing of fracture fixation • ICP monitoring • Use of angiography
• Evaluate practice in relation to outcome • e.g. timing of tracheostomy & pneumonia
© A
mer
ican
Col
lege
of S
urge
ons 2
013.
Al
l rig
hts r
eser
ved
Wor
ldw
ide .
Summary
• Data from TQIP reports can be used as a “dashboard warning light” • There is a problem, but where??
• There is more to TQIP reports than the data in the tables and graphs • Use the data to tell a story
• TQIP online can complement your existing PI processes
© A
mer
ican
Col
lege
of S
urge
ons 2
013.
Al
l rig
hts r
eser
ved
Wor
ldw
ide .
Summary
• Drill downs at the patient level should complement your existing PI processes • Identify unexpected deaths
• Evaluate the other end of the bell curve – unexpected survivors • A source of positive feedback for the team • Identify factors that lead to favorable
outcomes
© A
mer
ican
Col
lege
of S
urge
ons 2
013.
Al
l rig
hts r
eser
ved
Wor
ldw
ide .
Summary
• Drill downs provide good overview of your patients and practices
• Practice evaluation a major component of a drill down
• Practices evolve as a result of many factors • Resources • Right people • Tradition • Patients
• Drill downs at the patient level should complement your
existing PI processes • Identify unexpected deaths
Recommended