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A Pediatric Neurosurgeon’s
Toolbox for Meaningful
Quality Improvement
Associate ProfessorDepartment of Neurosurgery, Baylor College of MedicinePediatric Neurosurgeon, Texas Children’s HospitalBaylor Center for Ethics and PolicyTMC Innovation Institute
Sandi Lam MD MBA
Why?
Quality improvement
Big data
Bigger picture
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Modern day clinical practice
• Knowledge
• Technology
• Research
• Innovation
• Culture
• Spending
• = excellence in practice, right?
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Modern day medicine
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US healthcare
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Day to day
• Increasing complexity of hospital operations
• Competing demands on patient care team
How to fix?
Where to start?
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Aligning practice with the big picture
Why?
Quality improvement
Big data
Bigger picture
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Building a craniosynostosis
program
• Where are we?
– Program background
• What are we trying to accomplish?
– Deliver safe, high-quality clinical care
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Program background: 2013
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Patient experience
• Multiple visits
• Multiple specialists
• Information sources
• Confusion
• Anxiety
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surgeons
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Methods
• use national benchmarks
• pre- and post-implementation of the
multidisciplinary care pathway
– plan-do-study-act (PDSA) cycles
• track and examine metrics:
– clinical database
– medical records
– cross-referencing with national database [Pediatric
Health Information System (PHIS)]
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Data driven approach
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Multidisciplinary care pathway
driven by best practice guidelines/consensus/other:
• streamline preoperative workup
• improve perioperative communication
• reduce variation in care
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Change is not always welcomed.
How to motivate for change?
• People want to do the
right thing for patients
Make it easy to do the
right thing: build paths
of least resistance
• Reduce uncertainty &
build trust
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Process Map
Surgeon and staff education/counseling
Family interaction, peer support
Anesthesia eval, identify any other preop issues
Slots saved in other clinics for same-day appointments
Social work, genetics, peds, speech prn
Click to edit Master title style Volume Resuscitation Protocol
1. PRBC Transfusion Criteria:
A. Hgb < 8 or Hct < 24: Transfuse PRBC 10 ml/kg
B. Hgb 8-9 or Hct 24-27 with ongoing blood loss: Transfuse PRBC 10 ml/kg
C. Hgb >9 or Hct >27 do not transfuse PRBC
2. FFP Transfusion Criteria:
A. Signs and symptoms of coagulopathy/microvascular bleeding and (time permitting):
B. PT >18 s or PTT > 43 s or fibrinogen < 100: Transfuse FFP 10 ml/kg
C. INR > 1.5 and ongoing bleeding: Transfuse FFP 10 ml/kg
D. Blood loss ≥ one blood volume: Transfuse FFP 10 ml/kg
3. Platelet Transfusion Criteria:
A. Platelet count < 100,000 then transfuse platelets 10 ml/kg
4. Factor VIIa if:
A. Continued bleeding despite component therapy with prolonged PT/PTT and low fibrinogen
B. Initial dose 90 mcg/kg
C. Continued bleeding may give 150 mcg/kg 15 minutes after first dose
D. Continued bleeding may give 300 mcg/kg
Signs of Hypovolemia:
Major Criteria (requires 1)
A. MAP < 45 despite titration of anesthetic
B. UO < 0.5 ml/kg/hr
C. BD < -6
Minor Criteria (requires 2 or 3)
A. BD -5 to -6
B. Systolic pressure variation >7 mmHg
C. CVP < baseline
Hgb < 8
or
Hct < 24
Transfuse PRBC
10 ml/kg
Hgb 8-9
Or
Hct 24-27
Hgb > 9
or
Hct > 27
Transfuse Albumin
5% 10 ml/kg
Ongoing blood
loss?
No
No
Yes
Yes
Yes
Yes
No
Volume resuscitation & transfusion protocol
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Postoperative Pathway
• Education, expectations
• Transparent care plan to nursing, residents, family
• EPIC enhancements
Click to edit Master title styleIn-room care plans
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Patient
engagement
• Online and in-person
peer support
• Learn from families’
experiences
Click to edit Master title styleLearning curves
2014
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Program Growth
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PHIS – example dashboard
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Summary of program improvements
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Increased Value of Care
$77,655 median
$67,294 (avg)
yr pre-implementation
• Stable (<national average) complication rates
– 2% perioperative, 10% long term
$44,667 median
$60,138 (avg)
after implementation
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Quality improvement as a culture
• Implementation requires constant re-evaluation
• Behavior modification is
challenging
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Conclusion
• Implemented multidisciplinary pathway for
craniosynostosis surgery program
• Decrease in rates of blood transfusion, length of
stay, overall hospital charges; increased value
Why?
Quality improvement
Big data
Bigger picture
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Click to edit Master title style
CLINICAL ARTICLE
ABBREVIATIONS CI = confidence interval; EVD = external ventricular drain; OR = odds ratio; VP = ventriculoperitoneal.
ACCOMPANYING EDITORIAL DOI: 10.3171/2018.4.PEDS18184.
SUBMITTED December 12, 2017. ACCEPTED March 19, 2018.
INCLUDE WHEN CITING Published online June 8, 2018; DOI: 10.3171/2018.3.PEDS17234.
Complications following pediatric cranioplasty after decompressive craniectomy: a multicenter retrospective study
Brandon G. Rocque, MD, MS,1 Bonita S. Agee, PhD,1 Eric M. Thompson, MD,2 Mark Piedra, MD,3
Lissa C. Baird, MD,4 Nathan R. Selden, MD, PhD,4 Stephanie Greene, MD,5
Christopher P. Deibert, MD,6 Todd C. Hankinson, MD, MBA,7 Sean M. Lew, MD,8
Bermans J. Iskandar, MD,9 Taryn M. Bragg, MD,10 David Frim, MD, PhD,11 Gerald Grant, MD,12
Nalin Gupta, MD, PhD,13 Kurtis I. Auguste, MD,13 Dimitrios C. Nikas, MD,14
Michael Vassilyadi, MD, CM, MSc,15 Carrie R. Muh, MD, MS,2 Nicholas M. Wetjen, MD,16 and
Sandi K. Lam, MD17
1Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama; 2Department of Neurosurgery, Duke University, Durham, North Carolina; 3Department of Neurosurgery, Billings Clinic, Billings, Montana; 4Department of Neurosurgery, Oregon Health Sciences University, Portland, Oregon; 5Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania; 6Department of Neurosurgery, Emory University, Atlanta, Georgia; 7Department of Neurosurgery, University of Colorado, Denver, Colorado; 8Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin; 9Department of Neurosurgery, University of Wisconsin, Madison, Wisconsin; 10Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona; 11Section of Neurosurgery, University of Chicago, Chicago, Illinois; 12Department of Neurosurgery, Stanford University, Palo Alto, California; 13Department of Neurosurgery, University of California at San Francisco, San Francisco, California; 14Department of Neurosurgery, University of Illinois, Chicago, Illinois; 15Department of Neurosurgery, University of Ottawa, Ottawa, Ontario, Canada; 16Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota; and 17Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
OBJECTIVE In children, the repair of skull defects arising from decompressive craniectomy presents a unique set of challenges. Single-center studies have identified different risk factors for the common complications of cranioplasty resorption and infection. The goal of the present study was to determine the risk factors for bone resorption and infection after pediatric cranioplasty.
METHODS The authors conducted a multicenter retrospective case study that included all patients who underwent cra-nioplasty to correct a skull defect arising from a decompressive craniectomy at 13 centers between 2000 and 2011 and were less than 19 years old at the time of cranioplasty. Prior systematic review of the literature along with expert opinion guided the selection of variables to be collected. These included: indication for craniectomy; history of abusive head trauma; method of bone storage; method of bone fixation; use of drains; size of bone graft; presence of other implants, including ventriculoperitoneal (VP) shunt; presence of fluid collections; age at craniectomy; and time between craniecto-my and cranioplasty.
RESULTS A total of 359 patients met the inclusion criteria. The patients’ mean age was 8.4 years, and 51.5% were female. Thirty-eight cases (10.5%) were complicated by infection. In multivariate analysis, presence of a cranial implant (primarily VP shunt) (OR 2.41, 95% CI 1.17–4.98), presence of gastrostomy (OR 2.44, 95% CI 1.03–5.79), and ventilator dependence (OR 8.45, 95% CI 1.10–65.08) were significant risk factors for cranioplasty infection. No other variable was associated with infection.
Of the 240 patients who underwent a cranioplasty with bone graft, 21.7% showed bone resorption significant enough to warrant repeat surgical intervention. The most important predictor of cranioplasty bone resorption was age at the time of cranioplasty. For every month of increased age the risk of bone flap resorption decreased by 1% (OR 0.99, 95% CI 0.98–0.99, p < 0.001). Other risk factors for resorption in multivariate models were the use of external ventricular drains and lumbar shunts.
J Neurosurg Pediatr June 8, 2018 1©AANS 2018, except where prohibited by US copyright law
Multicenter
• 13 centers (thank you, Gerry)
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Feasibility of Using
Administrative/ Claims Data
for Research, QI
Click to edit Master title styleWhy Administrative Data?
• Important to understand
what is collected
• Can we use these data in
a meaningful way?
• Growing number of big health care databases
• Insurance, hospitals, government, policy makers, economists using these data
Click to edit Master title styleBig data
•Large sample sizes
•Need to ask the right questions
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Aims
• Compare outcomes of endoscopic third
ventriculostomy (ETV) and CSF shunt placement
in children using an administrative claims
database
Click to edit Master title styleData source
Records from years 2003-2011
45 million total covered lives478 ETV patientsLongitudinal follow up
Click to edit Master title styleMethods
• Patients <19 years old
• ETV, shunt surgeries
Primary Endpoint:
Failure = need for further surgical treatment of hydrocephalus after initial ETV or VPS
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Canadian Pediatric Neurosurgery Study Group
• Retrospective
• 9 centers
• 15-year period
• 368 patients
Drake et al. Endoscopic third ventriculostomy in pediatric patients: the Canadian experience. Neurosurgery 60:881–886, 2007
Drake J et al 2007
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ETV: overall success
378 pts
468 pts
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ETV success by age
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Next: propensity score adjustment
Kulkarni et al. ETV vs CSF shunting in the treatment of hydrocephalus in children: a Propensity score-adjusted analysis. Neurosurgery 67: 588-593, 2010.
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Methods
• Propensity score
matching*
• Age
• Hydrocephalus etiology
• history of CSF shunt
• Kaplan-Meier survival
curves, stratified log-
rank test, Cox
proportional-hazard
models to analyze the
matched samples
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Results
• 3231 cases: 478 ETV, 2753 VPS
• 458 matched pairs
• Mean age 8.5yrs, SD 6.4
• 80% no prior shunt
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Results: unmatched
Unmatched sample, log rank p=0.306
Results: unmatched
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Results: matched
Matched sample, stratified log rank p=0.122
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Summary
• Identified a cohort of pediatric hydrocephalus patients
treated by ETV & shunt in administrative dataset
• Results mirror findings from multicenter clinical studies
• Administrative data reflects real-world practice
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Limitations
• Based on billing
• Quality of life/clinical
details lacking
• Longitudinal data
• Medicaid, PHIS, registries
• Financial records track real-
world practice
• Recognition of limits
• Impose rigor
• Evolution of data sets
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CPT coding: pilot validation
Chart review
Claims Data ETV recorded Not CPT
62200,62201
Total
ETV Recorded 46 5 51
Not CPT
62200, 62201
2 98 100
Total 48 103 151
>95%
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Going further
clinical
• Coding validations
• Complement other research
• Inform design of clinical
trials
socioeconomic
• Health care utilization,
delivery of care, policy
• Economic models
Develop best practices
Data quality and access will evolve
Why?
Quality improvement
Big data 2.0
Bigger picture
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Challenge of working with data
• Measure something meaningful
• Measure something that can be changed
• Show data in a way that is actionable
How?
• Listen
• Bridge the gap between data & clinical care
• Design actionable plans that people believe in
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Surgical infections
• Estimated cost of hospital acquired infections in
US: $10 billion
• Surgical site infections (SSI) account for 31%
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Example: intrathecal baclofen pumps
• Implant
• Treatment of spasticity
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Intrathecal baclofen pump surgery
• Challenging patient population
– 45% with feeding support
– 10% tracheostomy
• High ITBP infection/complication rates
– 30% in literature
– >10% at 30 days in NSQIP
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ITBP surgery
• Quality improvement
initiatives
• Variation in antibiotic use
motivated PHIS data
research study
SSI prevention bundle from best practice guidelines& by consensus
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Perioperative antibiotics:
prophylaxis for surgical site infections
• Measurable, trackable
• Potential to motivate informed choices
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Importance of antibiotic stewardship
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SCIP measures
• Process measures with perioperative antibiotics
are not new
• Equivocal improvement in adult outcomes with
increased SCIP antibiotic measure compliance
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Guidelines for antibiotic prophylaxis
in ITBP surgery, 2013
• Am. Society of Health-System Pharmacists
• Infectious Diseases Society of America
• Surgical Infection Society
• Society of Healthcare Epidemiology of America
• Evidence-based
standardized approach
for prevention of SSI’s
• Consideration for
antimicrobial resistance
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Clinical practice guidelines
• Single dose of cefazolin
• Clindamycin or vancomycin (if allergy for cefazolin)
Within 60 minutes of incision <24 hours of prophylaxis
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Aims
1. understand use of perioperative antibiotics
2. investigate compliance with practice guidelines
3. explore association between antibiotic
prophylaxis compliance and outcomes measures
outcomes measures:
-cost of ITBP surgical hospitalization
-6 month complication/infection rate
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Data source
• Pediatric Health Information System
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Study design
• <18 years of age
• ICD-9 procedure codes ITBP placement
• No outpatient antibiotic use or personal history of
infections 30 days prior to surgery
• Minimum 6 month follow up
• Perioperative antibiotic use examined
• Association with outcomes, regression models
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Outcomes
6 months after surgery
surgery
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1534 patients
Study cohort
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Surgical prophylaxis
• 91.5% received prophylactic antibiotics
• 37.6% received 2 or more agents
• Most common:
– cefazolin (62.2%)
– vancomycin (25%)
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Definitions
Within 60 minutes of incision <24 hours of prophylaxis
“Missed preoperative antibiotic” “Prolonged antibiotic”
Overall bundle compliance
Click to edit Master title styleOutcomes by bundle compliance
p=0.001 p=0.003 p=0.054
3.455 4.20
22.79
34.30
20.00
24.23
Click to edit Master title styleOutcomes by subgroup
3.19
22.8320.00
5.00
29.1027.03
4.08
37.66
22.03
p<0.001 p=0.065p=0.001
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Process measures are associated
with outcomes!?
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Surgical prophylaxis patterns are
associated with clinical outcomes
and health care utilization
• what is right for patient care is also good for the health
care system/delivering value
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Other findings
• Regional variation
• Racial disparities
• No differences by insurance type
• Compliance to guidelines increased over years
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Summary
• Evidence-based practice associated with higher
value of care
• Missed perioperative antibiotics associated with
higher risk of infection/complication at 6 months
• Prolonged antibiotic use associated with higher
hospital costs
• Future research to improve all facets of workflow
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Comments:
• My patients are more complicated
• My practices are the best practices
• Why should I change what I do?
• I don’t believe you
Chart review “more believable”
• Examine our own patients
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Retrospective review
• 50 consecutive VNS
• Based on surgeon preference of abx
Group 1:
single dose IV cefazolin
Group 2:
IV cefazolin
IV gentamycin/ IV vancomycin
10 day PO clindamycin
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50 patients
Patient Demographics
Variable Group 1 Group 2 p value
Age (y) 10.2 7.1 0.013
Male gender 58% 58% 1
# of surgeons scrubbed (#) 2.04 2.17 0.109
Length of surgery (minutes) 100 92 0.007
Tracheostomy present (%) 7.7 4.17 0.43
Gastrostomy present (%) 30.8 41.7 0.2
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Medical resource usage
Variable Group 1 Group 2 p value
VNS infection (%) 0 0 1
Other infections (%) 23.1 29.2 0.32
Emergency department
visits postop (#)
0.69 0.96 0.22
Readmission frequency (#) 0.81 1.08 0.24
Improved seizure control (%) 46 50 0.4
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Conclusions
• Surgeon choice of perioperative antibiotics did not
significantly influence outcome
Group 1:
single dose IV cefazolin
Group 2:
IV cefazolin
IV gentamycin/ IV vancomycin
10 day PO clindamycin
• Significance:
• Appropriate perioperative abx use for VNS (and
other surgeries?) warranted for quality
improvement, antibiotic stewardship
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Comments from colleagues
• Oh, that’s cool
• Maybe I will scale back my antibiotics now
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How best to measure and incentivize
clinical performance?
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What happened to the QI projects?
• Baclofen pumps 2010-2016
• Complication rate decreased
28.3% to 7.6%
88% bundle compliance
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Change management, implementation
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Challenge of working with data
• Measure something (clinically) meaningful
• Measure something that can be changed
• Disseminate data in a way that is actionable
How?
• Listen
• Bridge gap between data & clinical care
• Design actionable plans that people believe in
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Translating into clinical practice:
modulating clinical behavior
• Make it meaningful
• Make it easy to do the right thing
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Sharing solutions
• Pediatric Neurosurgery QI collaborative
Why?
Quality improvement
Big data (2.0)
Bigger picture
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Bigger picture
clinical
• Complement research trials
• Inform design of clinical
studies
• Develop best practices
• Genomics, personalized
medicine
socioeconomic
• Optimize delivery of care,
healthcare utilization, policy
• Economic models
• We need to be at the table
with financial and policy
decisions
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