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NSQIP at SMH September 2010. NSQIP. NSQIP Information Semiannual Report on Colorectal Surgery Colorectal Initiatives Implemented Colorectal Data 2009 Emergency Colorectal Surgery. What is NSQIP?. Program Overview. Outcomes-based program. Risk-adjusted. - PowerPoint PPT Presentation
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NSQIP at SMHSeptember 2010
NSQIP
• NSQIP Information
• Semiannual Report on Colorectal Surgery
• Colorectal Initiatives Implemented
• Colorectal Data 2009
• Emergency Colorectal Surgery
What is NSQIP?
Program Overview
• Outcomes-based program
• Risk-adjusted
• Reports – SAR , benchmarking, ,ad-hoc,
• 240 Participating Sites
• 5 Canadian Sites
• General, Vascular, ENT, Thoracic
More about NSQIP
• Systematic sampling process
• Inclusion/exclusion criteria
• Data
Preoperative
Intraoperative
Postoperative (30-day outcome) • Sources of Data - Chart, EMR, phone call/letter,
Dr office visits
Semiannual Report, June 2010Dates of Surgery: January 1, 2009-December 31,
2009Fraser Health - Surrey Memorial Hospital
American College of SurgeonsNational Surgical Quality Improvement Program
Results
• Risk adjustment use of preoperative risk factors to account for “patient risk”
• O/E Ratio “O” number of observed adverse events
“E” number of expected adverse events based on patients’ characteristics or preoperative risk factors
Interpretation of Results
Observed to Expected (O/E) Ratio• Represents the hospital’s outcomes compared to the other ACS NSQIP hospitals, adjusted for inter-hospital differences in patients’ characteristics, comorbidities, and preoperative laboratory values
LOW OUTLIER: If the upper bound of the O/E confidence interval is <1.0, the hospital’s outcomes are statistically better than expected. Thus, the hospital’s outcomes are “Exemplary.”
ACS NSQIP Hospital ID Number
HIGH OUTLIER: If the lower bound of the O/E ratio is >1.0, the hospital’s outcomes are statistically worse than expected. Thus, the hospital’s outcomes “Need Improvement.”
AS EXPECTED
Interpretation of Results
ACS NSQIP Hospital ID Number
Over-Time Performance• Represents the hospital’s previous O/E ratios from the 10 most recent semi-annual reports
Current O/E Ratio
Low Outlier
High OutlierAs Expected
Semiannual Report Statistics:
Jan 1, 2009 – Dec 31, 2009
NSQIP - 268143 cases SMH - 1321
General Surgery cases - 1251 Colorectal cases - 130
Colorectal Surgery 30-Day Mortality
Observed Rate: 9.23%Expected Rate: 5.87%O/E Ratio: 1.57Status: As Expected
Colorectal Surgery 30-Day Morbidity
Observed Rate: 29.23%Expected Rate: 34.53%O/E Ratio: 0.85Status: As Expected
Colorectal Surgery Length of Stay
Observed Rate: 42.39%Expected Rate: 37.43%O/E Ratio: 1.13Status: As Expected
Colorectal Surgery Surgical Site Infection
Observed Rate: 13.08%Expected Rate: 17.01%O/E Ratio: 0.77Status: As Expected
Colorectal Initiatives
• Colorectal carepath and orderset
Best practices for pneumonia and UTI
prevention
• Use of silver catheter in the OR
• Enhanced Stoma care
• Patient Education
• Colorectal Education Day
Colorectal Data
130 colorectal cases in 2009
Emergent 54 (42%) Elective 76 (58%)
Mortality Rate 12 ( 9.2%) Emergent 66.7% Elective 33.3%
SMH NSQIP
25,815 cases
16 %84%
4.1%62.9%37.1%
Colorectals
• Preop Risk Factors:
Colorectals
Preop Risk Factors: SMH NSQIP
Dyspnea 16.9% 11.7%DNR 6.2% 1.1%Partially Dependent 24.6% 7.1%Totally Dependent 6.2% 3.8%Ascites 2.3% 1.5%CVA 10.8% 4.9%Weight Loss 8.5% 5.6%Radiotherapy 7.7% 3.7%Sepsis/Shock 14.7% 9.2%
Preop Documentation
Missing data
Height 26/130 (20 %)Weight 24/130 (18 %)
Smoking History 55/130 (42 %) Functional Status Chemo/Radiotherapy Open Wounds Weight Loss
• Outcome SMH NSQIP
Pneumonia 6.2% 3.6%
PE 2.3% 0.7%
UTI 5.4% 4.0%
Cardiac Arrest 3.8% 1.1%
MI 3.8% 1.0%
Colorectals
Colorectal LOSAverage LOS Emergency vs Elective Colorectals
Trend over Time
0
5
10
15
20
25
2008 2009
YearNu
mber
of D
ays
Emergent SMH
Emergent NSQIP
Elective SMH
Elective NSQIP
Length of Stay Colorectal Surgeries (2008-2009)
0
10
20
30
40
50
60
< 4 4 to 6 7 to 9 10 to12
13 to15
16 to18
19 to21
22 to24
> 25
Number of Days
Num
ber o
f Pat
ient
s
Average: 13.5 daysMode: 6 daysMedian: 9 daysSD: 17
Mortality Report
Postop DNR 6/12 (50%)
Emergent cases: 8/12 (67%)
Wait TimeEmergent Case Wait Time (Door to Skin)
n = 54average 44 Hoursmode 3 Hoursmedian 4 Hourssd 152min 1.5 Hoursmax 762 Hours
Wait Time
0
20
40
60
80
100
120
24 48 72 96 120 144 168 More
Hours
# P
atie
nts
Wait Time Log(Hr)
0
10
20
30
40
50
0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2 2.2 2.4 2.6 2.8 3 3.2
Log(Hr)
# of
Cas
es
Emergency Colorectals
ASA Class Elective Emergent Total
1-No Disturb 7 5 (9.3%) 12
2-Mild Disturb 39 16 (29.6%) 55
3-Sever Disturb 28 19 (35.2%) 47
4-Lfe Threat 2 12 (22.2%) 14
5-Moribund 0 2 (3.7%) 2
Total 76 54 (100%) 130
NSQIP: Emergent with 0 risk factor: 11%ASA 1 vs NSQIP 0 Risk Factor :McNemar Test: p-value = <.001
Pearson Chi2 p-value = 0.001
Emergency Colorectals
Pearson chi2(2) = 24.3839 Pr = 0.000
Total 76 54 130 4-Dirty/Infected 8 23 31 3-Contaminated 22 19 41 2-Clean/Contaminated 46 12 58 Wound Classification NO YES Total Emergent Case
Emergency Colorectals
Pearson chi2(3) = 18.7420 Pr = 0.000
Total 76 54 130 4 14 0 14 3 24 9 33 2 26 34 60 1 12 11 23 Surgery NO YES Total Length of Emergent Case
Pearson chi2(3) = 66.8328 Pr = 0.000
Total 76 54 130 7:31 to 11:30 51 3 54 19:31 to 7:30 1 21 22 15:31 to 19:30 3 14 17 11:31 to 15:30 21 16 37 In Room Time NO YES Total Day - Patient Emergent Case Time of the
Emergency Colorectals
Outcome:
Cases with at least 1 postoperative occurrence 24/54 = 44%
Is our data reflective of what our patients are really like?
Request
• Enhance preoperative assessment
• Improve documentation
• Resume PDSA OR and Surgical Units
• Patient and staff education