PEDIATRIC NSQIPINTERNAL QUALITY ASSESSMENT

THINGS YOU CAN DO AT HOMESALT LAKE, 2012

IT ALL BEGINS WITH

ACCURATE AND CONSISTENT DATA

INTERNAL QUALITY AUDIT

INTERNAL QUALITY AUDIT

WHAT DO YOU KNOW ABOUT YOUR OWN DATA?

NSQIP IS NOT THE ONLY PROGRAM ANALYZING YOUR PERFORMANCE

SPEAK A COMMON LANGUAGE AT HOME CPT CODING CHART REVIEW, DESCRIPTIVE DATA

INTERNAL QUALITY AUDIT

WHO DOES IT?

IF THE SURGEON DOES IT, DOES EVERYONE DO IT THE SAME?

IF THE SURGEON DOESN’T DO IT, HOW IS THE DECISION MADE?

WHICH SOURCE IS USED FOR NSQIP SELECTION?

CPT CODING

CPT CODING FOR APPENDECTOMYPROCEDURE 44950 44955 44960 44970 444979

App with open Ladd’s

8

Acute pain, neglap app

1 7Lap app, not ruptured

8

Lap app ruptured

3 5Open app, not ruptured

8

Open app, ruptured

8Lap interval app

8

INTERNAL QUALITY ASSESSMENT

WOUND CLASSIFICATION CLEAN IS CLEAN BUT WHAT IS DIRTY?

HOW IS WOUND CLASS ASSIGNED AT YOUR INSTITUTION? COMPUTER- BASED ON PREOP CPT NURSE ASSESSMENT SURGEON ASSESSMENT

HOW DOES IT COMPARE WITH YOUR SCR ASSESSMENT?

515 PEDIATRIC SURGERY CASES

REVIEWED

481 CASES (93%) HAD A CORRECT

WOUND CLASSIFICATION

34 CASES (7%) HAD AN

INCORRECT WOUND

CLASSIFICATION

ALL THE WOUND CLASSIFICATION

ERRORS WERE AN UNDER ESTIMATE OF

THE CORRECT WOUND

CLASSIFICATION.

DISCOVERY OF A PROBLEM

9

• Lack of understanding of correct wound classification and its importance.

• Lack of awareness that wound classification discrepancies exist in the electronic charting.

• Auto population contains intrinsic errors

• Premature placement of wound classification data in computer flow algorithm.

• Auto population of wound classification produces errors.

PEOPLE TECHNOLOGY

OPERATIVE FINDINGS

CLEAN CLEAN‐CONTAMINATED

CONTAMINATED DIRTY

Ladd’s procedure 8Acute pain, negative appendix

8Edema, inflamed 4 4Edema, inflamed with cloudy fluid

2 6Edema, Inflamed with gross pus

2 6Acute inflam with exudate on appendix

1 6 1

Gangrene 2 6rupture 8Interval appendix 7 1

WOUND CLASS ASSIGNMENT FOR APPENDECTOMY BASED ON INTRAOPERATIVE FINDINGS

HEIGHT AND HEIGHT

WHY DOES IT MATTER?

INTERNAL QUALITY AUDIT

HEIGHT AND WEIGHT

IMPORTANT FOR PATIENT CARE IN DETERMINING MEDICATION DOSING

POTENTIAL VALUE FOR NSQIP TRANSFUSION VOLUMES RELATED TO WEIGHT RISING INCIDENCE OF PEDIATRIC OBESITY

Outcomes of perforated appendicitis in obese and nonobese children.Garey CL, Laituri CA, Little DC, Ostlie DJ, St Peter SD.J Pediatr Surg 2011 Dec:2346

Childhood obesity: a risk factor for injuries observed at a level-1 trauma center.Rana AR, Michalsky MP, Teich S, Groner JI, Caniano DA, Schuster DP.J Pediatr Surg 2009 Aug:1601

Determination of risk factors for deep venous thrombosis in hospitalized children.Vu LT, Nobuhara KK, Lee H, Farmer DL.J Pediatr Surg 2008 June:1095

CHILDHOOD OBESITY-A RISK FACTOR FOR SURGICAL MORBIDITY?

Abstract(text)Abstractabstractabstractabstract2020

RUPTURED APPENDIXPatient DemographicsJuly-December 2011

(35 Total Patients)

CHARACTERISTIC NUMBER

MALES 23

FEMALES 12

MEAN AGE(2-16 yr)

5

MEAN BMI (reported in 9/35 patients)

23.4

BMIsBEYOND BELIEF

Review of all pt BMI greater than 40 Range 41.7 to 152.6 22 patients

Data review 13 pts correct (BMI 41.7 to 57.3) 3 error due to data download 3 error due to typing entry 3 error due to height entered by nurse in inches but

recorded as cm

WEIGHT VARIABLE

NEONATES GROW QUICKLY EXAMPLE: 2 KG PTGROWS 15-20 GRAMS/DAY 7 X 20 = 140 2.14 KG 7% WT CHANGE IN ONE WEEK

SICK PATIENTS DON’T GROW WELL

SICK PATIENTS GET EDEMATOUS MAY DOUBLE OR TRIPLE WT DUE TO RETAINED FLUID

“WEIGHT FOR CALCULATION”

PEDIATRIC NSQIPINTERNAL AUDIT

PILOT PROJECTS REVIEW REPORT AND SEE WHAT CASES ARE MOST

COMMON REVIEW OCCURRENCE REPORTS BY COMMON CPT

AND SEE IF THERE ARE PROBLEM AREAS CHOOSE AN AREA OF LOCAL INTEREST TO VALIDATE

SAMPLING

CUSTOM FIELD DATA POINTS

ENLIST A SUBSPECIALIST FOR EACH SURGICAL SPECIALTY UROLOGY ENT PLASTICS NEUROSURGERY ORTHOPEDICS

INTERNAL QUALITY AUDITAT HOME

SHOW THEM WHAT WE COLLECT

DESCRIBE HOW IT MAY IMPACT THEM

ASK THEM HOW WE COULD DO MORE WITH THE DATA

INTERNAL QUALITY AUDITENLIST A SUBSPECIALIST

Laminectomy for Tethered CordPatient Demographics NSQIP Sample

July-December 2011

CHARACTERISTIC NUMBER

MALES 15

FEMALES 18

MEAN AGE(0-18 yr)

8

MEAN BMI (reported in 24/32 patients)

18

Laminectomy for Tethered CordJuly-Dec 2011

TOTAL CASES COMPARED TO NSQIP SAMPLE

Data Element All 33 Cases NSQIP 21 Cases

Primary Surgery 26 (79%) 15 (71%)

Reoperative Surgery 7 (21%) 6 (29%)

Mean Length of Surgery

(minutes)218 256

Mean LOS (days) 3 4

HOW TO MAKE IT WORK FOR YOU

ENGAGE A SUBSPECIALIST IN EACH AREA

LOOK FOR CONSTRUCTIVE PROJECTS

SHOW HOW GOOD DOCUMENTATION HELPS

FIND AREAS WHERE YOU CAN DO BETTER