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