Surgical Care Improvement Project

1
Surgical Care Improvement Project

• Mark A. Wilson, MD, PhD
• Vice-President, Surgery
• VA Pittsburgh Healthcare System

2
Objectives

• Define goals and organization of SCIP
• Discuss conceptual basis for SCIP elements
• Review performance measures and current data
• Explore the relevance of process measures to
  quality improvement in surgery

3
What is SCIP?

• American College of Surgeons
• American Hospital Association
• American Society of Anesthesiologists
• Association of peri-Operative Registered Nurses
• Agency for Healthcare Research and Quality
• Centers for Medicare Medicaid Services
• Centers for Disease Control and Prevention
• Department of Veterans Affairs
• Institute for Healthcare Improvement
• Joint Commission on Accreditation of Healthcare
  Organizations

4
Why SCIP?

• 69 of adverse events and deaths in healthcare
  are related to errors and are thus potentially
  preventable. (IOM)
• 2.6 of 30 million operations in the US -gt SSI
  significant impact on LOS, finances, etc.
  http//www.ihi.org/ihi/Topics/PatientSafety/Surgic
  alSiteInfections/SurgicalSiteInfectionsCaseForImpr
  ovement
• 7-8 million operated patients per year with
  significant cardiac risk factors and at least 1
  million cardiac events annually
• Significant risks for perioperative venous
  thromboembolism

5
SCIP Goal

• To reduce preventable surgical morbidity and
  mortality by 25 by 2010
• SCIP constituents believe that Medicare could
  annually prevent up to 13,027 perioperative
  deaths and 271,055 surgical complications in
  major surgical cases by a high level of
  compliance with evidence-based processes for
  surgical care.

6
Voluntary Reporting Hospitals
Deficit Reduction Act of 2005
7
SCIP Modules

• Complication prevention groups
• Surgical infection prevention
• Cardiovascular complication prevention
• Venous thromboembolism prevention
• Respiratory complication prevention
• Specifications Manual http//www.qualitynet.org/d
  cs/ContentServer?cid1142976368240pagenameQnetPu
  blic2FPage2FQnetTier3cPage

8
Surgical Infection Prevention

• SCIP INF 1 Prophylactic antibiotic received
  within one hour prior to surgical incision
• SCIP INF 2 Prophylactic antibiotic selection for
  surgical patients
• SCIP INF 3 Prophylactic antibiotics discontinued
  within 24 hours after surgery end time (48 hours
  for cardiac patients)

9
Surgical Infection Prevention - 2

• SCIP INF 4 Cardiac surgery patients with
  controlled 6 a.m. postoperative serum glucose
• SCIP INF 5 Postoperative wound infection
  diagnosed during index hospitalization (Outcome)
• SCIP INF 6 Surgery patients with appropriate
  hair removal
• SCIP INF 7 Colorectal surgery patients with
  immediate postoperative normothermia

10
Rationale

• Reduction of SSI when tissue levels of
  antibiotics are appropriate at time of surgery
• No demonstrated benefit to prophylaxis
  postoperatively, and higher infection rates if
  antibiotics are continued beyond 24 hours
• Hyperglycemia contributes to SSI risk
• Shaving pre-operatively increases SSI
• Data to support a reduction of SSI rates when
  normothermia is maintained are controversial.

11
SCIP 1-3

• 7 case types that are included
• CABG
• Other cardiac
• Colon surgery
• Hip arthroplasty
• Knee arthroplasty
• Hysterectomy
• Vascular surgery

12
Evolution of National Performance
National sample of 39,000 Medicare patients
undergoing surgery in US hospitals during 2001.
Bratzler DW, Houck PM, et al. Arch Surg.
2005140174-182.
13
National Performance Q3 2007
14
Correct Prophylactic Antibiotic Selection
National VA Data
15
Prophylactic Antibiotic Started Timely
National VA Data
16
Prophylactic Antibiotics DCd Timely
National VA Data
17
National Performance Q3 2007
18
Glucose Levels Cardiac Surgery
National VA Data
19
Hair Removal By Acceptable Method
20
First Temp in Range Colon Surgery
National VA Data
21
Colon Surgery Normothermia Postop
National VA Data
22
SCIP Modules

• Complication prevention groups
• Surgical infection prevention
• Cardiovascular complication prevention
• Venous thromboembolism prevention
• Respiratory complication prevention

23
Cardiovascular Complication Prevention

• SCIP Card 1 Non-cardiac vascular surgery
  patients with evidence of coronary artery disease
  who received beta-blockers during the
  perioperative period
• SCIP Card 2 Surgery patients on a beta-blocker
  prior to arrival that received a beta-blocker
  during the perioperative period
• SCIP Card 3 Intra- or postoperative acute
  myocardial infarction (AMI) diagnosed during
  index hospitalization and within 30 days of
  surgery (Outcome)

24
Beta Blocker Usage
National VA Data
25
Role of Beta Blockers ???
The Lancet 2008 3711839-1847 Effects of
extended-release metoprolol succinate in
patients undergoing non-cardiac surgery (POISE
trial) a randomised controlled trial POISE
Study Group
26
POISE Trial

• 190 hospitals, 23 countries
• 8351 patients with, or at risk of ASHD undergoing
  non-cardiac surgery
• Randomized to double-blinded receipt of extended
  release metoprolol or placebo
• Started 2-4 hours preop and continued for 30 days
  postop
• No dosage adjustment

27
POISE Trial - Results
MI findings are consistent with prior
trials Hypotension was more common in metoprolol
group.? contributor to stroke and death Would
titration by experienced clinicians decrease CVA
and/or death rates for beta blockers? Patient
criteria for beta blockers and time of initiation
continue to be discussed
28
SCIP Modules

• Complication prevention groups
• Surgical infection prevention
• Cardiovascular complication prevention
• Venous thromboembolism prevention
• Respiratory complication prevention

29
Venous Thromboembolism

• Leapfrog VTE is the most common preventable
  cause of hospital death in the United States.
• AHRQ Thromboprophylaxis is the number one
  patient safety practice.
• American Public Health Association VTE
  prophylaxis is a public health crisis.
• Guidelines
• American College of Chest Physicians
• Intervention must be tied to risk assessment
• Evolving Joint Commission patient safety goal

30
Thromboembolism Prevention

• SCIP VTE 1 Surgery patients with recommended
  venous thromboembolism prophylaxis ordered
• SCIP VTE 2 Surgery patients who received
  appropriate venous thromboembolism prophylaxis
  within 24 hours prior to surgery to 24 hours
  after surgery
• SCIP VTE 3 Intra- or postoperative pulmonary
  embolism (PE) diagnosed during index
  hospitalization and within 30 days of surgery
  (Outcome)
• SCIP VTE 4 Intra- or postoperative deep vein
  thrombosis (DVT) diagnosed during index
  hospitalization and within 30 days of surgery
  (Outcome)

31
Evolution in National Performance
National Data for All Hospitals
32
Appropriate VTE Prophylaxis Ordered
National VA Data
33
Received Appropriate VTE Prophylaxis
National VA Data
34
VHA Report Card on SCIP

• We concluded that all facilities evaluated
  during the CAP reviews implemented strategies to
  prevent or reduce the incidence of surgical
  infections. .For those measures that were below
  VHAs established goals, managers implemented
  appropriate action plans to improve performance.
• We made no recommendations.
• VHA OIG, Healthcare Inspection, Surgical Quality
  Improvement Program, March 2008
• http//www.va.gov/oig/54/reports/VAOIG-07-00773-10
  6.pdf

35
SCIP Impacts
Outcomes from SIP Overall surgical infection
rate decreased 27, from 2.28 in the first 3
months to 1.65 in the last 3 reporting months.
Dellinger EP, et al. Am J Surg. 2005190915.
36
National 30-day All Cause MortalityNon-cardiac
surgery
SCIP Impacts
Limited to all Medicare patients undergoing those
operations included in SCIP.
37
Self Analysis
Association of timely administration of
prophylactic antibiotics for major surgical
procedures and surgical site infection.
Hawn MT, Itani KM, Gray SH, et al.
Patients with EPRP SCIP-1 and NSQIP data were
studied Patient and facility level analyses
comparing SCIP-1 and SSI were performed Adjustment
for clustering effects within hospitals,
validation of SSI risk score and procedure type
(percentage of colon, vascular, orthopedic) 9,195
elective procedures (5,981 orthopedic, 1,966
colon, and 1,248 vascular) in 95 VA hospitals.

• J Am Coll Surg. 2008 May206(5)814-9

38

• Timely antibiotic administration occurred in
  86.4 of patients who had an SSI rate of 4.6
  untimely administration was associated with SSI
  rate of 5.8 in unadjusted analysis
• Patient level risk-adjusted multivariable
  generalized estimating equation modeling found
  the SSI risk score was predictive of SSI (p lt
  0.001) and SIP-1 was not associated with SSI.
• Hospital level multivariable linear modeling
  found procedure mix (p lt 0.0001), but not SIP-1
  rate or facility volume, to be associated with
  facility SSI rate.
• The study had 80 power to detect a 1.75
  difference for patient level SSI rates.
• Timely antibiotic administration did not markedly
  contribute to overall patient or facility SSI
  rates.

39
Observations

• Focus on surgical outcomes will continue
• driven largely by financial issues (payer cost
  and provider compensation)
• the right thing for all of us anyway
• Surgical process measures are increasingly
  accepted.data to assess efficacy are needed.
• Implications regarding P4P are significant!
• Definition of the processes that are of
  sufficient clinical importance to warrant
  resource commitment for standardization is
  critical

40
Some helps
An excellent summary of the background for SCIP
elements http//vaww.visn1.med.va.gov/Estrada.con
fig?resource52620 VA SCIP data http//vaww.oqp.
med.va.gov SCIP sites http//www.qualitynet.org
http//www.medqic.org/scip/ Special thanks to
Dale Bratzler, DO Chair, SCIP Steering
Committee, Oklahoma OIFO for sharing national
SCIP data