The Surgical Care Improvement Project Where we started and where were going

1
The Surgical Care Improvement ProjectWhere we
started and where were going
Dale W. Bratzler, DO, MPH QIOSC Medical
Director Oklahoma Foundation for Medical
Quality June 5, 2007
2
Why focus on surgical quality?

• 30 million major operations each year in the US
• Despite advances in surgical and anesthesia
  technique and improvements in perioperative care,
  variations in outcomes for patients having
  surgery are well known

3
Why focus on surgical quality

• Patients who experience a postoperative
  complication have dramatically increased hospital
  length of stay, hospital costs, and mortality
• On average, the length of stay for patients who
  have a postoperative complication is 3 to 11 days
  longer

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Consequences of Surgical Complications

• Dimick and colleagues demonstrated increased
  costs
• infectious complications was 1,398
• cardiovascular complications 7,789
• respiratory complications 52,466
• thromboembolic complications 18,310.

Dimick JB, et al. J Am Coll Surg 2004199531-7.
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Impact of Complications on Survival
Khuri and colleagues demonstrated that,
independent of preoperative patient risk, the
occurrence of a 30-day complication reduced
median patient survival by 69.
Khuri SF, et al. Ann Surg 2005242326-41.
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Who Pays for Surgical Complications?
Complications were always associated with an
increase in costs to healthcare payors
complications were associated with an average
increase in payment of 7645 (54) per patient.
Dimick JB, et al. Who pays for poor surgical
quality? Building a business case for quality
improvement. J Am Coll Surg. 2006202933-7.
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Medicare Surgical Infection Prevention (SIP)
Project Objective

• To decrease the morbidity and mortality
  associated with postoperative infection in the
  Medicare patient population

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Risk Factors for SSI
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Risk Factors for SSI
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Quality IndicatorsNational Surgical Infection
Prevention Project

• Proportion of patients with antibiotic initiated
  within 1 hour before surgical incision
• Proportion of patients who receive prophylactic
  antibiotics consistent with current
  recommendations
• Proportion of patients whose prophylactic
  antibiotics were discontinued within 24 hours of
  surgery end time

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Efficacy Of Prophylaxis Is Independent Of The
Specific Antibiotic
Penicillin, 40,000 U
Erythromycin, 0.1 mg/Kg
Control
Control
Staph Penicillin
Staph Erythromycin
Chloramphenicol, 0.1 mg/Kg
Tetracycline, 0.1 mg/Kg
Lesion Size, mm (24 Hours)
Control
Control
Staph Chloramphenicol
Staph Tetracycline
Age of Lesion at Antibiotic Injection (Hours)
Burke JF. Surgery. 196150161.
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Timing of Antibiotic ProphylaxisGI Operations
Stone HH et al. Ann Surg. 1976184443-452.
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Perioperative AntibioticsTiming of Administration
14/369
15/441
1/41
1/47
1/81
2/180
5/699
5/1009
Hours From Incision
Classen, et al. N Engl J Med. 1992328281.
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Clin Infect Dis. 2007 449217.
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Clin Infect Dis. 2007 449217.
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Discontinuation of Prophylaxis

• Numerous clinical trials have compared short-term
  to long-term antimicrobial prophylaxis
• Many compared single-dose prophylaxis to multiple
  dose prophylaxis
• Wide variety of operations using a wide variety
  of antimicrobial agents
• Infection rates are the same regardless of
  duration of prophylaxis
• Prolonged prophylaxis has been associated with
  higher rates of infections with resistant
  organisms (when infection occurs). Prolonged
  prophylaxis only changes the flora it does not
  lower infection rates.

Prolonged prophylaxis is a patient safety issue.
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C. difficile enterocolitis

• In epidemiologic studies of C. difficile
  enterocolitis, surgical antimicrobial prophylaxis
  is the single most common indication for use of
  antibiotics. Although even single dose
  prophylaxis increases the risk of carriage of C.
  difficile, in a case control study of patients
  all of whom received surgical prophylaxis,
  carriage of C. difficile was more common in
  patients who received prophylaxis for gt 24 hours
  (56 versus 17).

Jobe BA, et al. Am J Surg. 1995169480-483. Privi
tera G, et al. Antimicrob Agents Chemother.
199135208-210.
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Conclusions One-dose antibiotic prophylaxis did
not lead to an increase in rates of surgical site
infection and brought a monthly savings of 1980
considering cephazolin alone. High compliance to
1-dose prophylaxis was achieved through an
educational intervention encouraged by the
hospital director and administrative measures
that reduced access to extra doses.
Arch Surg. 20061411109-1113.
19
http//www.aaos.org/about/papers/advistmt/1027.asp
Recommendation 3 Duration of prophylactic
antibiotic administration should not exceed the
24-hour post-operative period. Prophylactic
antibiotics should be discontinued within 24
hours of the end of surgery. Medical literature
does not support the continuation of antibiotics
until all drains or catheters are removed and
provides no evidence of benefit when they are
continued past 24 hours.
20
http//www.sts.org/sections/aboutthesociety/practi
ceguidelines/antibioticguideline/
Conclusions The duration of antibiotic
prophylaxis should not be dependent on indwelling
catheters of any type. There is evidence
indicating that antibiotic prophylaxis of 48
hours duration is effective. There is some
evidence that single-dose prophylaxis or 24-hour
prophylaxis may be as effective as 48-hour
prophylaxis, but additional studies are necessary
. There is no evidence that prophylaxis
administered for longer than 48 hours is more
effective than a 48-hour regimen.
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Antibiotic Recommendation Sources

• American Society of Health System Pharmacists
• Infectious Diseases Society of America
• The Hospital Infection Control Practices Advisory
  Committee
• Medical Letter December 2006
• Surgical Infection Society
• Sanford Guide to Antimicrobial Therapy
• The Johns Hopkins Guide
• Society of Thoracic Surgeons February 2007

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Recently Updated Antibiotic Recommendations
For the purposes of national performance
measurement a case will pass the antibiotic
selection performance measure if vancomycin is
used for prophylaxis (in the absence of a
documented beta-lactam allergy) if there is
physician documentation of the rationale for
vancomycin use (effective for July 2006
discharges).
Bratzler DW, Hunt DR. The Surgical Infection
Prevention and Surgical Care Improvement
Projects national initiatives to improve
outcomes for patients having surgery. Clin Infect
Dis. 200643322-30.
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Recently Updated Antibiotic Recommendations
(continued)
Ciprofloxacin, levofloxacin, gatifloxacin, or
moxifloxacin (effective for July 2006
discharges). For the purposes of national
performance measurement, a case will pass the
antibiotic selection indicator if the patient
receives oral prophylaxis alone, parenteral
prophylaxis alone, or oral prophylaxis combined
with parenteral prophylaxis.
Bratzler DW, Hunt DR. The Surgical Infection
Prevention and Surgical Care Improvement
Projects national initiatives to improve
outcomes for patients having surgery. Clin Infect
Dis. 200643322-30.
24
Antibiotic practices that have been shown to
reduce the risk of SSI.

• Administration of the antibiotic dose just before
  incision
• Antibiotic selection for the common organisms to
  be encountered
• Appropriate dose adjustment based on patient
  weight
• Re-dosing the patient in the operating room for
  long cases

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Surgical Care Improvement ProjectNational Goal

• To reduce preventable surgical morbidity and
  mortality by 25 by 2010

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SCIP Steering Committee

• 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

• American College of Surgeons
• American Hospital Association
• American Society of Anesthesiologists
• Association of peri-Operative Registered Nurses
• Agency for Healthcare Research and Quality

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Surgical Care Improvement Project (SCIP)

• Preventable Complication Modules
• Surgical infection prevention
• Cardiovascular complication prevention
• Venous thromboembolism prevention

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Surgical Care Improvement ProjectPerformance
measures - Process

• Surgical infection prevention
• Antibiotics
• Administration within one hour before incision
• Use of antimicrobial recommended in guideline
• Discontinuation within 24 hours of surgery end
• Glucose control in cardiac surgery patients
• Proper hair removal
• Normothermia in colorectal surgery patients

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Furnary et al. Ann Thorac Surg 199967352
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Pre-operative shaving

• Shaving the surgical site with a razor induces
  small skin lacerations
• potential sites for infection
• disturbs hair follicles which are often colonized
  with S. aureus
• Risk greatest when done the night before
• Patient education
• be sure patients know that they should not do you
  a favor and shave before they come to the
  hospital!

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Temperature Control

• 200 colorectal surgery patients
• control - routine intraoperative thermal care
  (mean temp 34.7C)
• treatment - active warming (mean temp on arrival
  to recovery 36.6C)
• Results
• control - 19 SSI (18/96)
• treatment - 6 SSI (6/104), P0.009

Kurz A, et al. N Engl J Med. 1996. Also Melling
AC, et al. Lancet. 2001. (preop warming)
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Cardiovascular Complication Prevention
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Prevention of Cardiac EventsIntroduction

• As many as 7 to 8 million Americans that undergo
  major noncardiac surgery have multiple cardiac
  risk factors or established coronary artery
  disease
• More than 1 million cardiac events annually
• Myocardial ischemia either clinically occult or
  overt confers a 9 - fold increase in risk of
  unstable angina, nonfatal myocardial infarction,
  and cardiac death

Schmidt M, et al. Arch Intern Med.
200216263-69. Mangano DT, et al. N Engl J Med.
19963351713-1720. Selzman CH, et al. Arch Surg.
2001136286-290.
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Surgical Care Improvement ProjectPerformance
measure - Process

• Perioperative cardiac events
• Perioperative beta blockers in patients who are
  on beta blockers prior to admission

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http//www.acc.org/clinical/guidelines/perio/perio
betablocker.pdf
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Venous Thromboembolism Prevention
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Prevention of Venous Thromboembolism

• Recent estimates show that
• more than 900,000 Americans suffer VTE each year
• about 400,000 of these being DVT
• About 500,000 being manifest as PE
• In about 300,000 cases, PE proves fatal it is
  the third most common cause of hospital-related
  deaths in the United States.

Heit JA, Cohen AT, Anderson FA on behalf of the
VTE Impact Assessment Group. Abstract American
Society of Hematology Annual Meeting, 2005.
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National Body Position Statements

• Leapfrog1
• PE is the most common preventable cause of
  hospital
• death in the United States
• Agency for Healthcare Research and Quality
  (AHRQ)2
• Thromboprophylaxis is the number 1 patient
  safety practice
• American Public Health Association (APHA)3
• The disconnect between evidence and execution
  as it
• relates to DVT prevention amounts to a
  public health crisis.

1. The Leapfrog Group Hospital Quality and Safety
Survey. Available at www.leapfrog.medstat.com/pdf
/Final/doc 2. Shojania KG, et al. Making
Healthcare Safer A Critical Analysis of Patient
Safety Practices. AHRQ, 2001. Available at
www.ahrq.gov/clinic/ptsafety/ 3. White Paper.
Deep-vein thrombosis Advancing awareness to
protect patient lives. 2003. Available at
www.alpha.org/ppp/DVT_White_Paper.pdf
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Acquired Risk Factors
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Thromboprophylaxis Use in Practice 1992-2002
Prophylaxis Patient Group Studies
Patients Use (any) Orthopedic surgery
4 20,216 90 (57-98)
General surgery 7 2,473
73 (38-98) Critical care
14 3,654 69 (33-100)
Gynecology 1 456
66 Medical patients 5
1,010 23 (14-62)
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Surgical Care Improvement ProjectPerformance
measures - Process

• Prevention of venous thromboembolism
• Proportion who have recommended VTE prophylaxis
  ordered
• Proportion who receive appropriate form of VTE
  prophylaxis (based on ACCP Consensus
  Recommendations) within 24 hours before or after
  surgery

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ACCP Guidelines for VTE Prevention
Geerts WH, et al. CHEST. 2004126338S-400S.
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Public Accountability and SCIP
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Hospital Public Reporting P4R
0.4 Incentive
98.3 of PPS hospitals now reporting
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Deficit Reduction Act of 2005
For purposes of clause (i) for fiscal year 2007
and each subsequent fiscal year, in the case of a
subsection (d) hospital that does not submit, to
the Secretary in accordance with this clause,
data required to be submitted on measures
selected under this clause with respect to such
a fiscal year, the applicable percentage increase
under clause (i) for such fiscal year shall be
reduced by 2.0 percentage points. The Secretary
shall expand, beyond the measures specified under
clause (vii)(II) and consistent with the
succeeding subclauses, the set of measures that
the Secretary determines to be appropriate for
the measurement of the quality of care furnished
by hospitals in inpatient settings. The
Secretary shall report quality measures of
process, structure, outcome, patients'
perspectives on care, efficiency, and costs of
care that relate to services furnished in
inpatient settings in hospitals on the Internet
website of the Centers for Medicare Medicaid
Services.
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OPPS RuleFinal Rule Posted on November 1, 2006

• Expands required measures for hospital public
  reporting
• 21 current measures
• Adds
• SCIP Infect 2 (antibiotic selection)
• SCIP VTE 1 and 2
• HCAHPS (consumer satisfaction)
• Three new CMS 30-day mortality measures for AMI,
  HF, and Pneumonia (based on CMS analysis of
  Medicare fee-for-service claims data)

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Hospital Acquired Infections (provisions of the
Deficit Reduction Act) In order to manage the
costs associated with Hospital Acquired
Infections, the DRA requires the Secretary to
identify, by October 1, 2007, at least two
conditions that are o High cost or high volume
or both o Result in a DRG that has a higher
payment when present as a secondary diagnosis
o Could have been reasonably prevented through
the application of evidence based guidelines
The IPPS proposed that for discharges on or
after October 1, 2008, that have one of the two
selected conditions as a secondary diagnosis that
was not present at admission will be paid as if
the secondary diagnosis was not present.
Therefore any charges associated with the
infection would not be paid.
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Deficit Reduction Act - 2005

• the Secretary is directed to begin phasing out
  payment increases associated with complications
  of care

Remember who pays for surgical complications
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Deficit Reduction Act 2005Pay for performance

• . the Secretary is directed to develop a plan
  to implement a value-based purchasing program
  based on the expanded measure set for which
  hospitals will submit data starting in FY 2007.
  The program will begin implementation in FY 2009
  (2008).

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Surgical Care Improvement Project
NQF endorsed.
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Preliminary SCIP DataQtr. 1, 2005
National sample of 19, 497 Medicare patients. The
charts were independently abstracted by the CMS
CDAC.
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SCIP Baseline AntibioticsPreliminary National
Data
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SCIP Baseline VTE ProphylaxisPreliminary
National Data
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Reporting Hospitals (Voluntary)Surgical
Infection Prevention Project
Proposed IPPS rule suggested that hospitals
needed to start reporting SIP measures in January
to avoid losing 2 of their Medicare annual
payment update. Final rule did not require
reporting until July 2006.
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Surgical Infection PreventionHospital Voluntary
Self-Reporting, Qtr. 3, 2006
Based on medical record abstraction from the
charts of patients discharged in the 3rd quarter
of 2006. Benchmark rates were calculated for all
HQA reporting hospitals in the US (N3670) based
on discharges during the 3rd quarter of 2006
using the Achievable Benchmarks of CareTM
methodology (http//main.uab.edu/show.asp?durki14
527).
30 Connecticut hospitals reporting.
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Surgical Care Improvement Project Why?

• Medicare could prevent up to
• 13,027 perioperative deaths
• 271,055 surgical complications

Major surgical cases
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Patient Outcomes Can Improve
The overall surgical infection rate fell 27,
from 2.28 (215 infections among 9435 surgical
cases) in the first 3 months to 1.65 (158
infections among 9584 cases) between the first
and the last 3 reporting months.
Dellinger EP, et al. Am J Surg.2005190915.
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Summary

• As the SIP project is expanded into the new
  Surgical Care Improvement Project we need to find
  ways to make evidence-based processes of care
  routine
• We have to quit relying on memory to ensure high
  quality care
• Recognize that there is now a national commitment
  to improving outcomes for surgical patients

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www.medqic.org/scip