NSQIP program finds 44 stars
"Meritorious" designation for stellar surgical programs
The top 10% of the 445 participants in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) were recognized in October for hitting the mark on a variety of data points deemed important to surgical outcomes. Although the merit recognition program has been around for five years, Pegi Wasserman, RN, BSN, the ACS NSQIP Perioperative Clinical Reviewer in the department of clinical excellence at Advocate Illinois Masonic Medical Center in Chicago was completely taken aback that her program was one of them. "I had no idea it even existed," she says.
The merit recognition program ranks participating hospitals on composite scores for eight data points. They are:
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mortality;
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cardiac: cardiac arrest and myocardial infarction;
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pneumonia;
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unplanned intubation;
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ventilator > 48 hours;
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renal failure;
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surgical-site infections (SSI): superficial incisional SSI, deep incisional SSI, and organ/space SSI;
urinary tract infection (UTI).
Wasserman says that of all the issues that the task force worked on related to the metrics, the work on surgical-site infections (SSIs) has been the most gratifying. Over the course of 2013, the rates for infections in colon surgery went down from 30% to 16% — just shy of the 50% drop she and her quality improvement team were looking for.
The multidisciplinary task force initially met to go over literature on existing best practices. Seminal work done by the Mayo Clinic and Johns Hopkins in particular helped them create a skeleton of best practices that they then adapted to their own needs in Chicago. "We needed to look at what to change preoperatively, intra-operatively, postoperatively, and post-hospitalization," she says.
NSQIP, she explains, follows patients for 30 days post discharge, so that post-hospitalization piece is as important as any other and something that many other organizations don’t include in their quality efforts.
Data was kept meticulously — Wasserman handled that role herself — and analyzed at six, nine, and 12 months.
Among the changes in care, Wasserman noted these 12 items:
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Two showers at home with chlorhexidine, and a bath cloth wipe down with chlorhexidine in the surgical holding area.
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All hair clipping done in the surgical holding area.
Previously used bowel techniques were brought back into use: instruments used before closing were kept on a separate tray from those used for closing.
Gowns and gloves are changed and the surgical site is reblocked for closing.
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The surgical team ensures that the dressing is on before the drapes are removed. "This is supposed to be done all the time, but it really isn’t," she says.
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The patient is warmed intra-operatively to prevent hypothermia.
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Post-surgical glycemic index is monitored and controlled.
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Removal of Foley catheter within 48 hours.
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Removal of dressing on the second post-surgical day.
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Appropriate VTE and antibiotic prophylaxis.
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Patient teaching for good hand-washing techniques, chlorhexidine washing, and wound cleaning.
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Patient teaching on 12 warning signs of infection. The purpose, Wasserman says, is to help patients to know when to call their surgeon, and when to go to the hospital. In the end, the goal is to prevent readmissions and unnecessary trips to the hospital alike.
The numbers continue to hold steady, Wasserman says. One thing she noticed as she looked through data is that surgical infections for general surgeries also declined, as did urinary tract infections, which she is sure happened because of the change in policy to remove catheters within two days. Another positive impact that is probably harder to directly correlate, but which she thinks is definitely related to this program: an increase in top-tier patient satisfaction ratings of 35%, and a decrease of "needs improvement" ratings from 8% to 5%. "All of that came from this one initiative," she says.
The coming year will see a continued focus on surgical-site infections, and the hospital in general is looking at UTI rates. Renal failure has been up a bit in vascular cases, so Wasserman will be pulling charts to see what went wrong in them and find areas for improvement.
"All of the things in this composite score are important and inter-related," she says. "The only thing not included that we are working on is venous thromboembolism. We are looking at that critically, particularly in orthopedics."
In Houston, Memorial Hermann Northeast Hospital also achieved meritorious status. Tal Raphaeli, MD, FACS, a colon-rectal surgeon at Houston Colon and Rectal Surgery, PA, says they have been involved in NSQIP before last year, but "only in a passive sense. We had not taken real control of the data to be able to identify areas for improvement. Once we saw the power of the data, it was clear that we had to be more active in using it."
The area of biggest concern for Memorial Hermann was post-operative pneumonia, which they have been able to "nearly eliminate" with some simple steps.
They created a checklist to give patients visual reminders and cues regarding pulmonary hygiene that can help prevent postoperative pneumonia. "The nurses on the floor bought in completely," he says, "and the patients have been eager to really be involved actively in their own care."
Back in Chicago at Advocate Lutheran General Hospital, Chief of Surgery John White, MD, is enjoying his fifth designation as head of a meritorious surgical program. One of the things he has learned is that there is no destination in quality improvement. "Despite this acknowledgement, we have found a great many areas we could improve upon each year," he says. "The true value in these measures lies not in the recognition for achievement but in the greater understanding of the human body and how to better protect it during and after surgery."
He gives the example of initially addressing surgical-site infections by changing how surgeons scrubbed their hands and how they prepped the patient’s skin at the time of surgery. "We embraced the Surgical Care Improvement Program recommendations for antibiotic use," White continues. "Then we recognized that how we treat the incision after surgery is also important, so we began to standardize wound care. Finally, we are now aware that when patients are discharged earlier we must communicate more clearly with them or their caregivers about wound care to prevent delayed surgical-site infections. Meritorious care does not stop with discharge but with full recovery and ongoing health maintenance."
Surgeons may solve the problems posed by these eight metrics some day. But there will always be something new to focus on. "What will we focus on now? Everything!" White exclaims. "We believe that the future of surgery is to disrupt less normal tissue, to heal injured or diseased tissues and thus to promote a more rapid and full recovery. To accomplish this, we must continue to pay attention to every aspect of the patient’s treatment program from pre-op assessment to full recovery and learn how to be better. We can always be better."
The complete list of programs that achieved meritorious status is available at https://www.facs.org/~/media/files/quality%20programs/nsqip/meritoriousposter2014.ashx
For more information on this topic, contact:
John White, MD, Chief of Surgery, Advocate Lutheran General Hospital, Chicago, IL. Email:
[email protected]
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Pegi Wasserman, BSN, RN, ACS NSQIP Perioperative Clinical Reviewer, Department of Clinical Excellence, Advocate Illinois Masonic Medical Center, Chicago, IL. Telephone: (773) 296-8373.
Tal Raphaeli, MD FACS, Colon and Rectal Surgeon, Houston Colon and Rectal Surgery, PA, Memorial Hermann Northeast Hospital, Houston, TX. Email:
[email protected]
