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ACS NSQIP:
Preventing complications
Reducing costs
Improving surgical care
May 17, 2014
Scott Ellner, DO, MPH, FACS
Saint Francis Hospital and Medical Center
Disclosures
No relevant disclosures related to this
presentation.
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Increasing Focus on Improving Quality While
Reducing Costs
Decisions are
being made
now – and we
have
opportunities
to get ahead of
CMS actions:
• CMS readmissions
penalties and valuebased purchasing
• Hospital Compare
and other public
reporting
• Physician quality
reporting
• General surgery
registry rule
3
Which Direction will
Quality Improvement Go?
We’ve Found Common Ground
5
ACS NSQIP: What’s Different?
Developed by surgeons
Clinical, not administrative, data
Risk-adjusted and case-mix adjusted
National benchmarking
30-Day patient follow up
Audited
Trained data collector
6
Clinical Data Better for
Measuring Quality
7
Risk and Case-Mix Adjustment Matters
To judge care fairly and understand where
problems are occurring:
Health of the patient must be considered
Risk of the procedure must be considered
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Following Patients After Discharge
• Half or more of all complications occur after
discharge1
• Quality programs based on admin data don’t
track post-discharge
• Complications after discharge can lead to
readmissions2
Tracking quality can’t stop at the hospital’s door
1 Ko CY. “ACS NSQIP Conference Overview.” Presentation to the 2009 ACS NSQIP National Conference. July 2009.
2 Kassin MT et al. “Risk Factors for 30-Day Hospital Readmissions among General Surgery Patients.” J Am Coll Surg. 2012; 215: 322-30.
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ACS NSQIP: Proven to Reduce
Complications, Save Lives
2009 Annals of Surgery
study:
Prevent 250-500
complications
annually
Save 12-36 lives
annually
Leading to reduced
costs
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Surgical Complications Drive
Readmissions
2012 Journal of the
American College of
Surgeons study:
• Surgical complications
key driver of 30-day
readmissions
• SSIs – 22%
• Gastrointestinal – 28%
• Pulmonary – 8%
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ACS NSQIP: Better Care,
Lower Costs
Not only will patients benefit,
but hospitals see a significant
return on their investment with
ACS NSQIP.
• Significant cost savings per
year
• Reduced readmissions and
reduced lengths of stay
translate to better patient
outcomes, better satisfaction
and even more cost reduction
• Pays for itself by avoiding
about a dozen surgical
complications
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ACS NSQIP Meets Regulatory
Requirements
CMS general surgery registry rule began this FY
ACS NSQIP measures reported on Hospital Compare
(voluntary)
Five ACS NSQIP measures being considered for
national adoption by CMS
ACS NSQIP’s SSI harmonized with CDC’s NHSN
program
Joint Commission Quality Check for participation
Part of SUSP program supported by AHRQ
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ACS NSQIP Meets Regulatory
Requirements
CMS general surgery registry rule began this FY
ACS NSQIP measures reported on Hospital Compare
(voluntary)
Five ACS NSQIP measures being considered for
national adoption by CMS
ACS NSQIP’s SSI harmonized with CDC’s NHSN
program
Joint Commission Quality Check for participation
Part of SUSP program supported by AHRQ
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Why the Foley?
Everybody gets a catheter
Post-Operative Urinary Tract Infections
Observed Rate:
2.41%
Expected Rate:
1.47%
O/E Ratio: 1.64
Status: Needs
Improvement
2008
The CAUTI Gang
32-40% of all nosocomial
infections
Adds an average of 1-3
additional hospital days
UTIs increase a patient's
hospital costs by 47 % at
teaching hospitals and 35 %
at community hospitals
Roberts RR Clin Infect Dis , 2009
Next Steps
Build a guiding coalition
Drill down on data
Determine why patients
developed the infection
Share key findings with key
stakeholders
Share
Data
Leadership
Model the Way
Challenge the Process
Share a Vision
Empowerment
CAUTI Sub-Committee
Goals – Time Sensitive
Drill down
Pilot Audit
Implementation
Sustainability
ACS Clinical Guidelines
Prior to Insertion:
• Education
During Insertion:
• Trained personnel
• Hand hygiene
After Insertion:
• Secured catheter
• Closed Drainage
• Urimeter positioning
Nurse Driven Protocol
Automatic Order Set
Catheter Needed?
Remove by Post-op Day 2
Catheter Still In? Why?
Documentation
Situational Leadership
Nurse Driven Protocol
Patients
UTI
Pre
Intervention
Post
Intervention
N=1,404*
N=2,469*
36
2.6%
38
p
1.5%
<.05
Pre-Intervention: September 2007 – December 2008
Post-Intervention: January 2009 – December 2010
*Number of patients undergoing
general surgery captured in the NSQIP database.
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C. Difficile Prevention
Derkonja DM JAMAintmed 2013
Silver Prices
Pickard P Lancet 2012
$160,000 savings/year
Barriers
1)
2)
3)
4)
Complacency
Resistance
Exposing failures
Challenging years of
embedded culture
5) Compliance
6) Training
7) Uneasy Leadership
Return on Investment
A Business Case for Reducing CatheterAssociated Urinary Tract Infections
A Study Using ACS National Surgical
Quality Improvement Program Data
Return on Investment
General &
Vascular
Surgery
UTI
Length of
Stay (days)
Excess
Costs/Patient*
N=74
Mean
Mean
Cases Identified
Inpatient
Comments
Patient
Occurrences
5 deaths
9 C. Diff (+)
41
28.5
$52,384
2 readmissions
4 ED visits
Outpatient
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Zimlichman E JAMAint 2013
6
$758
* Variable
Costs
62% Reduction
Observed Rate:
1.23%
Expected Rate:
1.43%
O/E Ratio: 0.86
Status: As
Expected
2008
2014
Surgical Checklist Verified with ACS
NSQIP Data
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Take Home Points
• ACS NSQIP metrics are actionable
• Share data and acknowledge need
for change
• Implement a CAUTI prevention protocol
• Recognize and address barriers
• It’s all about leadership