When Quality Improvement Meets Surgery, Complications Will Plummet

Of the more than 42 million operations performed in the United States each year, up to 40% have postoperative complications.(1)

The statistics certainly are eye-catching. And the numbers have captured the attention of leaders at the Centers for Disease Control and Prevention (CDC) and the Centers for Medicare & Medicaid Services (CMS). As a result, the two groups have launched the Surgical Care Improvement Project (SCIP), a national quality improvement initiative that aims to reduce the incidence of surgical complications by 25% by the year 2010.

“Surgical care obviously has many risks associated with it. The fact that we know how to prevent many of these complications makes it a worthwhile area for quality improvement. We know that we can help a lot of patients by focusing on surgical care,” says Paul Schyve, M.D., senior vice president at the Joint Commission on Accreditation of Healthcare Organizations. The Joint Commission is a member of SCIP’s steering committee.

SCIP aims to achieve its goal by doing the following:

• Increasing the amount of attention paid to quality improvement efforts in the surgical arena
• Eliciting the support and cooperation of major health care organizations
• Focusing quality improvement efforts on system level improvements
• Developing effective, easy to implement quality measures

Zeroing in on Surgery
For years, quality improvement efforts focused principally on primary care. However, in 2003, leaders at the CDC and CMS realized that there was a need to get the nation’s hospitals to target quality improvement in surgical care—an area that was often relegated to the back burner, according to David R. Hunt, M.D., FACS, medical officer with the CMS Quality Improvement Group.

“The health care industry had basically left untouched the area of surgical care. So, there was a big hole in terms of quality improvement,” Hunt says.

Certainly, a number of research studies verify the need for quality improvement in surgical care. For example, the Institute of Medicine, in its groundbreaking report To Err Is Human: Building a Safer Health System, revealed that 5.4% of surgical patients suffered complications—nearly half of them attributable to error—during a three-year period at a major academic medical center.(2) In addition, a 2003 study published in the Journal of the American Medical Association found that postoperative complications accounted for up to 22% of preventable deaths among patients.(3)

With their work clearly cut out for them, the CDC and CMS launched the National Surgical Infection Prevention Project in December 2002. The goal of this program was to reduce postoperative infections in Medicare beneficiaries. This initiative worked with individual hospitals to identify targeted interventions to help reduce surgical site infections.

Although the project focused attention on the reduction of surgical infections, the need for more comprehensive surgical care quality improvement programs still existed, Hunt says. As a result, the CDC and CMS launched SCIP. The initiative expands on the previous effort by broadening its focus to surgical care overall, not just surgical site infections.

Power in Numbers
While broader in terms of scope, SCIP is also seeking a greater impact as well. The program is eliciting the support and participation of a bevy of diverse health care organizations.

In addition to CMS and CDC, SCIP’s steering committee includes representatives from a number of influential organizations, including American Hospital Association, American College of Surgeons, American Society of Anesthesiologists, Association of periOperative Registered Nurses, Joint Commission on Accreditation of Healthcare Organizations, Institute for Healthcare Improvement, Department of Veterans Affairs, and Agency for Healthcare Research and Quality.

“When there is collaboration among a number of influential organizations, the likelihood of success is so much greater than when each organization merely works on it individually,” says Schyve.

Broadening the scope of participation beyond quality and regulatory organizations to include professional caregiver organizations also helps to increase support for the initiative, Schyve points out. “About 50 organizations have agreed to support the project. When people hear that their own professional organization is supporting the initiative, then they will be more likely to support the program,” says Schyve.

In addition, SCIP is seeking the support of top-level executives and board members to get complete buy-in from provider organizations.

System Level Improvements
With so much support from a variety of health care professionals, SCIP leaders decided to make the program as meaningful as possible by targeting areas where the incidence and cost of complications are high—such as surgical site infections, adverse cardiac events, deep vein thrombosis, and postoperative pneumonia (see sidebar, SCIP Target Areas).

To pack an even greater punch, program leaders decided to target “system level” improvements, Hunt says. “We didn’t choose improvements that can be implemented by one department or person. We chose improvements that require buy-in and action from an entire system, things that require many departments of the hospital to get involved,” Hunt says.

For example, the group is working to get antibiotics to surgical patients on time—something that only about 56% of providers currently do.(4) To make such an improvement requires the coordination of multiple players, from pharmacy to anesthesiology to nursing to surgery.

“It’s not something that can be improved through a simple directive issued by the quality improvement department,” Hunt says.

Doing It Right
Identifying the targeted areas, however, is just the beginning. To make the program a success, SCIP also is developing the right quality improvement tools. The group’s first challenge is deciding if the quality improvement efforts should zero in on processes or outcomes.

“At first, we thought that it was an either/or proposition. We thought we either had to focus on processes or outcomes. But then we decided to take the Solomon approach and use both,” says Hunt.

To come up with an effective set of measures, the SCIP partnership launched a Medicare demonstration pilot project in 2003. The demonstration pilot tested the feasibility of collecting, reporting, and analyzing surgical process and outcome measures in a community setting.

The demonstration project resulted in the following draft performance outcome and process measures:

• Perioperative cardiac events
  • In-hospital cardiac event rates (outcome)
  • 30-day readmission rate (outcome)
  • 30-day mortality rate (outcome)
  • Perioperative beta-blockers in noncardiac vascular surgery patients
  • Perioperative beta-blockers in patients with known coronary artery disease
  • Perioperative beta-blockers in patients who are on beta-blockers before surgery
• Prevention of venous thromboembolism
  • Rates of DVT/PE diagnosed during index hospitalization (outcome)
  • Proportion who receive any form of VTE prophylaxis
  • Proportion who receive appropriate form of VTE prophylaxis (based on ACCP Consensus Recommendations)
• Prevention of ventilator-associated pneumonia
  • Rate of postoperative pneumonia cases that are diagnosed during index hospitalization (outcome)
  • Proportion of patients on ventilator with head of bed elevated 30 degrees
  • Proportion of ventilator patients put on a rapid weaning protocol (test)
  • Proportion of ventilator patients who receive peptic ulcer disease prophylaxis (test)
• Surgical infection prevention
  • SSI rates during index hospitalization (outcome)
  • Antibiotics
• Administration within one hour before incision
• Use of antimicrobial recommended in guideline
• Discontinuation within 24 hours of surgery end
  • Gluocose control in cardiac surgery patients
  • Glucose control in diabetics undergoing noncardiac surgery (test)
  • Proper hair removal (test)
  • Normothermia in colorectal surgery patients (test)

Representatives from the Joint Commission are working to make sure all organizations will use the measures in the same manner, Schyve says. For example, if a measure calls for a “30-day-period,” each organization has to agree on what constitutes the first day.

The Joint Commission also is working to make sure that the data measures and requirements do not provide any additional burden for providers.

“Hospitals are always concerned about the resources that it takes to measure,” says Schyve. “We are working with CMS to make sure that the measures do not force hospitals to do any additional work. We don’t want the measure to become an unnecessary burden.”

The official launch of the program was slated for July 2005. With the program in place, hospitals will be able to tap into SCIP to make improvements in surgical care. First, hospitals can sign the dotted line and become a part of the initiative. Then, they need to start collecting the data measures—which can be used in their own internal quality improvement initiatives and as part of the national effort.

“Quite frankly, though, the most important thing is not whether hospitals sign on as partners or whether they are collecting the right data. What is most important is that they are looking at their surgical practices and making the changes necessary to improve quality in their organizations,” Schyve says.

SCIP Target Areas Surgical site infections (SSIs). SSIs account for 14% to 16% of all hospital-acquired infections and are among the most common complications of care, occurring in 2% to 5% of patients after clean extra-abdominal operations and up to 20% of patients undergoing intra-abdominal procedures. By reducing SSIs, hospitals on average could recognize a savings of $3,152 and reduction in extended length of stay by seven days on each patient developing an infection.(5) Adverse cardiac events. Between 2% and 5% of patients undergoing noncardiac surgery and as many as 34% of patients undergoing vascular surgery experience adverse cardiac events. Appropriately administered beta-blockers, however, reduce perioperative ischemia, especially in patients considered to be at risk. Nearly half of the fatal cardiac events could be preventable with beta-blocker therapy.(5) Deep vein thrombosis (DVT). This condition occurs after approximately 25% of all major surgical procedures performed with prophylaxis and pulmonary embolism (PE) occurs in 7% of surgeries conducted without prophylaxis. More than 50% of major orthopedic procedures are complicated by DVT, and up to 30% by PE, if prophylactic treatment is not instituted. Despite the well-established efficacy and safety of preventive measures, studies show that prophylaxis is often underused or used inappropriately. Both low-dose unfractionated heparin (LDUH) and low-molecular-weight heparin (LMWH) have similar efficacy in DVT and PE prevention but LDUH is approximately half the cost of LMWH.(5) Postoperative pneumonia. This complication occurs in 9% to 40% of patients and has an associated mortality rate of 30% to 46%. Many of the risk factors for this even respond to medical intervention and thus are preventable. A conservative estimate of the potential savings from the reduced hospitalization due to postoperative pneumonia is $22,000 to $28,000 per patient admission.(5)

References

1. Surgical Care Improvement Project Introduction. http://www.medqic.org/scip/pdf/SCIPintroduction_092704.pdf (accessed Jul. 25, 2005).
2. Kohn L.T., et al.: To Err Is Human: Building a Safer Health System. Washington, DC: Institute of Medicine, 2000.
3. Zhan C., Miller M.R.: Excess length of stay, charges and mortality attributable to medical injuries during hospitalization. JAMA 290:1868–1874, 2003.
4. Bratzler D., et. al.: Use of antimicrobial prophylaxis for major surgery. Arch Surg 140:174–182, 2005.
5. Surgical Care Improvement Project Summary. http://www.medqic.org/scip/pdf/SCIPsummary_092704.pdf (accessed Jul. 25, 2005).

Source: Joint Commission Resources: When quality improvement meets surgery, complications will plummet. Benchmark 7:8–11, Sep./Oct. 2005.

Patient Safety FYI: Wrong site surgeries and other serious complications of surgery and invasive procedures account for 24.8% of the cases in the Joint Commission’s Sentinel Event Database.