Using the American College of Surgeons Strong for Surgery ...2.6% of 30 million operations per year are complicated by SSI (800,000 – 2 million SSI annually)

A partnership of the Healthcare Association of New York State and the Greater New York Hospital Association

Using the American College ofSurgeons Strong for SurgeryToolkit to OptimizePatients for SurgeryApril 2018

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NYS PARTNERSHIP FOR PATIENTS

Agenda

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Topic Speaker

Welcome and Introductions NYSPFP Staff

SSI Rates in New York NYSPFP Staff

Optimizing Peri-Operative Outcomes: Strong for Surgery Public Health Campaign

Thomas K. Varghese, Jr., MD, MS, Co-Director of the Thoracic Oncology Program and Associate Professor of Surgery, University of Utah,

Hospital Questions and Discussion Hospital Participants Facilitated by NYSPFP Staff

Next Steps NYSPFP Staff


Why Focus on Surgical Site Infections?

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○ 2.6% of 30 million operations per year are complicated by SSI (800,000 – 2 million SSI annually)

○ SSI accounts for 38% of HAI in surgical patients○ SSIs are associated with:

○ Increased length of stay ○ Increased hospital costs (estimated increase of $1,300 – $5,000 per case)○ Increased patient morbidity and mortality ○ Increased readmission rates


NYSPFP SSI SIR: Colon

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NYSPFP SSI SIR: Hip Replacement

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NYSPFP SSI SIR: CABG

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NYSPFP SSI SIR: Hysterectomy

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Surgery Bundle Elements Applicable Across Multiple Surgical Service Lines

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Implementation of Cross Applicable Bundle Elements

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Surgical subspecialties where

implementation of bundle has begun

% of hospitals that have started

implementation in NYSPFP (n=108)*

Hysterectomy 50%

Cardiac Surgery 15%

Orthopedics (Hip/Knee prosthesis) 57%

Our hospital has not begun implementation

of the colon bundle on any other surgical

subspecialties

23%

Other 15%


NYSPFP Advanced Bundle Pre-operative Interventions

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NYSPFP Advanced Bundle Pre-operative Interventions

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Optimizing Peri-Operative Outcomes: Strong for Surgery Public Health CampaignThomas K. Varghese, Jr., MD, MSAmerican College of SurgeonsUniversity of Utah

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Optimizing Peri-Operative Outcomes Strong for Surgery Public Health

Campaign

Thomas K. Varghese Jr. MD, MS, FACS@tomvarghesejr

[email protected]

April 9, 2018

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Initial Funding: 2012 to 2015

• AHRQ• Life Sciences Discovery

Fund• UW Dept of Surgery• UW Patient Safety

Innovation Program

• QI Programs• Nutrition:

• Nestle HealthCare • Opioid Minimization:

• Pacira• Plan My Quit

• Pfizer

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Quality Program of the AC

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Problems

• Every year there are 210,000 Preventable Deaths• ½ associated with an operation• $30 billion per year

J Patient Safety Sept 2013; 9(3): 122-128Wick EC, et al. 2011; 54(12):1475-1479

Eappen S JAMA. 2013;309(15):1599-160616

Problems

• Every year there are 210,000 Preventable Deaths• ½ associated with an operation• $30 billion per year

• 1 in 4 colon resections readmitted within 90 days• $300 million per year

• Soft Tissue Surgical Site Infections• $3 billion in direct costs

J Patient Safety Sept 2013; 9(3): 122-128Wick EC, et al. 2011; 54(12):1475-1479

Eappen S JAMA. 2013;309(15):1599-160617

Generation of Evidence

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Reality

• 15 to 17 years before findings from RCTs and cohort studies implemented into clinical practice.

• Healthcare is inefficient.

JAMA 1999; 282: 1458-1465; Health Professions Education 2003J Am Med Inform 2001; 8(4):398-399N Engl J Med 2003; 348:2635-2645 19

Quality Practice Improvement (QPI)

• Science that defines tools and implements solutions • to translate evidence-based knowledge into actionable items for

effective incorporation into daily clinical practice.

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21

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JAMA 2015; 313(5):496-504

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Surgical Outcomes 263 NSQIP hospitals 526 non-NSQIP

Mortality4.9% 5.0%

Serious Complications 11.3% 10.2%Reoperation 0.5% 0.5%

Readmissions 13% 12.6%

JAMA 2015; 313(5):496-504 24

“Feedback of outcomes alone may not be sufficient to improve surgical outcomes”

JAMA 2015; 313(5):496-50425

Focus on Decision Making

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Focus on Decision Making in Clinic

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Raising AwarenessChanging Practice

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Pilot Year - 2012

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Pilot Year - 2012

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Behavior Change in the 21st Century

Public health campaign focused on surgeons, patients and other important stakeholders

+Implementation Bundles

• Interactive tools (checklists) to help optimize patients prior to surgery• Integrated into workflow• Surveillance and data feedback

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Why Blood Sugar?

Latham. Inf Contr Hosp Epidemiol. 2001;22:607Dellinger. Inf Contr Hosp Epidemiol. 2001;22:604Lancet 2012; 2279-22902011 US Department of Health and Human Services

Why Blood Sugar?

• Hypergycemia doubles the risk of SSI• In some studies 47% of hyperglycemic episodes in nondiabetics


Why Blood Sugar?

• Hypergycemia doubles the risk of SSI• In some studies 47% of hyperglycemic episodes in nondiabetics

• 470 million people worldwide → Prediabetes by 2030

• 2005-200835% of US adults ≥ 20 yrs

50% greater ≥ 65 years


Prediabetes

Why Blood Sugar?

• > 65 years• 1 in 4 will have Diabetes• 2 in 4 are Prediabetic

2011 US Department of Health and Human Services

Why Medications?

• Some meds & herbal remedies ↑ risk of bleeding• Echinacea, Garlic, Ginkgo, Ginseng, Kava, Saw

Palmetto, St. John’s Wort, Valerian

Chest 2012; 141:e326S-e350S; JAMA 2008; 300(24):2867-2878; Ann Surg 2012; 255(5):811-819; Arch of Surg 2012; 147(5):467-473

Why Medications?

• Some meds & herbal remedies ↑ risk of bleeding• Echinacea, Garlic, Ginkgo, Ginseng, Kava, Saw

Palmetto, St. John’s Wort, Valerian

• Aspirin can be safely continued

• Beta-blocker continuation associated with fewer cardiac events and mortality

Chest 2012; 141:e326S-e350S; JAMA 2008; 300(24):2867-2878; Ann Surg 2012; 255(5):811-819; Arch of Surg 2012; 147(5):467-473

Why Smoking?

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

All Patients Neurosurgery Orthopedic

Never SmokerPrior SmokerCurrent Smoker

Mary T Hawn et al., “The Attributable Risk of Smoking on Surgical Complications,” Annals of Surgery 254, no. 6 (December 2011): 914–920.

Adju

sted

Odd

s Ra

tioCo

mpl

icat

ions

Ass

ocia

ted

with

Sm

okin

g

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Post-Operative Outcomes by Pack-Years Smoked

0.8

1

1.2

1.4

1.6

1.8

2

Surgical Site Infection Pulmonary 30-day Mortality

Adju

sted

Odd

s Ra

tio

0 1-20 21-40 41-60 >60

Mary T Hawn et al., “The Attributable Risk of Smoking on Surgical Complications,” Annals of Surgery 254, no. 6 (December 2011): 914–920. 41

Why Nutrition?

• Malnutrition is prevalent in surgical patients

• Immunonutrition may improve recovery

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Nutrition Screening

• Any YES → refer to RD/Nutrition Specialist

Ana Isabel Almeida et al. Clinical Nutrition 31 (2012) 206-211.H.M. Reilly, et al. Clinical Nutrition (1995) 14 269-273. 44

Nutrition Screening

• Any YES → refer to RD/Nutrition Specialist

1. Is BMI less than 19?2. Has patient had unintentional weight loss of >8 pounds

in 3 months?3. Has the patient had a poor appetite eating less than

half of meals or fewer than two meals per day?4. Is the patient unable to take food orally due to

dysphagia or vomiting?

Ana Isabel Almeida et al. Clinical Nutrition 31 (2012) 206-211.H.M. Reilly, et al. Clinical Nutrition (1995) 14 269-273. 45

Risk Stratification

• Hypoalbuminemia is an independent risk factor for SSI following surgery

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Hennessey DB, et al. Ann Surg. 2010;252:325–329.

SCOAP: Albumin & ComplicationsElective colon/rectal procedures

0.0%

3.0%

6.0%

9.0%

12.0%

15.0%

<2.0 2.0-2.4 2.5-2.9 3.0-3.4 3.5-3.9 4.0+

Adve

rse

Out

com

e Ra

tes

Albumin Levels (g/dL)

Re-operation Death

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Surgery and trauma patients are immune suppressed making them more susceptible to infection due to arginine depletion.

50Popovich 2006; McClave 2009; Zhu 2010

Surgery and trauma patients are immune suppressed making them more susceptible to infection due to arginine depletion.

Immune- modulating formulas → Arginine + Ω-3 fatty acids + Nucleotides 5 to 7 day regimen, 3 times daily

Popovich 2006; McClave 2009; Zhu 2010 51

Literature Review• Systematic Review

• N=3,438• 35 studies focused on elective surgery• Procedure types

• 25 GI: 18 upper; 2 lower; 5 mixed• 10 non-GI

• 23 – used arginine-based supplements• Pre-Op Use: ↓ Infectious complications 43%

Drover JW, et al.JACS 2011; 212 (3):385-399

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Literature Review

• Meta-analysis: 26 RCTs• N = 2496

• 1252 Immunonutrition vs 1244 Control (Isocaloric)

• ↓ infection rates by 46%• ↓ length of stay ~ 2 days

53Marimuthu K, et al.Ann Surg 2012; 255:1060-1068

Goals of Nutrition Target

• Universal measurement of albumin• Pre-operative screening for malnutrition• Increase the use of appropriate, evidence-based

nutritional support• Malnourished• Complex Surgery

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Focus on Four Modifiable Areas:

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Checklists

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Program Implementation

Hospital/Clinic Expectations:• Change team formation• Commitment through post-

implementation Strong For Surgery:• Workflow Mapping

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Change Team Components

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CHANGE TEAM

Executive Sponsors: CMO and CNO

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Raising Awareness – a Roadmap

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Raising Awareness – a Roadmap

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Measurable Impact

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Reach

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Global Impact – Online Outreach

Since Launch• 173,519 total page views• 122,038 Unique Page views

Implementation Guide requests 2013 to 2015

268 sites, 15 countries

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Media

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Effectiveness

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• Clinician-led QI using clinical data

• Focus on quality and cost-effectiveness data

• Impacts behavior through:• Benchmarking• Education• Standard orders• Checklists

www.scoap.org76

• Launched in 2003

• 3 years before launch: Composite Adverse Event rates for Colorectal Surgery around 19%

• 3 years after launch: Composite Adverse Event rates for Colorectal Surgery around 9.8%

77www.scoap.org

SCOAP Immunonutrition Use

Q4 2014 – S4S Hospitals 85.4% (540/632) Elective Colorectal Procedures

(w/anastomosis)

Thornblade L, Varghese T, et al.Dis Col Rectum 2017; 60(1):68-75

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Q4 2014 – S4S Hospitals 85.4% (540/632) Elective Colorectal Procedures (w/anastomosis)

Composite Adverse Event Rates (Reintervention, Infection, Anastomotic Leak ± death)

• Patient who did not receive immunonutrition: 9.5%• Patients receiving immunonutrition: 7.0%*

p = 0.04

[Q1 2013 to Q4 2014] n=8,680


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Propensity Score Matching (346 pts each group)• CAE

• No immunonutrition: 11.6% • Immunonutrition use: 7.2% (p=0.05)

• Length of stay• No immunonutrition: 6.9 days • Immunonutrition use: 5.8 days (p<0.01)


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Decrease in Smoking Rates

• 25.6% in Q4 of 2011 to 15.8% in Q2 of 2014

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

2011 Q4 2014 Q2

% c

igar

ette

smok

ers

Procedure Date

Percentage of cigarette smokers among spine cases over time

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World J Surg 2013 37; 25982

Peri-Operative Glucose Guidelines• Franciscan Health

System• Harrison Medical

Center• MultiCare Health

System• PeaceHealth

Southwest MedicalCenter

• Providence RegionalMedical Center

• Skagit Valley Hospital• Swedish• UW Medical Center• UW Harborview

Medical Center• Virginia Mason

Presented at Washington State Hospital Association Safe Table on April 23, 201483

Optimizing Peri-Operative Glucose

2014 Best Practices

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Adoption

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Collaborators• Washington State Medical Association• Washington State Hospital Association• Washington State Nurses Association• Washington State Academy of Nutrition and Dietetics• Washington Patient Safety Coalition• Washington State Society of Anesthesiologists• Washington St. Chapter – American College of Surgeons• Qualis Health• American Lung Association• American College of Surgeons

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Pilot Year - 2012

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2015

50 practices, 205 surgeonsGeneral, Colorectal, Plastic, Bariatric, Spine, Thoracic, Vascular Surgery

50 practices, 206 surgeonsGeneral, Colorectal, Bariatric, Spine, Vascular Surgery 88

Implementation

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Phases of Implementation

• Explore• Needs Assessment• Engage with stakeholders, Form relationships, Identify local barriers

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• Initiate Action• Convene Change Team• Focus on initial team & infrastructure

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• Initiate Action• Convene Change Team• Focus on initial team & infrastructure

• Learn Together• Surveillance and Feedback• Action plans for maintenance

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Virtual Check-listing(prior to surgery)Anesthesia/ PreOp Clinic

Clinic Nurses

Medical AssistantsSurgeons

+/- Residents, PAs

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Clinic Nurses

Anesthesia/ PreOp Clinic

Surgeons+/- Residents,

PAs

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ImplementationFactors for Success

• Recent completed QI projects• Leadership support• Alignment

• ERAS• SSI programs

• Change team met at frequent intervals, surveillance & feedback

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ImplementationBarriers

• EMR or other projects competing for staff time & attention• Change in Leadership

• Friction b/w surgeon and hospital• Independent surgeon practices

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Maintenance

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200

400

600

800

1000

Q1 12 Q2 12 Q3 12 Q4 12 Q1 13 Q2 13 Q3 13 Q4 13 Q1 14 Q2 14 Q3 14 Q4 14Cum

ulat

ive

Num

ber o

f Cas

es

Quarter

Any Nutrition InterventionElective Colorectal Procedures: 2012 - 2014

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Maintenance

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Raising AwarenessChanging Practice

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https://www.facs.org/quality-programs/about/optimal-resources-manual 104

https://www.facs.org/quality-programs/about/optimal-resources-manual

Pre Op, Immediate Pre Op, Intraoperative, Post Op, Post Discharge

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National/International Pilot Sites

Christus HealthTexarcana, TX

Horizon Health NetworkSt. John, Canada

Wake Forest Baptist HospitalWinston Salem, ND

Rochester Regional HospitalRochester NY

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• 150 sites from WA state

• 4 national pilot sites• 36 sites accessed the

toolkit

• 40 additional sites nationally registering

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End of Year Projection: 230 sites implementing S4S

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Hospital Discussion and QuestionsHospital Participants Facilitated by NYSPFP Staff

Thank You!

[email protected]

@tomvarghesejr

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Next Steps

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○ Contact your project manager to discuss: ○ Using the Strong for Surgery Toolkit to implement pre-operative optimization

for elective surgery patients. ○ Hardwiring the Advanced Colon Bundle Elements into workflow and expanding

to other types of surgery if you have not already

Workflow Mapping

• Maximize patient value + eliminate waste

• Optimize the flow of services through the system• Map out processes• Identify value & non-value steps• Create implementation bundles incl. Checklists• Empower staff

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Documents

Using the American College of Surgeons Strong for Surgery ...2.6% of 30 million operations per year are complicated by SSI (800,000 – 2 million SSI annually)