A significant number of the nearly 30 million operations performed each year have surgical care complications. Each complication is estimated to increase the length of hospital stay, the likelihood of a critical care admission, the incidence of readmission, and the risk of mortality. An estimated 50% of surgical complications are thought to be preventable with appropriate interventions. On the basis of that estimate, Baystate Health (BH) decided to participate in the nationwide quality improvement initiative, the “Surgical Care Improvement Project (SCIP),” led by the Centers for Medicare & Medicaid Services (CMS). SCIP is the expansion of the Surgical Infection Prevention Collaborative (SIP) which began in 2002. The goal of SCIP is to optimize the outcomes of patients undergoing surgery by improving the use of evidence-based practices shown to reduce the incidence of surgical complications.
Since 2004, all Baystate Health facilities have been publicly reporting Heart Attack care through the Hospital Quality Alliance (HQA). This reporting helps to ensure that every patient who comes to BH with a heart attack receives all appropriate treatments to reduce sickness and death.
All 3 Baystate Hospitals, Baystate Medical Center, Baystate Franklin Medical Center and Baystate Mary Lane Hospital, are represented here.
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<To view selected graphs and data over time, click here.>
|
July - September 2013
|
Baystate Medical Center |
Benchmark* |
How we're doing |
| HEART ATTACK care measures |
| Aspirin at arrival: Early treatment with aspirin has been shown to decrease deaths from heart attack. |
100% |
100% |
|
| Aspirin prescribed at discharge: Long-term use of aspirin in patients who have survived a heart attack has been shown to reduce the chance of having another heart attack or dying. |
100% |
100% |
|
| ACEi or ARB for LVSD: ACEi and ARBs are medications prescribed for patients with heart failure symptoms or reduced heart function due to a heart attack to reduce the risk of death. |
100% |
100% |
|
| Beta blocker prescribed at discharge: Prescribing beta blockers to patients who have survived a heart attack helps to lower blood pressure, treat chest pain and heart failure, and helps to prevent another heart attack. |
100% |
100% |
|
| Primary PCI received within 90 minutes of hospital arrival: PCI procedures open blocked blood vessels that feed the heart, and help to prevent further damage to the heart. The earlier the PCI is performed, the better chance of survival. |
91.4% |
100% |
|
| Statin prescribed at discharge: Statins are drugs used to lower cholesterol levels and can lower the chance that patients will have another heart attack. |
99.5% |
|
|
| Composite Process Score: A summary score of how often we provide each of the above-listed recommended measures to patients based on their specific conditions. |
99.6% |
100% |
|
| Appropriate Care Score: A score that summarizes whether patients received all of the appropriate treatments that they should have based on their specific conditions. |
98.3% |
100% |
|
*Benchmark is HQID Top 10%
Performance improvement methods such as LEAN and PDSA (plan-do-study-act) with multiple small tests of change are used to ensure that all interventions are reliably applied. This work resulted in a complete overhaul of the peri-operative system and is now well integrated into the peri-operative culture. Adoption of the “Opt-Out” model ensures procedure-based interventions (antibiotic use and DVT care) are in CIS to guide and streamline ordering. Using this model promotes the desired action (the default) to be applied more consistently to a greater number of eligible patients. In the Opt-Out model, the clinician has to actively choose not to apply or prescribe the agreed-on process or intervention. Selecting to opt-out is more time consuming and difficult than allowing the agreed-on process to occur as part of the flow of work.
Other redesigned processes include the following: antibiotics are prepared in the pre-operative holding area and given in the OR by the anesthesiologists; all patients undergoing major non-cardiac surgery are screened for cardiac and VTE risk and started or continued on therapy (i.e., beta blockers, compression boots) if indicated; changes were made in operative forms to prompt and standardize antibiotic administration documentation; point-of-care blood glucose levels are obtained to guide the use of insulin infusions to optimize glycemic control; and new techniques for patient thermoregulation have been tested to identify which interventions work best in our operating rooms. Medical record review for potential preventability for any complication is in place to identify learning for future work.
Highlights
Baystate Medical Center
- Antimicrobial prophylaxis continues to be above national benchmarks.
- The current rates of on-time antibiotic administration, appropriate antibiotic selection, and discontinuing antibiotic therapy within 24 hours after surgery are at 99% or better.
- Appropriate use of VTE prophylaxis is currently at 100%, with a current post-procedure DVT rate of 0.28%.
- 100% of patients had appropriate hair removal, and are kept warm.
- Appropriate post-operative use of urinary catheter is at 100%, with decreasing rates of catheter-related urinary tract infections.
- This sustained superior performance places BMC in the top 1% of U.S. hospitals for quality surgical care based on the “Why Not the Best?” national comparative database (whynotthebest.org).
- In 2011 BMC was recognized as a top performer SCIP hospital in the Premier HQID.
Baystate Mary Lane Hospital
- The SCIP work team meets regularly to review progress and make changes to the process to support ongoing improvement.
- Continued focus this year has been on pre-op timing of antibiotic prophylaxis, currently at 100%; and on appropriate antibiotic selection and timely post-op discontinuation of antibiotics, both which are also at 100%.
- The current post-procedure VTE rate is zero. Application of DVT prophylaxis is at 77% and will be an area of focus going forward.
Baystate Franklin Medical Center
- Surgical site infections are closely monitored. An interdisciplinary group met for several months and made evidence-based practice changes in the areas of patient education, patient skin preparation, sterile processing techniques, gowning and hair covering of surgical staff, and re-education of door opening policy once a surgical case has started.
- The performance improvement project, "Increasing Compliance with Beta-Blocker Administration for the Surgical Patient," was honored with a Distinguished Performer Award at the 2010 Baystate Health President's Quality Award ceremony. The team implemented process and practice changes to increase compliance with the correct administration of this important medication for select surgical patients.
- The current rates of on-time antibiotic administration and appropriate antibiotic selection are 100%. Discontinuing antibiotic therapy within 24 hours after surgery is 89%, and is an area of continued focus.
- New processes have been effectively implemented in the medical-surgical units and intensive care unit (ICU) to ensure that patients receive proper measures to prevent VTE all the time. The current VTE prophylaxis rate is 93%, with a zero post-operative VTE rate.
- 100% of patients are kept warm, and 98% had appropriate hair removal.
- Management of urinary catheters post-operatively has been added as a new measure; 100% of patients had urinary catheter removal by post-operative day 2.
- Feedback loops have been developed to provide timely information to all clinicians when they miss an opportunity to provide optimal care.
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