Barbara J. Martin

Using the national surgical quality improvement program and the tennessee surgical quality collaborative to improve surgical outcomes

BACKGROUND Led by the Tennessee Chapter of the American College of Surgeons, in May 2008 a 10-hospital collaborative was formed between the Tennessee Chapter of ACS, the Tennessee Hospital Association, and the BlueCross BlueShield of Tennessee Health Foundation. We hypothesized that by forming the Tennessee Surgical Quality Collaborative using the National Surgical Quality Improvement Program (NSQIP) system to share surgical process and outcomes data, overall patient surgical outcomes would improve. STUDY DESIGN All NSQIP data from the 10-hospital collaborative for the time periods January to December 2009 (period 1) and January to December 2010 (period 2) were collected. Data on 20 categories of postoperative complications and 30-day mortality were compared between periods. Complication comparisons and hospital costs associated with complications were calculated per 10,000 procedures. Statistical analysis was performed by Z-test. RESULTS There were 14,205 total surgical cases in period 1 and 14,901 surgical cases in period 2. Between periods (per 10,000 cases) there were significant improvements in superficial surgical site infections (-19%, p = 0.0005), on ventilator longer than 48 hours (-15%, p = 0.012), graft/prosthesis/flap failure (-60%, p < 0.0001), acute renal failure (-25%, p = 0.023), and wound disruption (-34%, p = 0.011). Although mortality (per 10,000) was higher in period 2 (237.6 vs 232.3), no statistical difference was noted. Net costs avoided between these periods were calculated as

Nondepolarizing Neuromuscular Blocking Agents, Reversal, and Risk of Postoperative Pneumonia.

2,197,543 per 10,000 general and vascular surgery cases. CONCLUSIONS Data organization and scrutiny are the initial steps of process improvement. Participation in our regional surgical quality collaborative resulted in improved outcomes and reduced costs. Although the mechanisms for these changes are likely multifactorial, the collaborative establishes communication, process improvement, and frank discussion among the members as best practices are identified and shared and standardized processes are adopted.

Patient Complaints and Adverse Surgical Outcomes

Background:Residual postoperative paralysis from nondepolarizing neuromuscular blocking agents (NMBAs) is a known problem. This paralysis has been associated with impaired respiratory function, but the clinical significance remains unclear. The aims of this analysis were two-fold: (1) to investigate if intermediate-acting NMBA use during surgery is associated with postoperative pneumonia and (2) to investigate if nonreversal of NMBAs is associated with postoperative pneumonia. Methods:Surgical cases (n = 13,100) from the Vanderbilt University Medical Center National Surgical Quality Improvement Program database who received general anesthesia were included. The authors compared 1,455 surgical cases who received an intermediate-acting nondepolarizing NMBA to 1,455 propensity score–matched cases who did not and 1,320 surgical cases who received an NMBA and reversal with neostigmine to 1,320 propensity score–matched cases who did not receive reversal. Postoperative pneumonia incidence rate ratios (IRRs) and bootstrapped 95% CIs were calculated. Results:Patients receiving an NMBA had a higher absolute incidence rate of postoperative pneumonia (9.00 vs. 5.22 per 10,000 person-days at risk), and the IRR was statistically significant (1.79; 95% bootstrapped CI, 1.08 to 3.07). Among surgical cases who received an NMBA, cases who were not reversed were 2.26 times as likely to develop pneumonia after surgery compared to cases who received reversal with neostigmine (IRR, 2.26; 95% bootstrapped CI, 1.65 to 3.03). Conclusions:Intraoperative use of intermediate nondepolarizing NMBAs is associated with developing pneumonia after surgery. Among patients who receive these agents, nonreversal is associated with an increased risk of postoperative pneumonia.

Sustained Reduction of Ventilator-Associated Pneumonia Rates Using Real-Time Course Correction With a Ventilator Bundle Compliance Dashboard

One factor that affects surgical team performance is unprofessional behavior exhibited by the surgeon, which may be observed by patients and families and reported to health care organizations in the form of spontaneous complaints. The objective of this study was to assess the relationship between patient complaints and adverse surgical outcomes. A retrospective cohort study used American College of Surgeons National Surgical Quality Improvement Program data from an academic medical center and included 10 536 patients with surgical procedures performed by 66 general and vascular surgeons. The number of complaints for a surgeon was correlated with surgical occurrences (P < .01). Surgeons with more patient complaints had a greater rate of surgical occurrences if the surgeon’s aggregate preoperative risk was higher (β = .25, P < .05), whereas there was no statistically significant relationship between patient complaints and surgical occurrences for surgeons with lower aggregate perioperative risk (β = −.20, P = .77).

Intraoperative Care Transitions Are Not Associated with Postoperative Adverse Outcomes

BACKGROUND The effectiveness of practice bundles on reducing ventilator-associated pneumonia (VAP) has been questioned. OBJECTIVE To implement a comprehensive program that included a real-time bundle compliance dashboard to improve compliance and reduce ventilator-associated complications. DESIGN Before-and-after quasi-experimental study with interrupted time-series analysis. SETTING Academic medical center. METHODS In 2007 a comprehensive institutional ventilator bundle program was developed. To assess bundle compliance and stimulate instant course correction of noncompliant parameters, a real-time computerized dashboard was developed. Program impact in 6 adult intensive care units (ICUs) was assessed. Bundle compliance was noted as an overall cumulative bundle adherence assessment, reflecting the percentage of time all elements were concurrently in compliance for all patients. RESULTS The VAP rate in all ICUs combined decreased from 19.5 to 9.2 VAPs per 1,000 ventilator-days following program implementation (P<.001). Bundle compliance significantly increased (Z100 score of 23% in August 2007 to 83% in June 2011 [P<.001]). The implementation resulted in a significant monthly decrease in the overall ICU VAP rate of 3.28/1,000 ventilator-days (95% CI, 2.64-3.92/1,000 ventilator-days). Following the intervention, the VAP rate decreased significantly at a rate of 0.20/1,000 ventilator-days per month (95% CI, 0.14-0.30/1,000 ventilator-days per month). Among all adult ICUs combined, improved bundle compliance was moderately correlated with monthly VAP rate reductions (Pearson correlation coefficient, -0.32). CONCLUSION A prevention program using a real-time bundle adherence dashboard was associated with significant sustained decreases in VAP rates and an increase in bundle compliance among adult ICU patients.

890VAP to VAE: Exploring the Epidemiology of a New Surveillance Definition

Background:Whether anesthesia care transitions and provision of short breaks affect patient outcomes remains unclear. Methods:The authors determined the number of anesthesia handovers and breaks during each case for adults admitted between 2005 and 2014, along with age, sex, race, American Society of Anesthesiologists physical status, start time and duration of surgery, and diagnosis and procedure codes. The authors defined a collapsed composite of in-hospital mortality and major morbidities based on primary and secondary diagnoses. The relationship between the total number of anesthesia handovers during a case and the collapsed composite outcome was assessed with a multivariable logistic regression. The relationship between the total number of anesthesia handovers during a case and the components of the composite outcome was assessed using multivariate generalized estimating equation methods. Additionally, the authors analyzed major complications and/or death within 30 days of surgery based on the American College of Surgeons National Surgical Quality Improvement Program–defined events. Results:A total of 140,754 anesthetics were identified for the primary analysis. The number of anesthesia handovers was not found to be associated (P = 0.19) with increased odds of postoperative mortality and serious complications, as measured by the collapsed composite, with odds ratio for a one unit increase in handovers of 0.957; 95% CI, 0.895 to 1.022, when controlled for potential confounding variables. A total of 8,404 anesthetics were identified for the NSQIP analysis (collapsed composite odds ratio, 0.868; 95% CI, 0.718 to 1.049 for handovers). Conclusions:In the analysis of intraoperative handovers, anesthesia care transitions were not associated with an increased risk of postoperative adverse outcomes.

An enhanced recovery program in colorectal surgery is associated with decreased organ level rates of complications: a difference-in-differences analysis

Background: Due to concerns about the subjectivity and inter-rater reliability of the surveillance definition for VAP (ventilator-associated pneumonia), a more objective outcome measure, VAE (ventilator-associated event), was released in 2013. We examined the epidemiology of the traditional VAP and new VAE measures in 6 adult intensive care units (ICUs) and hypothesized that VAE rates would be considerably higher than the traditional VAP rates and that correlation between VAEs and traditional VAPs would be low. Methods: Traditional VAP events (TradVAP) and VAEs in six adult ICUs (medical, surgical, burn, trauma, cardiovascular, and neurosciences) at an academic medical center were determined by trained personnel for the study period from July to December 2012. VAEs were classified as a ventilator-associated condition (VAC), infection-related VAC (IVAC), and possible/probable VAP (PossVAP) based on NHSN definitions. Descriptive analyses were conducted to assess the proportion of TradVAPs that were also identified as VAEs; TradVAP and VAE rates were also compared. Results: During the study period, 15 TradVAPs and 91 VAEs were identified in all ICUs combined. Only 8/15 (53%) TradVAPs met the VAE definition, but of these, 75% (6/8) were identified as a PossVAP; the other two TradVAPs met criteria for an IVAC only. The VAE rate was higher than the TradVAP rate across all units, but units differed in the degree of rate increase (Table). Conclusions: The overall VAE rate was 6-times higher than the TradVAP rate with wide variation in the degree of increase across ICU types. Only half of the identified TradVAPs were captured as a VAE event, but the majority of these VAEs were classified as a possible VAP. Further research is needed to determine causes of the VAEs in these units and the preventability of these.