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Leap and SCIP Your Way to Better Outcomes

Leap and SCIP Your Way to Better Outcomes. Jennifer Joiner, MSN, RN, CCRN-CSC Clinical Nurse Educator, Cardiac Surgery Robert Wood Johnson University Hospital. SCIP. Surgical Care Improvement Project Goals: Decrease the incidence of surgical complications by 25% by 2010

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Leap and SCIP Your Way to Better Outcomes

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  1. Leap and SCIP Your Way to Better Outcomes Jennifer Joiner, MSN, RN, CCRN-CSC Clinical Nurse Educator, Cardiac Surgery Robert Wood Johnson University Hospital

  2. SCIP • Surgical Care Improvement Project • Goals: • Decrease the incidence of surgical complications by 25% by 2010 • Decrease mortality and morbidity through collaborative efforts

  3. In 2003: • Post-op complications accounted for ~22% of preventable deaths • Focused on 18 types of medical injuries related to 2.4 million additional hospital days and $9.3 billion in extra costs

  4. Surgical Site Infections (SSI’s) • Account for 14-16% of all hospital acquired infections • BUT- 40% of surgical patients’ infections are related to SSI’s

  5. Several Organizations Contribute to Better Outcomes • National Surgical Quality Improvement Program (NSQIP)- decreased mortality rate at the VA by 27% • National Nosocomial Infections Surveillance (NNIS) System of the CDC- decreased up to 44% in device-associated complications and infection rates • Medicare’s Quality Improvement Organizations (QIO’s)- Decreased SSI’s by 27% at 56 centers in the US (** contracts with CMS)

  6. Main Focus Areas of SCIP • Infection • Antibiotics given within 1 hr of incision time (91.2%) • Right Antibiotic ordered (100%) • Antibiotic discontinued within 24/48hr (83.8%) • 6am Blood Sugar (cardiac surgery patients) less than 200* (92%) • Post-op wound infections (0% Deep SWI) • Appropriate hair removal (100%)

  7. Adverse Cardiac Events • Occurs in • 2-5% of non-cardiac surgery patients • 34% of vascular surgery patients • BUT- Perioperative MI is related to a 40-70% mortality rate plus • Increased LOS, costs and morbidity • Nearly ½ of fatal cardiac events could have been prevented with Beta Blocker therapy during the perioperative period (by decreasing cardiac ischemia)

  8. Cardiac • Beta Blocker given during the perioperative period if on one pre-op (100%) • Acute MI within 30 days of surgery

  9. Venous Thromboembolism (VTE’s) • For all major surgeries without prophylaxis ordered: • 25% DVT rate • 7% PE rate • High risk: Orthopedic surgery without prophylaxis ordered: • Over 50% DVT rate • 30% PE rate • Problem: Underused or inappropriate treatment used for prophylaxis

  10. VTE (Venous Thromboembolism) • VTE Prophylaxis (95.3%) • VTE Prophylaxis from 24hr before surgery to 24 hr after surgery (94.6%) • PE within 30 days of surgery • DVT within 30 days of surgery

  11. Respiratory Complications • Post-op pneumonia-- 9-40% incidence rate • Pneumonia is associated with a 30-45% mortality rate as a complication after surgery

  12. Data Collection to be added at a later date • Respiratory • # of days vent patient had HOB documented through POD #7 • VAP rate • # of days PUD prophylaxis ordered through POD #7 • # of patients with vent weaning orders documented

  13. Mortality Rate within 30 days of surgery (1.49% vs. 3.4% expected rate) • Readmission Rate within 30 days of surgery

  14. The Leap Frog Group • Late 1990’s, a number of large US health care purchasers formed the Leap Frog Group to develop breakthroughs in safety and value of health care to US consumers. • Long-term goal: to reward hospitals and MDs on the basis of excellence in quality and quality improvement. • Inadequate IT systems and public reporting is not consistent to benchmark against; thus, group is focusing on patient safety

  15. Leap Frog Group • Offers valuable benchmarking capabilities to hospitals • Provide consumers and purchasers of health care with information on the quality and safety of their hospitals • Increases health care transparency by encouraging adoption of health IT standards, provision of options that promote quality and efficiency in health, and makes pricing and quality information publicly available

  16. RWJUH Named One of Top 33 Hospitals in Quality and Safety by the 2008 Leap Frog Group Survey • RWJUH is one of 2 hospitals in NJ • 33 hospitals chosen out of 1200+ nationwide • 26 hospitals, 7 children’s hospitals

  17. Leap Frog Patient Safety Standards Computer Physician Order Entry * costs r/t startup, equipment, training, maintanence * decreased med errors and adverse drug events- $180-900K/year * decreased repeated tests, lab, radiology, history, losing paper charts; increased efficiency ICU Physician Staffing *costs r/t salary; decreased LOS, inappropriate ICU admissions, inappropriate testing and consults, complications- $800K-$3.4 million Evidenced-Based Hospital Referral for high risk surgeries and neonatal intensive care * Idea is the more you do, the better you are at it * costs r/t administrative, moving patients, redundancy in testing and evaluation, more costly care in academic centers; smaller hospitals would suffer

  18. Never Events • 28 serious reportable events by NQF • Leaving foreign objects in patients after surgery/procedure • Death or serious injury related to: • Med error • ABO/HLA incompatible blood or blood product causing a hemolytic reaction • Electric shock or electric cardioversion • Fall • Hypoglycemia • Air embolism • Use or function of a device in a manner other than intended • Wrong patient, site, or procedure performed • Intra-operative or immediate post-op death in an ASA Class 1 patient • Stage 3 or 4 hospital-acquired pressure ulcer • Surgeon Mortality Rates

  19. National Quality Forum Safe Practices (NQF-SP) • Resource Utilization Measures (“Core Measures”) • CABG • PCI • AMI • Pneumonia • AAA Repair • NICU

  20. Cardiac Surgery Measures • ASA/Plavix at discharge- 99.3% • Use of IMA- 99.3% • Beta Blocker w/in 24h of sx 73.9% • Beta Blocker at discharge 94% • Anti-Lipid meds at discharge 95.5%

  21. Percutaneous Coronary Intervention (PCI) • PCI within 90 min of arrival- AMI 88.2% • ASA on arrival 98.4% • ASA at discharge 99.1%

  22. Acute Myocardial Infarction (AMI) • ASA on arrival 98.4% • ASA at discharge 99.1% • ACE-I or ARB for LVSD 95% • Adult Smoking Cessation Advice/Counseling 100% • Beta Blocker at discharge 100% • Beta Blocker on arrival 97.9% • PCI within 90min 88.2%

  23. Pneumonia • Oxygenation assessment-ABG within 24hr 100% • Pneumococcal vaccine for all with pneumonia (and all 65+) given prior to discharge 54.8% • Blood cultures within 24hr of admission to the ICU 100% • Smoking cessation advice/counseling 100% • Initial Antibiotic within 6hr of arrival 94.6% • Flu vaccine given prior to discharge (n/a for 2nd qtr)

  24. Hospital Acquired Conditions • Pressure Ulcers • Injuries • In addition- • Severity adjusted average LOS inflated by a 14day all-cause readmission rate

  25. How Can The RN Impact Outcomes? • Perioperative RN: • Abx within 1hr of incision time • Right Abx ordered/given • Appropriate hair removal • Beta Blocker prior to surgery • VTE prophylaxis • Peridex given prior to intubation • DOCUMENTATION!!! • Don’t be afraid to speak up!!!

  26. ICU RN: • Antibiotics stopped within the right time period? (cardiac sugery up to 48hr; all others 24hr) • 6am blood sugar under control (cardiac surgery) • Post-op wound infection- incision care and assessments • VTE prophylaxis? • VAP prevention bundle • Pulmonary toileting, ambulation • Vent weaning documentation (yes/no/why) • ASA/plavix, Beta Blocker, and Anti-Lipid on transfer out of ICU? (For AMI, ACE-I and/or ARB?) • Vaccine status/orders for discharge dose • ABG, blood cultures within 24hr and antibiotic given within 6hr for pneumonia? • Smoking cessation counseling for all smokers • Prevention of pressure ulcers and injuries • “Get the Red Out”!!! • DOCUMENTATION AND ADVOCACY!!!

  27. Med-Surg and Telemetry RN: • Antibiotics stopped within right time period? • 6am blood sugar under control? (cardiac surgery) • PUD, VTE prophylaxis ordered through POD #7 • Pulmonary toileting, ambulation • ASA/Plavix, Beta Blocker, Anti-Lipid, (ACE-I and ARB for AMI) at discharge? • Smoking cessation counseling • ABG, blood cultures within 24hr, antibiotic given within 6hr of arrival? • Vaccine status addressed and orders entered for day of discharge • Prevention of pressure ulcers and injuries • “Get the Red Out”!!! • DOCUMENTATION AND ADVOCACY!!!

  28. Resources • www.leapfroggroup.org • www.pronj.org • www.medqic.org • www.sts.org • www.va.gov • www.ihi.org • www.jcaho.org • www.ahrq.gov • www.cms.hhs.gov • www.hospitalcompare.hhs.gov

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