Archive for the 'newsletter' Category

SCOAP Community Speaks Up: Spine SCOAP

Surgeons at Virginia Mason have asked, “How can we get inovolved in the new SCOAP registry for spine surgery currently being developed?”

The surgical treatment of the human spine can be challenging in diagnosis, surgical decision-making, and technical execution. While there is general agreement among spine surgeons on appropriate care pathways, substantial variation exists in the rates of surgery, delivery and costs of care, and outcomes. Individual hospital sites often struggle with meeting the best practices involved in caring for this population, largely because they have limited tracking of performance or pathways to improve care delivery.

Beginning in 2009, a group of orthopedic and neurosurgeons became interested in developing a surveillance registry that would use the SCOAP platform because of its proven record as an impartial, objective, real world outcomes system not easily influenced by any stakeholder. A state-wide workgroup was formed and developed substantial momentum to choose metrics for process and outcome measures for a Spine data collection tool, with the goal of improving overall spine surgical care in Washington State. Led by a multidisciplinary group of clinicians across Washington State, this group is now poised to launch Spine SCOAP in several pilot hospitals beginning July 1.

Spine SCOAP is of particular importance because clinicians care for patients with serious, chronic diseases; use highly innovative, expensive, and emerging technology; function across a range of inpatient and outpatient practice settings; and count patient-reported outcomes as their most important treatment efficacy outcome. Stakeholders (Labor and Industries, industry, payers, regulators, advocacy groups) are interested and motivated to achieve the same goals (proof of benefit to patients, improving safety and quality of care) but for different, often competing, reasons. All see SCOAP as an objective, impartial, real world representation of truth that is not easily influenced by any stakeholder. Spine SCOAP fills a critical need in tracking care delivery and outcomes in this priority patient population and over time will allow best practices to emerge. SCOAP is also a proven platform for best practice dissemination through the Washington state community. By linking diverse practice environments across the continuum of care, Spine SCOAP benchmark reports allow clinicians to learn from one another and to perform statewide QI through benchmarking. Spine SCOAP aims to develop a diagnostic and outcomes surveillance registry vetted with providers and industry partners. Linking providers, industry partners, and patients is a unique approach for QI and will provide a necessary perspective for our community.

Currently the Spine SCOAP workgroup is finalizing the metrics and engaging surgeons across the state to encourage their hospitals to participate in this exciting work. The pilot data collection phase of Spine SCOAP starts July 1, for full deployment in January 2012. For more information about how you and your hospital can get involved, please contact Mike Kraemer at the Foundation for Healthcare Quality.

SCOAP Community Speaks Up: Bariatric Surgery

Clinicians at Evergreen Hospital asked us recently, “Can you update us on SCOAP’s data on quality and safety trends for bariatric surgery?”

We are frequently asked about the impact of SCOAP benchmarking on surgical quality and safety. SCOAP has been collecting data on bariatric procedures since its beginning in 2006. Recently, we reviewed trends for operative reinterventions, in-hospital mortality and 30-day mortality for gastric bypass, sleeve gastrectomy, and lap band procedures. Paralleling nationwide trends, bariatric surgery at SCOAP hospitals has gotten much safer in the last 5 years. Rates of operative reinterventions (mostly for leaks) for patients having gastric bypass have decreased from 5% to 2% from 2006-2010 (figure 1). Lap band reinterventions are expected to be infrequent, and to date, their rate has fluctuated between 0% and 1%. There was significant growth in the use of sleeve gastrectomies, with almost none being done in 2006, to and over 100 per quarter in 2010. In the last 2 years when the numbers have been more robust, we have seen reintervention rates of 1-2%, and in 2009 (when we started to get robust post-index hospitalization data), the rate of 30-day death and/or reintervention after sleeve was 2.68% (3 out of 112).

Of course, these improvements in leak rates are temporal trends, and it is almost impossible to attribute them to SCOAP alone. However, SCOAP continues to engage clinicians in changing practice patterns around important components of surgical site infection and leaks that should be expected to reduce the rates of these serious adverse events. Through newsletters, regional and annual meetings, and sharing actionable data and benchmarks about everything from glycemic control to leak testing, we are hoping to drive these rates even lower.

The SCOAP Advisory Board and metrics committees engage in a quarterly and annual process of review of all metrics to ensure that they remain useful, relevant, and a good use of abstracting resources. After reviewing data trends over the last five years, a few trends emerged related to bariatric surgery. As expected, short term lap band outcomes have remained stable with little variability, and the number of known process of care measures around adjustable banding have always been limited and have not expanded. The SCOAP Advisory Board determined that adjustable band procedures should be removed from the registry as a SCOAP-eligible procedure in order to increase the focus on gastric bypass, sleeve gastrectomy, and other newly added optional gastric procedures for ulcer or cancer. These procedures are higher risk, are increasingly utilized, and though 30-day mortality rates in Washington have declined considerably in the last decade (figure 2), there is still much opportunity for improvement. SCOAP will continue to shine the spotlight on aspects of these procedures that can contribute to better outcomes (e.g., by studying the use of sealing devices to decrease the rate of anastomotic leaks). Despite this change to SCOAP data collection, most adjustable banding centers in Washington are involved in a longer-term outcome tracking activity through the University of Washington’s Bariatric Outcomes and Obesity Modeling (BOOM) project. This survey-based data gathering activity is evaluating weight change, band adjustment patterns, and quality of life 2-5 years after banding and is providing benchmarked data to the centers. For more information about this project contact Brad Kramer, BOOM Project Manager at cbkramer@uw.edu) and expect an update in a future newsletter.

We still have opportunity to work together to make bariatric surgery safer. SCOAP is trying to focus the surgical community on achieving better glycemic control during and after bariatric surgery as a way to decrease infectious complications. There is still substantial variability between hospitals (figures 3 and 4) in how basic metrics of glycemic control and disturbing variation in even the checking of perioperative blood sugars, the use of insulin in diabetic patients with blood sugars of >200, and the effectiveness of glycemic control in the 2 days after surgery. While on average 90% of SCOAP bariatric patients with diabetes have a blood sugar checked (up from 45% when we started) there are still many hospitals where this is less common. As disturbingly, while on average 80% of patients with a very high blood sugar get started on insulin, that means that 1 in 5 do not, and there is even more variation in this metric. Where we all perform inconsistently is in how often we keep our patients’ blood sugar less than 200 during the 48-hour post op period. In keeping blood sugars less than 200 during the 48 hours post-op, the SCOAP average is even worse (40%), and only a few hospitals are considered high performing in this more complex metric. In SCOAP, 37% patients undergoing bariatric surgery are diabetic, so we have lots of opportunity to do a better job. Glycemic control may be one of our more effective strategies to improve outcome. A set of recent studies including one using NSQIP outcomes [1] found that for every 40 mg/dL increase in post-operative glucose above 140, there was a 30% increased risk of postoperative infection. SCOAP is conducting a series of regional meetings and workshops to learn more about best practices in perioperative glycemic control. This will also be a focus of part of the annual meeting in Chelan on June 17th. We hope to see you there and continue the hard work of driving quality improvement for our patients. Working together, the SCOAP community is aiming to get all of our patients the best possible outcomes.

Thanks for the question and all that you do to make SCOAP a success!

Reference

[1] Ramos M, Khalpey Z, Lipsitz, S, Steinberg J, Panizales MT, Zinner M, Rogers SO. Relationship of Perioperative Hyperglycemia and Postoperative Infections in Patients Who Undergo General and Vascular Surgery. Ann Surg 248 (4); Oct 2008.

SCOAP Community Speaks Up: VI-SCOAP

We were recently asked by colleagues at Northwest Hospital about an update on vascular intervention-SCOAP. How are surgeons, radiologists, and cardiologists participating in VI-SCOAP module, and what will the next 6 months look like for the program?

VI-SCOAP (Vascular Interventional Surgical Care and Outcomes Assessment Program) just completed its first year of data collection at 11 hospitals, representing 70% of the state’s vascular care. We are working to enroll 100% of the centers where vascular interventions and surgery are performed. If your hospital is not enrolled and you are interested in joining, please contact Rosa Johnson (rjohnson@qualityhealth.org).

Web-based reports based on our first 843 patients are now available. They represent care delivered by all three specialties and show the promise of VI-SCOAP (a demo version is available at http://cqi.armus.com/reports/SCOAP/Demo/DemoElectiveColon.xml, username “scoap” / password “demo”).  For more information on reports and how to access your hospital’s reports contact Rosa Johnson (rjohnson@qualityhealth.org).  Since October 2010, VI-SCOAP has benefitted from a $12 million grant from the Agency for Healthcare Reform and Quality (AHRQ) that partners VI-SCOAP hospitals and clinicians with Microsoft and leaders in health information technology to create more automated data flow in SCOAP and to reduce the burden on data abstractors. That collaboration will focus on the care of patients with claudication and will help VI-SCOAP expand its long term follow-up surveillance, as well as include a non-interventional comparator group.

Clinicians working with VI-SCOAP data reports have rolled up their sleeves to ask questions about “real world” outcomes and care variation that represent QI opportunities. VI-SCOAP reports highlight some things we do really well, such as delivering antibiotics on time and normothermia. It also shows us things we can do better. For example, 40 % of our patients are diabetic, but we only checked periprocedure glucoses 85% of the time. That’s 15% of patients who we missed an opportunity to have glycemic control and therefore reduce the risk of surgical site infection.  For our many patients on beta blockers, we only continue their use 89% of the time. That’s 11% of our patients who have a higher risk of heart attack after procedures because of a failure to continue these cardioprotective drugs. Metrics like these represent opportunities to impact the quality of care of patients receive, but it starts by knowing where you stand, and that’s what VI-SCOAP is all about.

Vascular care is a great arena for performance benchmarking.  There is significant variation in how the procedures are done, why they are done, and who does them.  For example, it’s interesting to see how the endovascular care is broken down in our state.  Forty-five percent of our patient population (carotid, aorta, and infrainguinal) underwent an endovascular procedure, with 18% of those being performed by cardiologists, 18% by Interventional Radiologists, and 61% by surgeons (see the figure included in this month’s newsletter). While this breakdown does not reflect all the cases performed by a specialty, it does represent a snapshot of our state’s robust endovascular landscape.  It highlights why we’ve built a level playing field for collaboration and why engagement of all specialties is so important.  VI-SCOAP is also important because we take care of some of the sickest patients out there. We see patients with DM (50%), coronary disease (80%) and symptomatic illnesses (75%) demanding high performing systems that to date have had very little in the way of performance monitoring.  These are also high complexity procedures with a risk of adverse events that must be monitored, understood and reduced.  Our early snapshot shows a rate of reintervention (percutaneous, endovascular, or open) in 2.8% of carotid procedures, 6.5% of aortic, and 6.0% of leg procedures. These all represent opportunities for QI, but it starts with knowing how we stand, and that’s what VI-SCOAP is all about.

Now we need you to get more involved. The VI-SCOAP advisory board is made up of interventional radiologists, interventional cardiologists, and vascular surgeons who meet quarterly to define and refine metrics for quality. That group is currently looking at variation in procedure-specific metrics like cerebral protection in carotid stenting and relevant outcome like stroke. They are also looking at an important feature of VI-SCOAP that is being enabled by the AHRQ grant – measurements of longer-term functional status for infrainguinal procedures. As we all know, having an open artery or stent is only important if it  improves functional status or healing. Tracking on this will help us all improve our selection of patients and show the value of our work.  These are just some of the metrics and outcomes that VI-SCOAP is currently addressing, and we invite you and your colleagues to participate in the process and direct future targets for performance monitoring.

Starting in 2011, VI-SCOAP – in concert with other SCOAP groups – will host a series of local, regional, and statewide meetings. You are encouraged to participate and be part of this process. This is an opportunity to direct the future of an exciting initiative-one that will change the scope of our practice and the way quality is defined for our field.

Thanks for all you do to make SCOAP and VI-SCOAP a success.

Ellen T. Farrokhi MD FACS , Associate Medical Director SCOAP
ellen@qualityhealth.org

SCOAP Community Speaks Up: Colorectal Surgery

We were recently asked by a colleague at Northwest Hospital, “Why does it seem as if SCOAP is always picking on colorectal surgeons?”

Some of the most common, hospitalization-requiring procedures we perform are colon and rectal resections.  While most surgeons only do a few of these procedures in any given year, SCOAP reports information on thousands of cases per year.  These cases offer many opportunities for quality improvement (QI).  As any surgeon knows, any time an anastomosis is created there is a risk of serious adverse outcomes.  For rectal cancer, great surgical and coordinated oncologic care can mean the difference between disease-free survival and a horrible recurrence.  For patients with diverticulitis, the indications for operation are in evolution, and there is significant variability in the use of these procedures across the state.  Reducing the risk of leak, delivering optimal coordinated care for patients with rectal cancer and assuring that all operations for diverticulitis are performed appropriately are just some of the goals of SCOAP.

Colorectal Interest Group Defines Metrics
Over the last year, groups of surgeons with an interest in focused clinical topics have been meeting monthly to help create the next generation SCOAP metrics that will add even greater value to surgeons and create opportunities to improve care.  A colorectal interest group has been working to improve rectal cancer care and diverticulitis management, and added a set of metrics about these conditions to SCOAP in January 2010.  All SCOAP surgeons are welcome to join this group.  The initial data about rectal cancer coming in to SCOAP indicate that there are significant opportunities to improve care delivery and quality.  SCOAP is finding significant under-reporting and under-use of standard preoperative staging tests to appropriately stage patients with rectal cancer; inconsistent reporting and use of neoadjuvant chemo/radiotherapy for Stage 3 patients; and a persistent subgroup of diverticulitis patients who don’t appear to have had standard indications for surgery reported.  As you see in this month’s data figure, while surgeons at just 5 hospitals perform 64% of the resections, another 27 hospitals perform the balance.  These cases are done in all of our communities, and QI initiatives in colorectal surgery have a spill-over effect to other procedures.  Getting colorectal resection “right” means an opportunity to impact almost all the people in our state.

 With the leadership of the colorectal workgroup, here is what SCOAP plans to focus on in the next year:

Universal Preoperative Staging of Rectal Cancer
Preoperative staging of rectal cancer with endoscopic transrectal ultrasound (EUS/TRUS) is essential for planning coordinated care.  Preoperative staging of rectal cancer can be either local or distant. Local staging incorporates the assessment of wall invasion, circumferential involvement, and nodal status. Distant staging assesses metastatic disease. The National Cancer Institute guideline for rectal cancer treatment[1] recommends that the initial staging procedures  include rigid proctoscopy, colonoscopy to rule out cancers elsewhere in the bowel, and a  computed tomography (CT) scan to rule out metastatic disease as well as endorectal ultrasound EUS/TRUS) or MRI.  MRI may be as accurate as EUS for staging of superficial tumors;[2] however, limited availability, high cost, and the limited field of view makes EUS the standard in most hospitals.

Universal Neoadjuvant Therapy in Indicated Patients
Preoperative combined modality therapy (CMT) including radiation and chemotherapy followed by radical resection is the preferred treatment paradigm for locally advanced rectal cancer (transrectal ultrasound staged uT3-T4 and/or N1-N2) in the United States, because the treatment decreases the size of the tumor and improves local control and sphincter preservation.  The landmark German Rectal Cancer Study, a large randomized trial of over 400 rectal cancer patients, demonstrated that local control was significantly improved when chemoradiotherapy was administered preoperatively.[3]  Castaldo et al[4]  corroborated these findings in the US SEER registry.

 The goals of this group are to help Washington state achieve universal preoperative staging (as appropriate), neoadjuvant treatment (as appropriate), and the use of total mesorectal excision (as appropriate) for rectal cancer, and universal appropriate indications of of diverticulitis cases.  To address issues of imprecise data gathering and variability in care delivery, the colorectal interest group also worked to create an operating room dictation template for colorectal cases that we are hoping will be adopted by all surgeons (download this guide at the SCOAP website). 

 Join the WA State Rectal Cancer Summit Planned for June 17th, Lake Chelan
To accomplish these broad goals, we are planning to create a half-day colorectal interest group meeting at the 2011 SCOAP Annual Retreat (June 17 in Chelan).  The day will include a focus on best practices in rectal cancer care and bring together surgeons and pathologists from across the state who are working in this area.  The goal of the summit will be to address the SCOAP data on rectal cancer care delivery, share best practices, and create interventions to improve care delivery. 

Many of you only operate on 1-2 rectal cancer patients a year, but we are trying to gather ALL surgeons who do this procedure to join the colorectal interest group phone calls.  If you do not operate on patients for diverticulitis or rectal cancer, please pass this on to one of your colleagues who does that work, but join SCOAP in one of our other interest groups (Vascular, Bariatric, Cancer care, Pediatric, Outpatient, Spine, Urology, Gynecology).

With these interest groups we are hoping to do something that is unique – lead QI without the government or insurers “making us do it.”  We are trying to do this in a way that honors our profession and keeps our patients central, but we need your help.

We ask only that you get involved.  The easiest way is to join the next colorectal work group phone meeting – Tuesday, December 15 at 6:30.  Contact Sarah Lawrence for call in information.

Please contact Rosa Johnson if you can attend the SCOAP Annual Retreat on June 17th and the colorectal interest group session that afternoon.

 Thanks for all you do to make SCOAP a success.


[1] National Cancer Institute. Rectal Cancer Treatment (PDQ) Health Professional Version. 20 September 2010

[2] Bianchi P, Ceriani C, Palmisano A, et al. A prospective comparison of endorectal ultrasound and pelvic magnetic resonance in the preoperative staging of rectal cancer. Annales de Italian Chirurgie 2006;77:41–6.

 [3] Sauer R, Becker H, Hohenberger W, et al: Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med 351:1731-1740, 2004

[4] Castaldo ET, Parikh AA, Pinson CW, Feurer ID, Merchant NB. Improvement of survival with response to neoadjuvant radiation therapy for rectal cancer. Arch Surg 2009; 144(2):129–34.

SCOAP Community Speaks Up: Radiation Safety

Radiologists at University of Washington have asked “What is SCOAP doing about reducing radiation exposure for WA State patients having surgical care?” 

In the March 2009 SCOAP Box, surgeons at Kadlec Hospital asked, “Why does it seem that SCOAP wants everyone to get a CT scan given recent evidence of radiation’s effect over time?”  We responded at that time that SCOAP’s focus is not on getting more CT scans but on getting more accurate scans and where the accuracy of ultrasounds is acceptable, increasing the use of ultrasound.  Since then, SCOAP data (see figure) shows that the relative use of CT and US scans has stayed about the same over SCOAP’s 5 years and that US accuracy remains highly variable across sites.

Consensus is growing that efforts are needed to minimize radiation exposure from CT scans. The National Academy of Sciences National Research Council[1] did an extensive review of the literature related to the health risks of radiation and found that patients who received radiation doses of a single CT scan were at increased risk of developing cancer. Surgical patients often receive multiple CTs, and their risks are even higher. A NEJM article[2] found that the risk of cancer from a single CT scan could be as high as 1 in 80. Radiation doses are not consistent across hospitals, and doses of radiation may be much higher at some centers than generally quoted. A study [3]describing radiation dose associated with the 11 most common types of diagnostic CT studies, performed on 1119 adult patients at 4 San Francisco Bay Area institutions, found that radiation doses between the institutions as well as within the individual hospital were extremely variable. Within each type of CT study, effective dose varied significantly within and across institutions, with a mean 13-fold variation between the highest and lowest dose for each study type.

Given these disturbing findings about unnecessary radiation exposure, there are two major recommendations to improve the safety of CT scans:  1) lower the radiation dose of routine CT scans and 2) use CT scans only when necessary.  The collection, standardization, and reporting of radiation dose information is currently limited and fragmented in the documented record.  More importantly, there are no clear standards or oversight for radiation dosing. For our patients this represents an opportunity for improved quality. As in many other areas of surgical quality improvement, SCOAP should be able to lead the way on radiation safety.  Beginning in January 2011 SCOAP will collect data on the Dose Length Product (DLP) for CT scans for non-elective appendectomies. DLP is a measure of the total radiation exposure for the whole series of CT images. The DLP is directly related to patient risk and may be used to set reference values for a given type of CT examination to help ensure patient doses at CT are as low as reasonably achievable. Tracking this information will help SCOAP hospitals work toward the goal of providing CT scans with the same quality but decreased radiation.  SCOAP is trying to foster partnerships between radiologists and surgeons to obtain and use these data for QI.

 We’ve also heard these questions from SCOAP surgeons:

 What strategies can our hospital use to decrease radiation exposure?

There are several recommendations for radiology departments to reduce radiation exposure. Some are simple – don’t scan parts of the body that are not needed; use shielding and train staff to monitor dose in order to make adjustments if doses are too high. (The latest generation of scanners provides automatic exposure-control options.)  For many types of CTs, the radiation dose can be reduced 50% or more without reducing quality[4], although it is true that as the radiation dose decreases, the relative “noise” in CT images increases, and this can limit the image quality.  Accepting more noise does not mean losing diagnostic power, as there are ways for the radiologist to compensate. SCOAP has assembled a group of experts who are available to come to any hospital in the state to hear more about this topic. Specific guidelines in how to lower dose per CT scan by up to 40% without compromising diagnostic power are available at CT.com or xrayrisk.com.

Are there special considerations for pregnant women and children?

Fetal exposure to CT radiation in the first trimester may double the risk of childhood cancer[5], thus ultrasound is often the first choice for pregnant women. High quality ultrasound is possible, but if the ultrasound is equivocal, MRI can be done.  MRI use and accuracy was added to SCOAP in 2010, and we should have enough information about it to report back to you by the end of the year. 

 Children also merit special consideration because their tissues are more radiosensitive, they often receive a larger effective dose for a given level of radiation, and they have a longer time to develop cancers resulting from radiation exposure. Ultrasound imaging of the appendix in children has the potential for excellent accuracy[6] and within pediatric SCOAP the most recent concordance (agreement between imaging and pathology diagnosis) rate of US is 78.6% for Quarter 1, 2010. Some SCOAP hospitals have established specific protocols to avoid the use of CT scans in the diagnosis of appendicitis, emphasizing ongoing training and review to improve ultrasound accuracy, with zero negative appendectomies and no increased rate of perforation. The Alliance for Radiation Safety’s Image Gently campaign (http://www.pedrad.org) provides resources, guidelines, protocols and educational materials for radiologists and pediatricians to lessen the risks of radiation exposure.

We would like to rely more on ultrasound, but our SCOAP data shows that we have work to do to improve concordance between ultrasound imaging and the pathologic diagnosis. What do you suggest?

Many hospitals have been able to successfully address issues around ultrasound accuracy and now have a high concordance between ultrasound imaging and pathologic diagnosis, but others continue to struggle with the quality of ultrasound imaging, with a resulting reliance on CT. The average rate of concordance among US and pathology in SCOAP is only 52.1% but some hospitals have been able to set the benchmark of 88.6 %.  That high level of accuracy in ultrasound is being achieved by just a few SCOAP hospitals, but this should be a target for all hospitals.  Accuracy and quality for ultrasound scans depend on the skills of the sonographer and there are best practices in sonography that can increase diagnostic accuracy and these can be shared between better performing SCOAP sites and others that are struggling with this metric.  SCOAP can help connect hospitals so they can share best practices.  It’s key that radiologists and sonographers at each SCOAP hospital know about benchmarking through SCOAP and that they be engaged in the process of improving accuracy. 

Technical improvements in US may not be enough.  Use of ultrasound imaging can only occur when skilled staff are present. Some smaller hospitals do not have 24-hour access to ultrasound.  Surgeons may be reluctant to hold patients in the ED and “wait for the day shift,” because they are concerned that delay may increase the risk of perforation.  Furthermore, ultrasound may not be the first imaging choice for all patients – patients who are obese may not be good ultrasound candidates. We encourage SCOAP surgeons and hospitals to engage radiologists in a QI activity surrounding diagnostic accuracy.  This is not commonly done, and we may be breaking new ground at some hospitals.

Is imaging even necessary in patients with presumed appendicitis?

SCOAP has been following the use of imaging in the diagnosis and treatment of appendicitis since we started. Initially, metrics focused on teasing out the use of either ultrasound or CT scans as part of the diagnostic work-up to determine whether the use of imaging was a factor in the incidence of negative appendectomy, whether the imaging impression was concordant with pathologic diagnosis, and also to learn whether use of imaging was related to a decrease in adverse outcomes such as perforation.  SCOAP also has gathered data on the use of imaging in women of reproductive age, where differential diagnosis is more complicated.   For women of reproductive age, the rates of negative appendectomy are VERY HIGH when no US or CT are used. Our experience with SCOAP data encourages the use of these tests among women of reproductive age. The use of imaging seems to matter less among young men but the rates are so low that it’s hard to assess the value of imaging in this.

Because of your hard work, we have seen the rate of negative appendectomy (among women) drop from 11% to 1.8%. Now we are adding a new and important piece to the puzzle to reduce radiation exposure without impacting quality outcomes. 

Thanks for the questions and for all you do to make SCOAP a success!


[1] National Council on Radiation Protection and Measurements. Ionizing Radiation Exposure of the Population of the   United States. 2009. NCRP report 160. http://www.ncrponline.org/.

[2] Smith-Bindman R. Is computed tomography safe? N Engl J Med 2010;363:1-4

[3] Smith-Bindman R, Lipson J, Marcus R, Kim K, Mahesh M, et al. (2009) Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer. Arch Intern Med 169: 2078–2086.

[4] McCollough CH, Primak AN, Braun N, Kofler J, Yu L, Christner J. Strategies for reducing radiation dose in CT. Radiol Clin North Am 2009; 47:27 -40

[5] HurwitzLM, Yoshizumi T, Reiman RE, et al. Radiation dose to the fetus from body MDCT during early gestation. AJR Am J Roentgenol2006; 186: 871–876.

[6] Dilley A, Wesson D, Munden M, et al. The impact of ultrasound examinations on the management of children   with suspected appendicitis: A 3-year analysis. J Pediatr Surg. 2001;36:303-308.

SCOAP Community Speaks Up: Tracking Length of Stay

Colleagues at Valley General Hospital in Renton asked “Why is SCOAP starting to ask questions about time of admission and discharge?” and others have asked similar questions what SCOAP is trying to get at when it focuses on length of stay.

Questions like these are a great opportunity to make sure all SCOAP surgeons are on the same page about how this grassroots collaborative picks metrics and why certain data points are being collected. Beginning January 2010, SCOAP added admission and discharge times for all cases, and for non-elective surgery (like appendectomies and some colorectal procedures) the time of arrival at the Emergency Room as well. Finding and abstracting times in a consistent manner has been a surprising challenge, prompting some of the above questions, but this metric is important. For non-elective surgery like appendectomies, the goal of time of arrival is tracking the time between first contact with the hospital and operation.  Adding times may help address a question that we’re often asked-can appendectomy be delayed until the morning without hurting patients (and its corollary-is it the standard of care to always have an in-hospital surgeon or night-time appendectomy by the on-call surgery for patients who come in at night). This is becoming increasingly relevant for all non-elective procedures where SCOAP surgeons are trying to reduce morbidity.

Calculating time to OR-Is SCOAP suggesting all appendectomy cases that come in at night be done in the middle of the night?

As you can see in the figures in this newsletter, the rates of perforated appendicitis in SCOAP varies considerably across hospitals.  Why is there so much variability in rates of perforation among our hospitals?  What can surgeons and ER docs do about higher rates of perforation?  Pre-hospital delays to first contact or misdiagnoses in the ER may also be linked with higher rates of perforation.  One way we can assess the frequency of modifiable, pre-hospital delay is by looking at the proportion of patients with perforation seen in the ER within a week prior to their appendectomy visit (Figure 2 in this month’s newsletter).  As you can see by the figure, at some hospitals there are very high rates of “missed opportunity” for an earlier diagnosis. There was a wide range (2% to 75%) of perforated patients who were in the system in the week prior.  Perhaps the main reason for getting ER evaluation time is that there has been a long held belief that delaying an appendectomy once the patient is admitted to the hospital will cause an increase in the rate of perforations-that’s something SCOAP is able to address. SCOAP surgeons are working on the length of time from first contact to imaging, and imaging to appendectomy to determine how much of this perforation rate is related to in-hospital delays.  Time from first contact to operation may be one of the only true modifiable risk factors for perforation.

It’s not all about in-hospital delay.  Patients with perforation often have delayed treatment and have limited access to healthcare -often linked to socioeconomic status. Several studies have looked at the time between symptom onset in appendicitis and surgery. In a retrospective review of 1081 adult patients who underwent appendectomy for acute appendicitis between 1998 and 2004, Detillo et al[1] found that the odds of having a perforation were 13 times higher when the total interval exceeded 71 hours compared with a total interval below 12 hours. Patient delay in presenting to the Emergency Room was more related to perforation than in-hospital delays.  Since our ability as surgeons to minimize delay in presentation to the ER is limited, the authors concluded that every effort should be made to expedite the evaluation and operation of admitted patients with suspected appendicitis. There are some that even believe that perforated appendicitis represents a different disease process that earlier intervention might not impact.  Evidence for this is inferred by a study of the National Hospital Discharge Survey 1970-1994[2] suggesting that perforated appendicitis has been “non-responsive” to trends in laparoscopy and advanced imaging.   

Information about the role of in-hospital delay has implications for staffing of “on-call” surgical services (very relevant for areas where surgeon supply is limited) and may help hospitals better understand the impact of in-house surgeons, another important emerging trend.  The same information may be relevant for other areas of non-elective surgery and will be the focus of SCOAP evaluations in the future.

Calculating Length of Stay (LOS)- Are we targeting LOS just for fiscal reasons?

Prolonged LOS after elective surgery is increases the risk of nosocomial infections like MRSA, VRE and C. Dificil colitis[3].  The Centers for Disease Control and Prevention (CDC) estimates that about 2 million people contract hospital-acquired infections each year, with nearly 90,000 fatalities. Every hour in the hospital increases a patient’s risk of nosocomial infection. The July 2010 issue of General Surgery News featured a study presented by Todd R. Vogel, MD, MPH, (Assistant professor of surgery, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, N.J. and a former contributor to SCOAP) at the 2010 annual meeting of the Surgical Infection Society. In this study focused on adults older than 40 years of age who underwent elective CABG, colon resection and lung resection, investigators identified more than 163,000 procedures that met study criteria and found that patients had markedly higher rates of all nosocomial infections if they had an in-hospital delay in surgery of just one day. With each day, risk for infection grew, particularly urinary tract infection and pneumonia. This is reason enough to work on decreasing our patient’s exposure to hospital pathogens by reducing length of stay.  

Prolonged length of stay also increases the cost of care, may limit bed availability, and decreases hospital profitability.  We need to continually make the business case for quality improvement in SCOAP. Given the costs of participation, the support and involvement of senior hospital leaders is crucial and that requires a sound business case. Data demonstrating both reduced complications and increased profitability through decreased LOS provides the justification needed to fund staff SCOAP participation.   

Several SCOAP initiatives have been focused on reducing length of stay and we’ve achieved remarkable success in shortening LOS in elective surgery over the last 5 years.  SCOAP’s previous unit of time measurement (using dates rather than hours) may have been too crude to identify the small changes that when used together may have impact measured in days.  For that reason as well we have added time of discharge to the dataset. 

 How can we be sure that emphasis on reducing length of stay does not result in unintended consequences? If patients are rushed out of the hospital, won’t there be more readmissions?

SCOAP’s primary goal is to make surgical care safer, higher quality and as efficient as possible. We include a set of post-discharge follow-up questions so that hospitals also benchmark on readmissions within thirty days and any complications that occurred after discharge.  These outcome data will answer the question about whether “Enhanced Recovery” or “Fast Track Protocols” aimed at reducing LOS are helping or hurting.  Hospitals can use their SCOAP data to measure the success of system changes and ensure that clinical quality improvement stays front and center.  As pressure increases from payers to pay for a global episode of care SCOAP surgeons are hoping to be positioned to make sure we are doing the right things for our patients and not just shifting care to the outpatient environment.  More news to follow as these data are gathered from all  the hospitals across the network.

Thanks for the great questions and all you do to make SCOAP a success! 

REFERENCES


[1] Ditillo MF, Dziura JD, Rabinovici R. Is it safe to delay appendectomy in adults with acute appendicitis? Ann Surg 2006;244(5):656–68.

[2]  Livingston EH, et al. Disconnect between incidence of nonperforated and perforated appendicitis: implications for pathophysiology and management. Ann Surg. 2007;245:886–92. doi: 10.1097/01.sla.0000256391.05233.aa.

 [3] Siegel JD, Rhinehart E, Jackson M, Chiarello L, Healthcare Infection Control Practices Advisory Committee. Management of multidrug-resistant organisms in healthcare settings. Atlanta (GA): Centers for Disease Control and Prevention; 2006

SCOAP Community Speaks Up: Advanced Pain Control

Surgeons at Sacred Heart in Spokane have asked “Is pain control getting in the way of recovery?”

Over the last five years, SCOAP has collected data to signal hospitals about their use of advanced pain control. One frequent question our patients ask when preparing for an elective surgery is, “How much pain will I have?” SCOAP recognizes that effective pain control requires giving patients active participation and control of their pain management and is the standard of care.  Evidence suggests that effective pain control reduces complications, decreases length of stay and improves patient comfort, satisfaction and outcome.  Effective pain control has included the element of advanced pain management, defined as a pain control method that is patient-controlled either through Patient Controlled Analgesia (PCA) or Patient Controlled Epidural Analgesia (PCEA).  SCOAP measures and benchmarks whether bariatric and colorectal patients receive advanced pain control (Patient-Controlled Analgesia or Epidural) following their operation.

Which method is preferable?
A meta-analysis[1] of 100 RCTs of randomized patients (abdominal surgery-36%, thoracic-24%, and lower extremity-12%) who received postoperative analgesia-either epidural analgesia or parenteral opioids found that for abdominal surgery, all epidural regimens were better postoperative analgesia than parenteral opioids.  Another meta-analysis of sixteen studies of only patients having colorectal surgery determined that although systemic opioids are effective for pain, they delay recovery of colonic mobility and prolong postoperative ileus.[2]

Do epidurals delay or help recovery?
Emerging evidence from multimodal “enhanced” recovery programs[3] – implementation of a perioperative patient care paradigm that reduces the time to discharge home and resumption of activities of daily living after surgical procedures – indicates that pain control, while an important aspect of patient care, needs to be considered not as a separate intervention but as one crucial component in a bundled care path.  

A key component of enhanced recovery programs is early ambulation. This is made possible by eliminating barriers such as the “two point restraint” of the Foley catheter and PCA, and the “three point restraint” when a routine NG tube is also in place.  In a recent SCOAP data review comparing length of stay (LOS) data from Q3 2008 through Q4 2009, hospitals in Washington State with lower LOS provided PCA’s to 90% of elective open colon/rectal patients and epidurals to 10%.   Hospitals with higher LOS used PCAs for 83% of these patients and epidurals for 28%.  In exploring this interesting finding it became apparent that we needed to get more information to better understand the reasons for prolonged length of stay.

As of January 2010 we are measuring how soon the patient is able to ambulate through the measure of the “voiding epidural” which is calculated using the date the patient’s Foley catheter is removed in patients who have epidurals. The recently issued Q1 2010 SCOAP report reflects these changes with new metrics. As more hospitals develop enhanced recovery protocols with multi-modal approaches, postoperative pain management is addressed in increasingly detailed and specific ways and SCOAP is evolving in response.

Is there evidence for the “voiding” epidural approach to pain control?
In a randomized trial of 54 patients[4] undergoing partial colectomy surgery, thoracic epidural analgesia (TEA) with bupivacaine and morphine inserted at the T8-T10 vertebral interspace was shown to provide the best balance of analgesia and side effects while accelerating postoperative recovery of gastrointestinal function and time to fulfillment of discharge criteria after colon surgery in relatively healthy patients within the context of a multimodal recovery program. The so-called “Walking/Voiding” epidurals provide pain relief and also allow patients to be up and out of bed sooner and more comfortably.  In another recent study,[5] sixty patients undergoing thoracic or thoraco-abdominal surgery were studied prospectively. Patients were randomly assigned   to receive either TEA or patient-controlled  i.v. opiate analgesia (PCA) after their operation. Visual analogue pain and sedation scores were recorded for the period of the study. The authors concluded that epidural analgesia with local anesthetic and opioid improved quality of life and delivered better analgesia compared with PCA.

There is also evidence that the practice of keeping a urinary catheter in place postoperatively when a patient has a thoracic epidural to avoid urinary retention may not be necessary.  A recent randomized study[6] of patients scheduled for thoracic and abdominal surgery and receiving continuous thoracic epidural analgesia found that leaving the bladder catheter as long as the epidural analgesia is maintained results in a higher incidence of UTI and prolonged hospital stay. Removal of the bladder catheter on the morning after surgery does not lead to higher rate of catheterizations.

Surgeons at Southwest asked “Are there special considerations for pain control with bariatric patients? We are concerned about using PCAs for these patients.”
For patients with clinically severe obesity (BMI≥35 kg/m2) who present for bariatric surgery, the incidence of obstructive sleep apnea (OSA) ranges from 71% to 77%. Postoperatively, patients with OSA present the anesthesiologist, surgeon, and nursing staff with a difficult situation. Although diminution of pain is the goal of every caregiver, the use of narcotics is especially dangerous in patients with OSA. After the use of any general anesthetic, the patient with OSA will exhibit a propensity for rapid eye movement (REM) sleep during the first several days after surgery.  In the patient with OSA, the genioglossus muscle is virtually paralyzed during REM sleep, allowing the tongue to fall posteriorly to the retroglossal space. Normally, such patients would arouse and terminate REM sleep, but this reflex is diminished with the administration of narcotics or sedatives.

For patients with severe pain and the need for opiates, the risk of over-sedation and airway compromise is clearly increased. In patients with OSA, respiratory depression culminating in respiratory arrest has been reported after an intravenous “push” of opioid analgesics, an epidural infusion of opioid analgesia  and with the use of patient-controlled opioid analgesia. Proper patient positioning (e.g., HOB to 30°), the administration of CPAP, nursing monitoring and limited use of narcotic analgesics have been recommended to address these risks.  Some hospitals admit these patients to the ICU for a brief period to provide more nursing support and assessment of the patient’s needs. Nonsteroidal anti-inflammatory drugs (NSAIDs) may be used as an adjunct for postoperative pain control as the use of NSAIDs can decrease opioid use by 20% to 35%.[7]  There is no literature that indicates a clear contraindication to use of a PCA or PCEA.

What about laparoscopic surgery?
Pain control following laparoscopic surgery is related to the size of incisions. Some colorectal surgeries that are hand-assisted may have a significant incision.  A retrospective analysis[8] of hospital records was performed for 16 patients undergoing laparoscopic colorectal surgery. Thoracic epidural in this study offered optimal analgesia and quality of care.  Other considerations for pain control in laparoscopic colorectal surgery have focused on decreasing length of stay. A randomized clinical trial[9] of patients undergoing segmental laparoscopic colectomy compared PCA vs. TEA and found that TEA significantly improved early analgesia following laparoscopic colectomy but did not affect the length of hospital stay.

What are best-performing SCOAP hospitals doing to ensure patients have optimal pain control and recovery?
SCOAP hospitals that are successfully addressing postoperative pain control have developed strategies and guidelines to standardize all aspects of care during the entire perioperative period.   They have formed teams that include key players such as anesthesia staff, nursing staff and other clinicians to address ongoing quality improvement activities and are providing training and coaching to staff so they understand and are supportive of the organization’s approach to postoperative recovery,  and the need to provide effective pain management that optimizes patient outcome.  They also use SCOAP data to figure out whether or not strategies like epidurals are helping or restricting their patients.  Evidence suggests that patients with open bariatric or colorectal operations should receive a thoracic epidural that is properly positioned to allow ambulation and voiding, and that pain control be considered as part of the multi-modal approach to surgical recovery. Patients with large laparoscopic incisions may also benefit from thoracic epidurals. Bariatric patients with OSA require careful monitoring and limited use of narcotic analgesics.  Only by tracking on the effectiveness and impact of advanced pain control will we balance the benefits and drawbacks of this powerful technology.

Thanks for all you do as a part of SCOAP.


[1] Block BM, Liu SS, Rowlingson AJ, Cowan AR, Cowan JA Jr, Wu CL. Efficacy of postoperative epidural analgesia: a meta-analysis. JAMA. 2003;290(18):2455-2463

[2] Marret E, Remy C, Bonnet F, Postoperative Pain Forum Group. Meta-analysis of epidural analgesia vs. parenteral opioid analgesia after colorectal surgery. Br J Surg. 2007; 94(6):665-673.

[3] Lassen K, Soop M, Nygren J, Cox PBW, Hendry PO, Spies C et al.  Consensus review of optimal perioperative care in colorectal surgery. Arch Surg 2009; 144: 961–969.

[4] Liu SS, Carpenter RL, Mackey DC, Thirlby RC, Rupp SM, Shine TS, Feinglass NG, Metzger PP, Fulmer JT, Smith SL: Effects of perioperative analgesic technique on rate of recovery after colon surgery. Anesthesiology 1995; 83:757-65

[5] Ali, M, Winter DC , Hanly AM, O’Hagan C,  Keaveny J, Broe P.  Prospective, randomized, controlled trial of thoracic epidural or patient-controlled opiate analgesia on perioperative quality of life. Br. J. Anaesth. 2010 104: 292-297.

[6] Zaouter C, Kaneva P, Carli F. Less Urinary Tract Infection by Earlier Removal of Bladder Catheter in Surgical Patients Receiving Thoracic Epidural Analgesia Regional Anesthesia & Pain Medicine: November/December 2009 – Volume 34 – Issue 6 – pp 542-548

[7] Bell R, Rosenbaum S. Postoperative considerations for patients with obesity and sleep apnea. Anesthesiol Clin N Am 23 (2005), pp. 493–500.

[8] Dennis, RJ, Mills, P. Thoracic Epidural versus Morphine Patient Controlled Analgesia After Laparoscopic Colectomy World Journal of Laparoscopic Surgery, September-December 2008.

[9] Senagore AJ, Delaney CP, Mekhail N, Dugan A, Fazio VW. Randomised clinical trial comparing epidural anaesthesia and patient controlled analgesia after laparoscopic segmental colectomy. Br.J.Surg 2003; 90: 1195–9.