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
The SCOAP Box 