外科监护治疗的改良方案（英文ppt）the surgical care improvement project课件

The Surgical Care Improvement Project Where we started and where were going,Dale W. Bratzler, DO, MPH QIOSC Medical Director Oklahoma Foundation for Medical Quality June 5, 2007,Why focus on surgical quality?,30 million major operations each year in the US Despite advances in surgical and anesthesia technique and improvements in perioperative care, variations in outcomes for patients having surgery are well known,Why focus on surgical quality,Patients who experience a postoperative complication have dramatically increased hospital length of stay, hospital costs, and mortality On average, the length of stay for patients who have a postoperative complication is 3 to 11 days longer,Consequences of Surgical Complications,Dimick and colleagues demonstrated increased costs: infectious complications was $1,398 cardiovascular complications $7,789 respiratory complications $52,466 thromboembolic complications $18,310.,Dimick JB, et al. J Am Coll Surg 2004;199:531-7.,Impact of Complications on Survival,Khuri SF, et al. Ann Surg 2005;242:326-41.,Khuri and colleagues demonstrated that, independent of preoperative patient risk, the occurrence of a 30-day complication reduced median patient survival by 69%.,Who Pays for Surgical Complications?,Dimick JB, et al. Who pays for poor surgical quality? Building a business case for quality improvement. J Am Coll Surg. 2006;202:933-7.,Complications were always associated with an increase in costs to healthcare payors: complications were associated with an average increase in payment of $7645 (54%) per patient.,Medicare Surgical Infection Prevention (SIP) Project Objective,To decrease the morbidity and mortality associated with postoperative infection in the Medicare patient population,8,Risk Factors for SSI,9,Risk Factors for SSI,Quality Indicators National Surgical Infection Prevention Project,Proportion of patients with antibiotic initiated within 1 hour before surgical incision Proportion of patients who receive prophylactic antibiotics consistent with current recommendations Proportion of patients whose prophylactic antibiotics were discontinued within 24 hours of surgery end time,Efficacy Of Prophylaxis Is Independent Of The Specific Antibiotic,Age of Lesion at Antibiotic Injection (Hours),Lesion Size, mm (24 Hours),Penicillin, 40,000 U,Staph + Penicillin,Control,Chloramphenicol, 0.1 mg/Kg,Erythromycin, 0.1 mg/Kg,Tetracycline, 0.1 mg/Kg,Control,Control,Control,Staph + Erythromycin,Staph + Tetracycline,Staph + Chloramphenicol,Burke JF. Surgery. 1961;50:161.,12,Stone HH et al. Ann Surg. 1976;184:443-452.,Timing of Antibiotic Prophylaxis GI Operations,13,Classen, et al. N Engl J Med. 1992;328:281.,Perioperative Antibiotics Timing of Administration,Hours From Incision,14/369,5/699,5/1009,2/180,1/81,1/41,1/47,15/441,Clin Infect Dis. 2007; 44:9217.,Clin Infect Dis. 2007; 44:9217.,Discontinuation of Prophylaxis,Numerous clinical trials have compared short-term to long-term antimicrobial prophylaxis Many compared single-dose prophylaxis to multiple dose prophylaxis Wide variety of operations using a wide variety of antimicrobial agents Infection rates are the same regardless of duration of prophylaxis Prolonged prophylaxis has been associated with higher rates of infections with resistant organisms (when infection occurs). Prolonged prophylaxis only changes the flora it does not lower infection rates.,Prolonged prophylaxis is a patient safety issue.,17,C. difficile enterocolitis,In epidemiologic studies of C. difficile enterocolitis, surgical antimicrobial prophylaxis is the single most common indication for use of antibiotics. Although even single dose prophylaxis increases the risk of carriage of C. difficile, in a case control study of patients all of whom received surgical prophylaxis, carriage of C. difficile was more common in patients who received prophylaxis for 24 hours (56% versus 17%).,Jobe BA, et al. Am J Surg. 1995;169:480-483. Privitera G, et al. Antimicrob Agents Chemother. 1991;35:208-210.,Conclusions: One-dose antibiotic prophylaxis did not lead to an increase in rates of surgical site infection and brought a monthly savings of $1980 considering cephazolin alone. High compliance to 1-dose prophylaxis was achieved through an educational intervention encouraged by the hospital director and administrative measures that reduced access to extra doses.,Arch Surg. 2006;141:1109-1113.,/about/papers/advistmt/1027.asp,Recommendation 3 Duration of prophylactic antibiotic administration should not exceed the 24-hour post-operative period. Prophylactic antibiotics should be discontinued within 24 hours of the end of surgery. Medical literature does not support the continuation of antibiotics until all drains or catheters are removed and provides no evidence of benefit when they are continued past 24 hours.,/sections/aboutthesociety/practiceguidelines/antibioticguideline/,Conclusions: The duration of antibiotic prophylaxis should not be dependent on indwelling catheters of any type. There is evidence indicating that antibiotic prophylaxis of 48 hours duration is effective. There is some evidence that single-dose prophylaxis or 24-hour prophylaxis may be as effective as 48-hour prophylaxis, but additional studies are necessary . There is no evidence that prophylaxis administered for longer than 48 hours is more effective than a 48-hour regimen.,Antibiotic Recommendation Sources,American Society of Health System Pharmacists Infectious Diseases Society of America The Hospital Infection Control Practices Advisory Committee Medical Letter December 2006 Surgical Infection Society Sanford Guide to Antimicrobial Therapy The Johns Hopkins Guide Society of Thoracic Surgeons February 2007,Recently Updated Antibiotic Recommendations,* For the purposes of national performance measurement a case will pass the antibiotic selection performance measure if vancomycin is used for prophylaxis (in the absence of a documented beta-lactam allergy) if there is physician documentation of the rationale for vancomycin use (effective for July 2006 discharges).,Bratzler DW, Hunt DR. The Surgical Infection Prevention and Surgical Care Improvement Projects: national initiatives to improve outcomes for patients having surgery. Clin Infect Dis. 2006;43:322-30.,Recently Updated Antibiotic Recommendations (continued),* Ciprofloxacin, levofloxacin, gatifloxacin, or moxifloxacin (effective for July 2006 discharges). For the purposes of national performance measurement, a case will pass the antibiotic selection indicator if the patient receives oral prophylaxis alone, parenteral prophylaxis alone, or oral prophylaxis combined with parenteral prophylaxis.,Bratzler DW, Hunt DR. The Surgical Infection Prevention and Surgical Care Improvement Projects: national initiatives to improve outcomes for patients having surgery. Clin Infect Dis. 2006;43:322-30.,Antibiotic practices that have been shown to reduce the risk of SSI.,Administration of the antibiotic dose just before incision Antibiotic selection for the common organisms to be encountered Appropriate dose adjustment based on patient weight Re-dosing the patient in the operating room for long cases,Surgical Care Improvement Project National Goal,To reduce preventable surgical morbidity and mortality by 25% by 2010,SCIP Steering Committee,American College of Surgeons American Hospital Association American Society of Anesthesiologists Association of peri-Operative Registered Nurses Agency for Healthcare Research and Quality,Centers for Medicare & Medicaid Services Centers for Disease Control and Prevention Department of Veterans Affairs Institute for Healthcare Improvement Joint Commission on Accreditation of Healthcare Organizations,Surgical Care Improvement Project (SCIP),Preventable Complication Modules Surgical infection prevention Cardiovascular complication prevention Venous thromboembolism prevention,Surgical Care Improvement Project Performance measures - Process,Surgical infection prevention Antibiotics Administration within one hour before incision Use of antimicrobial recommended in guideline Discontinuation within 24 hours of surgery end Glucose control in cardiac surgery patients Proper hair removal Normothermia in colorectal surgery patients,Furnary et al. Ann Thorac Surg 1999:67:352,Pre-operative shaving,Shaving the surgical site with a razor induces small skin lacerations potential sites for infection disturbs hair follicles which are often colonized with S. aureus Risk greatest when done the night before Patient education be sure patients know that they should not do you a favor and shave before they come to the hospital!,Temperature Control,200 colorectal surgery patients control - routine intraoperative thermal care (mean temp 34.7C) treatment - active warming (mean temp on arrival to recovery 36.6C) Results control - 19% SSI (18/96) treatment - 6% SSI (6/104), P=0.009,Kurz A, et al. N Engl J Med. 1996. Also: Melling AC, et al. Lancet. 2001. (preop warming),Cardiovascular Complication Prevention,Prevention of Cardiac Events Introduction,As many as 7 to 8 million Americans that undergo major noncardiac surgery have multiple cardiac risk factors or established coronary artery disease More than 1 million cardiac events annually Myocardial ischemia either clinically occult or overt confers a 9 - fold increase in risk of unstable angina, nonfatal myocardial infarction, and cardiac death,Schmidt M, et al. Arch Intern Med. 2002;162:63-69. Mangano DT, et al. N Engl J Med. 1996;335:1713-1720. Selzman CH, et al. Arch Surg. 2001;136:286-290.,Surgical Care Improvement Project Performance measure - Process,Perioperative cardiac events Perioperative beta blockers in patients who are on beta blockers prior to admission,/clinical/guidelines/perio/periobetablocker.pdf,Venous Thromboembolism Prevention,Prevention of Venous Thromboembolism,Recent estimates show that more than 900,000 Americans suffer VTE each year about 400,000 of these being DVT About 500,000 being manifest as PE In about 300,000 cases, PE proves fatal; it is the third most common cause of hospital-related deaths in the United States.,Heit JA, Cohen AT, Anderson FA on behalf of the VTE Impact Assessment Group. Abstract American Society of Hematology Annual Meeting, 2005.,National Body Position Statements,Leapfrog1: PE is “the most common preventable cause of hospital death in the United States” Agency for Healthcare Research and Quality (AHRQ)2: Thromboprophylaxis is the number 1 patient safety practice American Public Health Association (APHA)3: “The disconnect between evidence and execution as it relates to DVT prevention amounts to a public health crisis.”,1. The Leapfrog Group Hospital Quality and Safety Survey. Available at: /pdf/Final/doc 2. Shojania KG, et al. Making Healthcare Safer: A Critical Analysis of Patient Safety Practices. AHRQ, 2001. Available at: /clinic/ptsafety/ 3. White Paper. Deep-vein thrombosis: Advancing awareness to protect patient lives. 2003. Available at: /ppp/DVT_White_Paper.pdf,Acquired Risk Factors,Thromboprophylaxis Use in Practice 1992-2002,Prophylaxis Patient Group Studies Patients Use (any) Orthopedic surgery 4 20,216 90 % (57-98) General surgery 7 2,473 73 % (38-98) Critical care 14 3,654 69 % (33-100) Gynecology 1 456 66 % Medical patients 5 1,010 23 % (14-62),Surgical Care Improvement Project Performance measures - Process,Prevention of venous thromboembolism Proportion who have recommended VTE prophylaxis ordered Proportion who receive appropriate form of VTE prophylaxis (based on ACCP Consensus Recommendations) within 24 hours before or after surgery,Geerts WH, et al. CHEST. 2004;126:338S-400S.,ACCP Guidelines for VTE Prevention,Public Accountability and SCIP,Hospital Public Reporting “P4R”,98.3% of PPS hospitals now reporting,0.4% Incentive,For purposes of clause (i) for fiscal year 2007 and each subsequent fiscal year, in the case of a subsection (d) hospital that does not submit, to the Secretary in accordance with this clause, data required to be submitted on measures selected under this clause with respect to such a fiscal year, the applicable percentage increase under clause (i) for such fiscal year shall be reduced by 2.0 percentage points. The Secretary shall expand, beyond the measures specified under clause (vii)(II) and consistent with the succeeding subclauses, the set of measures that the Secretary determines to be appropriate for the measurement of the quality of care furnished by hospitals in inpatient settings. The Secretary shall report quality measures of process, structure, outcome, patients perspectives on care, efficiency, and costs of care that relate to services furnished in inpatient settings in hospitals on the Internet website of the Centers for Medicare & Medicaid Services.,Deficit Reduction Act of 2005,OPPS Rule Final Rule Posted on November 1, 2006,Expands required measures for hospital public reporting: 21 current measures Adds SCIP Infect 2 (antibiotic selection) SCIP VTE 1 and 2 HCAHPS (consumer satisfaction) Three new CMS 30-day mortality measures for AMI, HF, and Pneumonia (based on CMS analysis of Medicare fee-for-service claims data),Hospital Acquired Infections (provisions of the Deficit Reduction Act) In order to manage the costs associated with Hospital Acquired Infections, the DRA requires the Secretary to identify, by October 1, 2007, at least two conditions that are: o High cost or high volume or both o Result in a DRG that has a higher payment when present as a secondary diagnosis o Could have been reasonably prevented through the application of evidence based guidelines The IPPS proposed that for discharges on or after October 1, 2008, that have one of the two selected conditions as a secondary diagnosis that was not present at admission will be paid as if the secondary diagnosis was not present. Therefore any charges associated with the infection would not be paid.,Deficit Reduction Act - 2005, the Secretary is directed to begin phasing out payment increases associated with complications of care,Remember who pays for surgical complications,Deficit Reduction Act 2005 Pay for performance,. the Secretary is directed to develop a plan to implement a value-based purchasing program based on the expanded measure set for which hospitals will submit data starting in FY 2007. The program will begin implementation in FY 2009 (2008).,54,Surgical Care Improvement Project,*NQF endorsed.,Preliminary SCIP Data Qtr. 1, 2005,National sample of 19, 497 Medicare patients. The charts were independently abstracted by the