Carlos S. Morales, MD; Foula Kontonicolas MD; Anita Volpe DNP; Pierre F. Saldinger MD, FACS Royd Fukumoto, MD, FACS Department of Surgery and Department of Performance Improvement Danbury Hospital, Danbury CT Performance Improvement: Getting an Early Start

INTRODUCTION INTRODUCTION NSQIP - a measurement of surgical outcomes Why NSQIP for PI? - Standard methodology for abstraction and collection of data - Allows for equitable comparison of variables - Enables honest evaluation of system process SCIP - process measure – Timing of VTE or antibiotic prophylaxis

METHODS Resident Champion (RC) was started in July 2010, as a way to introduce residents to NSQIP/SCIP NSQIP 1.Identify target 2.Deep dive 3.Identify involved services 4.Create taskforce 5.Create action plan 6.Implementation 7.Monitor and validate

METHODS METHODS The RC presents timely feedback on NSQIP and SCIP performance to other residents at our weekly residency program meeting The RC participates in multidisciplinary committees

Residents as active participants of PI ACGME – Systems Based practice – Practice Based Learning and Improvement – Medical Knowledge – Patient Care – Professionalism – Interpersonal and communications skills

RESULTS Surgical Progress Note Accelerated computer tomography of the abdomen and pelvis (ACTAP) Modified risk assessment tool (MRAT) for VTE prevention

Surgical Progress Note Incorporates 5 of the 10 core SCIP measures that are pertinent to general surgery - Appropriate antibiotic prophylaxis - Prophylactic antibiotics discontinued within 24 hours of surgery - Urinary catheter removed on postoperative day 2 - Appropriate perioperative temperature management - Appropriate VTE prophylaxis Increased SCIP compliance to 100% in those 5 measures over last quarter

ACTAP 2009 risk model for age 65 or greater identified increased mortality in general surgery

MRAT In 2010, we were failing VTE SCIP measures, our O/E patients with VTE were identified - 48% had inadequate prophylaxis based on current guidelines MRAT

Validation of the tool MRAT and the Caprini model was applied to 1000 patients 1.1% had a VTE score that differed from Caprini’s 0.1% would have required a change in prophylaxis O/E- 0.95

Conclusions Conclusions ACGME Competencies Practice-Based Learning and Improvement Using NSQIP / SCIP data for performance improvement Medical Knowledge Science supporting SCIP measures Science supporting VTE prophylaxis Potential catastrophic events behind acute abdominal pain Systems-based Practice Developing system wide protocols to address VTE prophylaxis and acute abdominal pain Interpersonal and Communication Skills NSQIP / SCIP liaison to surgical residency Participation in multi-disciplinary committees Professionalism Interaction with other physician departments and nursing in formulating and carrying out initiatives Patient Care SCIP measures and relation to outcomes Changes in VTE rates Changes in mortality in patients with abdominal pain