Surgical Mortality

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Surgical Mortality Powered By Docstoc
					Strategies to Reduce Surgical
    Mortality and Morbidity
     Leigh Hamby, MD, MHA
   EVP and Chief Medical Officer
      Piedmont Healthcare
         Agenda for this AM
• Important contributions of surgical
  mortality and morbidity to overall hospital
• Is there a difference between
  “complications” and “preventable events”
• What can we do to reduce surgical
  morbidity and mortality?
  Is Mortality a Useful Measure to
         Improve Quality?
• Can it be measured?
• Is there a gap between what we “know”
  and what we “do”?
• Does it excite people and tap into “intrinsic
• Does it invite continuous feedback and
• Does it build our “improvement capacity”?
    Surgery and Mortality Data
• Surgical cases were                 Preportion of Deaths FY 10
  24% of Total IP cases
  FY 10
• Surgical patients were
  17% of Total IP
  Mortality for FY 10
• However 50% of            0%
  deaths after elective           Emergent          Urgent           Elective
  admit were surgical                        Surgical Non Surgical
        Mortality Rate for Urgent
           /Emergent FY 10

               Surgical   Non Surgical
                       AHRQ PSI
                Morbidity / Complications
•   Complications of anesthesia      •   Post-operative respiratory
•   Death in low mortality DRGs          failure
•   Decubitus ulcer                  •   Post-operative pulmonary
•   Failure to rescue                    embolism or deep vein
•   Foreign body left in during      •   Post-operative sepsis
•   Iatrogenic pneumothorax          •   Post-operative wound
•   Selected infections due to       •   Accidental puncture or
    medical care                         laceration
•   Post-operative hip fracture      •   Transfusion reaction
•   Post-operative hemorrhage or     •   Birth trauma- Injury to Neonate
•   Post-operative physiologic and   •   Obstetric trauma – vaginal with
    metabolic derangements               instrument
                                     •   Obstetric trauma, vaginal
                                         without instrument
                                     •   Obstetric trauma, cesarean
 My Philosophy on Complications /
• “When you are the numerator, the
  denominator doesn‟t matter”
  – Dale Nordenberg
• We should strive to eliminate the things
  that we don‟t want to happen to someone
  we love
  Framework for Consideration
• Surgical Mortality has two different
  – Emergent / Urgent
     • Highest Risk / Most Impact
     • Strategies around intra-op and post-op
  – Elective
     • Most compelling
     • Strategies around pre-op / intra-op / post-op
• Strategies should address both Morbidity
  and Mortality
    Specific Pre-op Strategies
• Checklist
• Pre-op Briefing
• Medical staff governance has to “own this”
• Make sure your pre-requisites are in place
                                                   Human Factors
                                             Preoperative Briefing - Kaiser
Human Factors addresses the interpersonal skills generally implicated in adverse outcomes. It is about
detecting threats to patient safety, avoiding errors, and managing in a team–based environment. The
primary concept applied in the preoperative setting is the use of briefings similar to the pre-flight
briefings in the aviation industry.

A Briefing is an opportunity for team members to share pertinent information regarding the patient‟s
care prior to and during the surgical procedure. This allows all team members to share the same mental

WHO participates in a Safety Briefing? There are 4 roles in a Safety Briefing, each equally important. A
Safety Briefing is the responsibility of the entire team.

WHEN & WHERE does a Safety Briefing occur? In the operating room-post induction, precut.

Surgeon                                      Circulator                           Scrub                        Anesthesia
•ID patient and site                                                              •Do we have all the          •What type of anesthesia will be
                                             •Identify patient site and marking
                                                                                  instruments?                 used?
What type of surgery?                       •Allergies?
                                                                                  •Are there any instruments   •Risks?
Realistic Time Estimate                                                          missing from the tray?       Should we anticipate any
                                             •Verification of Medication on the
                                             back table
                                                                                  •Are all the instruments
What is the desired position?                                                    working?                     •Any special needs –
                                             •X-ray available and other special
                                             services, (i.e., X-Ray, Pacemaker,                                positioning, medications?
Any special equipment needed?                                                    •What special
                                             Cell Saver, Sales Rep, Laser)
                                             Blood available?                     instrumentation do we        •Special Lines driven by
Is this a standard procedure or are there                                        need?                        Anesthesia
special needs?                                                                    •Does the team       have
Are there any Anticipated problems?                  Anesthesia                  any questions about the
                                                                                                               Will we need pathology?
                                                                                                               Are there any special
Use of drugs on the field?
                                                                                                               intraoperative requests, i.e.,
                         Surgeon                     Successful                            Scrub               wake-up, hypothermia?

                                                    Briefing Model
Intra-op Framework / Strategies
• Framework
• Strategies
             Intra-op Failure Modes
                             June 2003 • Volume 133 • Number 6
                                 Surgical Outcomes Research
            Invited commentary: Analyzing adverse medical events—it's the system!
•                            Robert Rhodes, MD Philadelphia, PA

    … error in medicine is almost always seen as a
    special case of medicine rather than as a special
    case of error … The unfortunate result has been
    the isolation of medical errors from much of the
    body of theory, analysis, and application that has
    developed to deal with error in fields such as
    aviation and nuclear power … Much as human
    behavior in a medical setting is still behavior and
    not medicine, human error in a medical setting is
    still an error and not medicine.3
      3. Gaba DM: Human error in dynamic medical domains. In: Bogner MS, editor. Human error in
      medicine. Hillsdale, NJ: Lawrence Erlbaum Associates, Inc; 1994. p. 197-224.
• We should think about “surgical errors” the
  same way we think about any other error
• What would you guess is the most
  common cause of intra-op „error‟?
           Intra-op Strategies
• Develop an understanding of failure modes
  – Need surgeons / anesthesia/ OR staff participation
• Start a journey of a thousand steps
• Capture useable information for learning and
• “What an organization becomes emerges from
  the relationships of its members rather than
  being determined by the choices of individuals..”
  – Ralph Stacey
          Post-op Strategies
• Prevent things we know are a risk and
  measure performance
  – DVT, SCIP, etc
• Assessment of patient risk after surgery
• Early detection if things begin to go awry
  – Is Sepsis going to be the 6th vital sign?
• Prevention of Surgical M&M goes WAY
  BEYOND prevention of DVT and SSI
• Break up strategies into Pre-op, Intra-op,
• Consider different levels of risk for elective
  and urgent/emergent
• Would like to close with a (hopefully)
  provocative thought…
           Think about this…
• Recall the “organizational” energy you expend to
  drive SCIP improvement at your hospital (for
  example colon resection)
• To move our system from 93% to 95% on all
  SCIP measures positively improved care for 20
  additional patients in 1 year
• We improved colon cancer screening by 10%
  from Jan – Sept 2010
• This improved care for 900+ patients!
  – Some of these will NOT NEED surgery!