Examination of Hospital-Level Variation in Preventing Post-Operative Sepsis

Transcription

1 Examination of Hospital-Level Variation in Preventing Post-Operative Sepsis Elizabeth Berger, MD; Sanjay Mohanty MD MS; Lynn Zhou PhD; Mark Cohen, PhD; Bruce Hall MD PhD MBA; Cliff Ko, MD MS MSHS; Karl Bilimoria MD MS

2 Disclosures None

3 Impact of Sepsis Estimated 1 million cases of sepsis annually in United States Associated mortality rate of greater than 30% Occurs in 10% of hospitalized patients and contributes to nearly half of all hospital deaths Sepsis rates of 1.2% -4.5% in patients undergoing surgery Liu et al. JAMA Niemeier et al. Raising Awareness of Sepsis

4 Clinical Laboratory News How Deadly is Sepsis?

5 Factors Affecting Surgical Patients Surgical patients are high risk group for developing sepsis Invasiveness of surgery predisposing to iatrogenic and hospital acquired infections Hemorrhage and blood transfusions leading to immunologic vulnerability Significant metabolic imbalances post-operatively Liu et al. JAMA. 2014

6 Sepsis Rates Continue to Rise Sepsis rates have doubled from From , sepsis-related hospital stays increased 150% Death due to septicemia increased 17% from z Walkey et al. Annals of the American Thoracic Society. 2015

7 Cost of Sepsis 3 rd largest consumer of Medicare Dollars $54 billion annual cost Vogel et al. Surg Infect. 2009

8 Public Reporting Initial Severe Sepsis and Septic Shock: Management Bundle measure endorsed in 2008 Sepsis measure reviewed in 2014 after ProCESS trial published Early CMS announced data collection of measure will begin in late 2015 The ProCESS Investigators. NEJM. 2014

9 Sepsis Modeling in NSQIP Historically, sepsis was included in morbidity in NSQIP modeling Beginning with July 2014 SAR, sepsis modeled as stand alone event Hospitals will know performance on post-operative sepsis distinct from other morbidities

10 Objectives 1. To demonstrate varying rates of post-operative sepsis between surgical procedures 2. To examine sepsis and other morbidities as predictors of mortality 3. To evaluate variation in hospital level postoperative sepsis rates

11 2013 All Surgical Patients in 2013 Hospital Characteristics Associated with Hospital Performance Raw Rates of Post-Operative Sepsis Event 1. All Cases 2. General Cases 3. General/Vascular Cases 4. Colorectal Cases Hospital Performance on post-operative sepsis outcome

12 Raw Rates of Post-Operative Sepsis Colorectal Cases 3.88% General Cases General/Vascular Cases Vascular Cases All Cases 1.49% 1.48% 1.41% 1.12% 0.00% 1.00% 2.00% 3.00% 4.00% 5.00%

13 Factors Associated with Sepsis ASA Class 3 ASA Class 4-5 Smoker Diabetes Inpatient Surgery Steroid Use Totally Dependent

14 Predictors of Mortality All Cases Odds Ratio Cardiac Arrest * Acute MI 3.38* Cerebrovascular Event 12.18* Septic Shock 20.93* Sepsis 3.85* Renal Failure 4.49* Re-Intubation 1.89* Pneumonia 2.58* *p<0.01

15 Predictors of Mortality General Cases Odds Ratio Cardiac Arrest * = Acute MI 1.99* Cerebrovascular Event 9.24* Septic Shock 31.64* Sepsis 4.41* Renal Failure 3.47* Re-Intubation 1.77* Pneumonia 2.01* *p<0.01

16 Exemplary Performing Hospitals Poor Performing Hospitals Hospital Location AGCME Residency Programs Joint Commission Accreditation Teaching Affiliation Bed Size Hospitalists Intensivists Surgical Operations

17 Summary Sepsis continues to be significant contributing factor in serious morbidity and mortality Considerable hospital-to-hospital variation in ability to prevent post-operative sepsis No distinct associations between hospital characteristics and poor or exemplary performing hospitals in postoperative sepsis rates

18 Limitations Modeled only post-operative cases of sepsis removed pre-operative or present at time of operation sepsis NSQIP definitions of sepsis and septic shock are slightly different than standard definitions Actual reason of mortality could be multifactorial

19 Conclusions To improve post-operative sepsis rates, individual hospitals should be aware of their performance Adding sepsis to risk-calculator could help hospitals monitor high-risk patients more closely and intervene more promptly if necessary Further work is needed to identify underlying factors affecting performance on sepsis measure at the hospital level

20 Acknowledgments CQI Team: Karl Bilimoria, MD MS Bruce Hall, MD PhD MBA Cliff Ko, MD MS MSHS Mark Cohen, PhD Lynn Zhou, PhD Sanjay Mohanty, MD MS

21 Thank you!