ACS NSQIP Coalition for Quality in Geriatric Surgery Project

Transcription

1 ACS NSQIP Coalition for Quality in Geriatric Surgery Project Julia BerianMD, MS; Marcia McGory-Russell MD; JoAnn Coleman, DNP, ANP, ACNP, AOCN; Emily Finlayson MD, MS; Mark Katlic, MD; Sandhya Lagoo-DeenadayalanMD, PhD; Thomas Robinson MD, MS; Victoria Tang MD, MAS; Ronnie A. Rosenthal MD,MS & Clifford Y. Ko

2 Disclosure Slide James C. Thompson Geriatric Surgery Fellow, position supported by the John A. Hartford Foundation & American College of Surgeons

3 The Coalition for Quality in Geriatric Surgery Project Goal: To develop a comprehensive, systematic program that will improve the quality of surgical care for older adults Eligibility: All hospitals regardless of size, location or teaching status

4 Primary Discussion Points Why improve quality in geriatric surgery? What would a quality program look like? How are we building it?

5 Primary Discussion Points Why improve quality in geriatric surgery? What would a quality program look like? How are we building it?

6 The population is aging Roughly 10,000 adults turned 65 today The same tomorrow x19 years

7 Older adults have lots of surgery Disproportionate share of surgical procedures: 38% or 19.2 million procedures Worse outcomes with age: CDC NHDS 2010 Operative mortality, by procedure and age. Light gray bar, aged 65 to 69 years; dark gray bar, aged 70 to 79 years; black bar, aged 80 years. Finlayson, Fan, Birkmeyer J Am Coll Surg 2007; 205:

8 And different priorities Decision-making in chronic illness: 75-89% would forgo lifesaving treatment if it meant severe functional or cognitive impairment Fried et al NEJM

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10 Structured literature review 21-member multidisciplinary panel 4-rounds of consensus panel sessions Pre-Op Assessment Cardiac / Pulmonary Cognition Depression Delirium risk Alcohol / substance use Functional status / falls Frailty Nutritional status Goals /Expectations for treatment Social support system

11 Audience Response How many of you perform a geriatric assessment at your hospital? A. Yes! B. Well, yes I just use the eyeball test C. Do medical comorbidities count?

12 Immediate Preoperative 6 Recommendations Post-Op Care Intraoperative 9 Recommendations Postoperative 8 Domainsincluding 35 Recommendations Similar methodology from Pre-Op BPG Structured literature review 28-member multidisciplinary panel 3 phases of care

13 Guidelines are a necessary first step, but are not sufficient to truly change care

14 Primary Discussion Points Why improve quality in geriatric surgery? What would a quality program look like? How are we building it?

15 Primary Discussion Points Why improve quality in geriatric surgery? What would a quality program look like? How are we building it?

16 The American College of Surgeons Quality Programs

17 Four Guiding Principles of Continuous Quality Improvement 1. Set the Standards - Highest clinical standards - Based on evidence - Individualize to the patient 3. Collect Robust Data - From medical charts - Post-discharge tracking - Continuously updated - Risk adjusted 2. Build the Right Infrastructure - Appropriate, adequate staffing levels, specialists, equipment and IT systems 4. Verify through a Third Party - External peer review - Establish public assurance

18 Quality Programs Improve Outcomes 18 level-1 trauma hospitals compared to 51 non-trauma hospitals 5191 pts After case-mix adjustment, in-hospital mortality and one-year mortality rates significantly lower in trauma centers 20 to 25% reduction in risk of death! NEJM :366-78

19 Primary Discussion Points Why improve quality in geriatric surgery? What would a quality program look like? How are we building it?

20 Primary Discussion Points Why improve quality in geriatric surgery? What would a quality program look like? How are we building it?

21 Project Goals & Deliverables Engage Key Stakeholders Set the Standards Develop Measures that Matter

22 Project Goals & Deliverables Develop the Verification Process to Ensure Delivery of High Quality Care Educate Patients and Providers Pilot the Program Launch the Geriatric Surgery Quality Campaign

23 AARP ACS Advisory Council for Rural Surgery ACS Committee on Surgical Palliative Care Aetna AMDA The Society for Post Acute and Long Term Care Medicine American Academy of Ophthalmology American Academy of Orthopaedic Surgeons/American Association of Orthopaedic Surgeons American Academy of Otolaryngology American Academy of Physical Medicine and Rehabilitation American College of Emergency Physicians American College of Physicians American Geriatrics Society American Hospital Association, Health Research & Educational Trust American Society of Anesthesiologists American Society of Consultant Pharmacists American Society of Health-System Pharmacists American Society of PeriAnesthesia Nurses American Urological Association Association of perioperative Registered Nurses Association of VA Surgeons Carealign Case Management Society of America Center to Advance Palliative Care Centers for Medicare and Medicaid Services Eastern Association for the Surgery of Trauma Family Caregiver Alliance Florida Hospital Association Geriatrics for Specialists Initiative Gerontological Advanced Practice Nurses Association Hartford Institute for Geriatric Nursing Hospital Elder Life Program Kaiser Permanente Memorial Sloan Kettering Cancer Center National Association of Social Workers National Committee for Quality Assurance National Gerontological Nursing Association Nurses Improving Care for Healthsystem Elders Patient and Family Centered Care Partners Penn Medicine Department of Anesthesiology & Critical Care Pharmacy Quality Alliance Society for Academic Emergency Medicine Society of Critical Care Medicine Society of General Internal Medicine Society of Hospital Medicine The American Association for the Surgery of Trauma The American Board of Surgery The American Congress of Obstetricians and Gynecologists The Beryl Institute The Gerontological Society of America The John A. Hartford Foundation The Society of Thoracic Surgeons UAB The Division of Gerontology, Geriatrics and Palliative Care University of Chicago the MacLean Center for Clinical Medical Ethics University of Colorado/Care Transitions University of Pittsburgh Medical Center University of Wisconsin School of Medicine & Public Health US Department of VA Geriatrics and Extended Care Yale New Haven Patient Experience Council

24 Literature Review Goals & Decision- Making Clinical Care 210 Pre-op Optimization Transitions of Care

25 Audience Question 2. Surgical skill being equal,i would prefer my elderly family member, friend or colleague receive surgical careat an institution with standardized, thoughtful pathways to promote cognitive and functional outcomes. For example, that might beastandardized protocol for identifying older adults athigh-risk for delirium preoperatively, and a pathway forpreventing, detecting and managing delirium postoperatively. A. Strongly disagree - do not think that such pathways make any difference B. Disagree C. Neutral D. Agree E. Strongly Agree -an organized approach to adverse outcomes is important to me (even if it cannot always prevent the event)

26 Standards Development Process Stakeholder Input (58) Literature Review (100s) & Pre- and Peri-Op Guidelines Targeted Stakeholder Calls (20) Preliminary Standards Hospital Field Visits (11)

27 Field Visits across the U.S.A 11 Hospitals 7 Cities 4 Community-based 3 Academic centers 1 ACO System 1 VA 1 Safety Net 1 Rural

28 100+ People interviewed Administrative Leadership CEO, CNO, COO Chiefs/Chairs of Surgery, Medicine, Anesthesia Directors of Nursing, Education Quality & Safety Team Quality Officers, Data Abstractors Frontline Providers Surgical Staff Medical Staff PT/OT, behavioral health Care Transitions Team Members Patient Experience Team, Patient Navigator

29 What we found Shared perceptions Older adults require special efforts Lack of clarity on what that entails Variability Some standard approaches to falls and delirium Overall lack of standardized processes for older surgical patients Siloed care leads to problematic transitions

30 Preliminary Standards Section 1: Continuum of Care Goal Setting & Decision Making (1-29) Preop Optimization (30-118) Transitions of Care ( ) Section 2: Clinical Care Immediate Preop( ) Intraop( ) Postop ( ) Section 3: Program Management ( ) Section 4: Outcomes & Follow Up ( )

31 RAND/UCLA Appropriateness Methodology CQGS Adaptation: Criteria 1) Validity 2) Feasibility Analysis: Median rating Measure of agreement

32 Overview of Preliminary Results Strong support for majority of standards 52/308 (17%) were uncertain Primary areas of uncertainty: Preoperative screening for high risk patients Multidisciplinary preoperative conference Uncertainty mostly in feasibility vs. validity

33 Measures that Matter

34 NSQIP Geriatric Surgery Pilot Four domains: Function Pre Origin from home with support Baseline living status among patients admitted from home (lives alone at home, lives with support in the home, origin status is not from home) Mobility Post Use of mobility aid at discharge Mobility at discharge (new use of mobility aid, walker / cane at the time of discharge yes/no) Cognition Decision Making Post Pre Postoperative delirium Competency status on admission Delirium is present if there are one or more episodes of acute confusion during the hospital stay Capacityto consent for procedure (consent signed by patient or by surrogate yes/no)

35 Next Steps Round 2 Stakeholder Ratings Analysis Prioritization among many important standards Measures & Education development Pilot the Program!

36 Acknowledgements Dr. Jeffrey Matthews Dr. Mitchell Posner Dr. Kevin Roggin Dr. David Hoyt Dr. Clifford Ko Dr. Ronnie Rosenthal Drs. Marcia Russell, Mark Katlic, Tom Robinson, Emily Finlayson, Sandhya Lagoo-Deenadalayan, JoAnn Coleman, Victoria Tang and Sanjay Mohanty Sameera Ali, Tracey Baker and Kitty Vineyard Marcus Escobedo

37 Questions?