549761
research-article2014
AJMXXX10.1177/1062860614549761American Journal of Medical QualityCounihan et al
Article
Surgical Multidisciplinary Rounds: An Effective Tool for Comprehensive Surgical Quality Improvement
American Journal of Medical Quality 1–7 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1062860614549761 ajmq.sagepub.com
Timothy Counihan, MD, FACS, FASCRS1, Monique Gary, DO1, Enrique Lopez, MD1, Sharyl Tutela, BSN1, Gray Ellrodt, MD1, and Richard Glasener, RN1
Abstract An analysis of outcomes, quality, and survey data was carried out to evaluate the impact of surgical multidisciplinary rounds (SMDR) at a community teaching hospital. Surgical inpatients were reviewed over a 4-year period. Realtime changes to clinical care, documentation, and programs were enacted during the rounds. SMDR contributed to reductions in length of stay (6.1 to 5.1 days), postoperative respiratory failure (15.5% to 6.8%), deep venous thrombosis/pulmonary embolism (2.8% to 2.3%), cardiac complications (7.0% to 1.6%), and catheter-associated urinary tract infection (5.2% to 1.5%), and increased Surgical Care Improvement Program All-or-None compliance (95.6% to 98.7%). Additionally, SMDR increased awareness of Accreditation Council for Graduate Medical Education core competencies among surgical residents and was associated with enhanced job satisfaction among participants. Twiceweekly SMDR is an effective care paradigm that has changed culture, improved care coordination, and facilitated rapid, sustained process improvement along multiple patient safety indicators and core measures. Keywords surgical multidisciplinary rounds, ACS-NSQIP, quality improvement The complexity of health care delivery has drastically increased throughout the first decade of the 21st century. In efforts to improve patient safety, the Centers for Medicare & Medicaid Services (CMS) and the Agency for Healthcare Research and Quality (AHRQ) have called for an environment of transparency and public reporting of many different quality indicators.1 Health care reform has created a payment system now directly linked to both the reported process measures and outcomes.2 The need for rapid and sustained quality improvement in this environment has become paramount to the success of health care organizations. With the explosion of medical information, clinicians are challenged to adjust their care to reflect evidence-based best practice.3 To address these issues simultaneously, the study hospital developed a system of evaluating each patient on a periodic basis during hospitalization. Originally developed within the Department of Medicine to address CMS core measures and the American Heart Association’s Get With the Guidelines compliance, this multidisciplinary process resulted in measurable improvements in care of medical inpatients.4 In an effort to reap similar benefits, this collaboration was employed within the Department of Surgery. In other centers, a multidisciplinary approach to
the management of surgical patients has been documented within limited, specific surgical settings,5,6 but no comprehensive program has been reported that addresses all surgical inpatients. The multidisciplinary meeting at the study institution is a patient-focused communication system integrating care using concurrent feedback, redundancy, and rapid-cycle improvement. All the frontline stakeholders of care delivery are involved. The primary goal of this study is to characterize the process of surgical multidisciplinary rounds (SMDR) and to evaluate the overall effect on improving the quality of care for surgical inpatients. The study also sought to evaluate employee satisfaction among members of the team and the impact of SMDR on the American Council of Graduate Medical Education (ACGME) core competency of systems-based practice in residents participating in rounds. 1
Berkshire Medical Center, Pittsfield, MA
Corresponding Author: Timothy Counihan, MD, FACS, FASCRS, Berkshire Medical Center, Department of General Surgery, 725 North Street, Pittsfield, MA 01201. Email:
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Table 1. Issues Addressed During Surgical Multidisciplinary Rounds. Monitoring evidence-based approach to programs: total joint, bariatric, trauma, fast track colon surgery, etc Detecting complications earlier Complying with preoperative lab testing guidelines Code status documentation Appropriate admission status (observation vs inpatient) Antibiotic stewardship Risk stratification and anticoagulation bridging Reducing unnecessary medications (eg, proton pump inhibitors) Documentation of multidisciplinary care for JCAHO Discharge planning SCIP compliance Foley initiative Comorbidity and present-on-admission coding Assessment for medical comanagement Abbreviations: JCAHO, Joint Commission on Accreditation of Healthcare Organizations; SCIP, Surgical Care Improvement Program.
Methods A multidisciplinary group consisting of all essential members of the patient care team was convened twice weekly for one hour to comprehensively review inpatient care practices. These participants included the chairman of surgery (or attending designee), the charge nurse from the surgical ward, hospital quality improvement representatives, electronic health records and clinical documentation/coding specialists, surgical residents and/or physician extenders, perioperative nursing leadership, a pharmacist, and a surgical case manager. During the conference a surgical resident or physician assistant presented each inpatient to the group while the patient’s electronic medical record (EMR) was systematically evaluated. A large screen facilitated review of vital signs, medications, comorbid conditions, operative reports, laboratory results, imaging, Surgical Care Improvement Program (SCIP) compliance measures, coding, and documentation. Use of standardized order sets and adherence to various programs was addressed. Input from the various stakeholders was solicited. The issues commonly monitored and discussed are listed in Table 1. Recommendations were made to the presenting clinical team member for discussion with the attending regarding patient management. Additionally, the EMR was reconciled to include necessary documentation. It is important to note that the amount of time and attention directed to each patient’s review varies based on (a) the patient’s condition and hospital course and (b) the pathway/protocol to which patients are assigned (eg, bariatric protocol, fast-track colon protocol, robotic prostatectomy/nephrectomy). For the latter patients, as the
EMR is displayed, a single sentence such as “postop day 1 lap gastric bypass, on protocol” might be the only discussion. Members of the service will have reviewed any issues on wards prior to SMDR, and if there are no problems to address, the team moves to the next patient. To further expedite reviews, some services are discussed only once a week. For instance, all elective total joint replacements are done by Wednesday afternoon to facilitate discharge prior to the weekend, so this service is reviewed on Thursday only. Using a very disciplined approach to presenting uncomplicated patients, the team is able to spend more time discussing the more complicated patients, with each aspect of the EMR systematically reviewed and relevant input obtained from the stakeholders present. As an example, this input might include selection of appropriate antibiosis, documentation of present-on-admission comorbidities, review of patient volume status and electrolyte abnormalities, glycemic control, and ability of patients to meet criteria for discharge. In general, approximately 30 patients are reviewed during each session, and the time spent per patient is weighted and proportionate to the complexity of the patient’s condition. To evaluate the impact of this program on outcomes over a 4-year period, the SCIP All-or-None composite score, AHRQ measures of respiratory failure and deep venous thrombosis/pulmonary embolism (DVT/PE), mortality, adjusted hospital length of stay (ALOS), and complication codes for respiratory, urinary, and cardiac complications were assessed. These were selected from the hospital’s computerized administrative database (MIDAS) for evaluation because of the potential ability of SMDR to directly affect these measures. Of note, commonly reported and closely monitored central line–associated bloodstream infections and ventilator-associated pneumonias were not selected in this study because of infrequency at the study institution during the study period, with surgical patient rates as low as 1 to 2 a quarter. Though discussed within the context of the weekly SMDR, these cases were referred to other hospital committees for review. All inpatients on the surgical service were included in this administrative data review. Data from calendar years 2008 and 2011 were compared using 2-sample percent defective t test. To validate findings based on the review of administrative data, outcomes from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) during the same time period were evaluated. Annual risk-adjusted odds ratios for complications were compared to detect a possible trend in improvement. To assess the SMDR effects on one specific initiative, the study team reviewed the frequency of catheter-associated urinary tract infection (CAUTI), which utilized SMDR reporting and surveillance as a primary tool for
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Counihan et al Table 2. Administrative Surgical Quality Data. Measure a
SCIP All-or-None % AHRQ—PO Resp Failure AHRQ—PO DVT/PE Surgery ALOS (days) Complication code/1000 admissions Respiratory complications Urinary complications Cardiac complications
2008
2009
2010
2011
P Value
95.6 15.5 2.8 6.1
95.8 10.6 6 6.1
95.4 9 4.1 5.5
98.7 6.8 2.3 5.1
P < .0001 P = .051 P = .485 P = .007
11.3 5.2 7.0
6.9 5.4 10.3
4.9 3.8 0.5
3.6 1.6 1.6
P = .003 P = .038 P = .007
Abbreviations: AHRQ, Agency for Healthcare Research and Quality; ALOS, adjusted length of stay; DVT/PE, deep venous thrombosis/pulmonary embolism; PO, postoperative; SCIP, Surgical Care Improvement Program. a Total n increased from 3 to 10.
intervention. To investigate the effect of SMDR on members of the team, the Press Ganey employee satisfaction survey was administered, and responses were compared with institutional and nationwide employee responses. Surgical resident–reported competency in systems-based practice was assessed utilizing a survey administered to incoming surgical house officers in 2012 before they began participating in SMDR, and again after 12 weeks. A 5-point Likert-type scale was used to quantify resident responses to questions regarding their understanding of national quality improvement initiatives, the ACGME core competency systems-based practice, roles, values, and perceptions within the heath care team.
Results Administrative Data Administrative data for AHRQ DVT/PE and respiratory failure, SCIP All-or-None composite score, and complication codes for respiratory, cardiac, and urinary complications are shown in Table 2. In the first 4 years following implementation of SMDR, a 3-fold increase in the total number of institutionally reported SCIP measures occurred. Despite this, compliance with SCIP measures increased from 95.6% to 98.7% (P < .0001). There were decreases in postoperative respiratory failure (8.7% decrease, P =.051) and postoperative DVT/PE (decrease of 0.5 day per 1000 patient days, P = .485). A reduction in ALOS by 24 hours (P = .007) was observed. Complication codes (per 1000 admissions) for respiratory, urinary, and cardiac complications in surgical patients decreased significantly (P = .003, .038, and .007, respectively).
Clinical Data For clinical validation of administrative quality data, the ACS-NSQIP database was utilized. Risk-adjusted results for 600 to 1200 general/vascular patients per year from
Table 3. ACS-NSQIP Results: Risk-Adjusted Odds Ratios (General/Vascular). Year
2008
2009
2010
2011
Mortality Morbidity Cardiac Pneumonia Unplanned intubation Ventilator >48 hours DVT/PE Renal failure UTI SSI
1.47 1.11 0.96 0.72 2.25 2.23 0.87 1.42 0.97 0.95
1.51 1.07 1.44 1.23 1.53 0.82 0.65 0.95 2.02 0.97
1.29 1.03 0.92 1.12 0.86 0.84 0.75 1.01 1.13 1.08
1.04 0.94 0.70a 1.07 0.84a 0.70a 0.92 0.94 1.13 0.80
Abbreviations: ACS-NSQIP, American College of Surgeons National Surgical Quality Improvement Program; DVT/PE, deep venous thrombosis/pulmonary embolism; SSI, surgical site infection; UTI, urinary tract infection. a Confidence interval does not reach 1.0, indicating statistical significance.
the study institution were entered prospectively into the database over the 4-year period (Table 3). In 2008, the reported odds ratios for morbidity, mortality, unplanned intubation with subsequent prolonged mechanical ventilation (>48 hours), as well as incidence of renal failure in postoperative patients were substantially greater than expected. By 2010, with the exception of urinary tract infection and pneumonia, after implementation of SMDR for each category listed there was a decrease in the riskadjusted odds ratio with trends toward the expected (1.0), which by 2011 continued to trend, reaching statistical significance for cardiac, unplanned intubation, and ventilator dependence (>48 hours) reporting. After the observed 2-fold incidence in likelihood of developing a urinary tract infection from 2008 to 2009, a separate prospective initiative to prevent CAUTIs was implemented (Figure 1). Using SMDR for biweekly reporting, surveillance for compliance, and documentation of
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American Journal of Medical Quality Catheter Associated Urinary Tract Infections (CAUTI) Monthly April 2010 to June 2012 MDPI UCL=6.35 6
Number of Infections
UCL=4.28 4
_ X=2.63
2
_ X=0.82
0 LCL=-1.10 -2 LCL=-2.64 Apr 2010
Jul 2010
Oct 2010
Jan 2011
Apr 2011
Jul 2011
Oct 2011
Jan 2012
Apr 2012
Month
Figure 1. Six Sigma control chart showing monthly number of infections.
Abbreviations: LCL, lower control limit; MDPI, Multidisciplinary Performance Improvement Conference; UCL, upper control limit.
Foley catheter insertion criteria, timely removal, and the presence of a CAUTI, there was a decrease in CAUTIs from a mean of 2.59 in 2010 to 0.8 in 2011.
Survey Data Secondary outcomes of participant job satisfaction (as reported by Press Ganey employee survey) and resident core competency learning also were examined in association with SMDR. The hypothesis was that job satisfaction among team members of SMDR would be high because of the rewarding nature of working in a collaborative manner. Figure 2A shows that SMDR participants reported much higher satisfaction scores when compared to the study institution’s employees and across the health care system at large. Participants specifically cited a greater sense of accomplishment, opportunities for innovation and creativity, perceived job meaningfulness, and increased overall satisfaction. Results from surveys administered to incoming surgical residents were tabulated, and those questions most relevant to SMDR are reported in Figure 2B. Twelve weeks after the onset of SMDR, all new surgical house staff reported SMDR enhanced competency in systemsbased practice, there was a greater appreciation for the roles within the multidisciplinary team, and, most notably, a working knowledge of NSQIP, SCIP, and AHRQ within the context of importance to both the profession and to patient care.
Discussion The concept of “rounds” predates the advent of modern medical education, with roots extending as far back as Hippocrates, whose methodology included principles that admonished trainees to (a) observe all and (b) study the patient rather than the disease.7 Although the practice of rounding within disciplines has persisted, the more inclusive, interdisciplinary approach to patient care has gained popularity only recently. This approach has been studied and proven beneficial in a number of inpatient settings.4,8-11 Measurable outcomes such as shorter length of stay, improved morbidity and mortality, and decreased pulmonary complications (ventilator-associated infections, acute respiratory distress syndrome) have been reported in trauma, orthopedic, cardiac surgery, and critical care programs that utilize a format including care providers across multiple specialties and all points of patient care.5,12-14 Berkshire Medical Center applied this multidisciplinary approach to the care of all medical inpatients. Initially, the primary focus was to improve process measures such as the American Heart Association’s Get With the Guidelines program and CMS core measures related to acute myocardial infarction and community-acquired pneumonia.4 The Department of Surgery established its own twice-weekly review to evaluate patients and their clinical course with all invested clinical stakeholders, based on these successes and a need to meet similar quality benchmarks.
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Counihan et al Berkshire Medical Center Employees Mean
SMDR Attendees
National 90th (Mean)
My work gives me a feeling of accomplishment.
100% (n=13)
91.6%
(n=1230)
86.70%
My work provides me an opportunity to be creative and innovative.
92% (n=13)
76.8%
(n=1228)
80.70%
My work is meaningful.
100% (n=13)
95.2%
(n=1230)
89.10%
Overall, I am satisfied with my job.
100% (n=13)
86.1%
(n=1230)
84.50%
Figure 2A. Press Ganey employee survey results.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
1
2
3
4
5
Pre
50%
50%
Post
25%
75%
4
5
Participation holds educational value as a new surgical resident
Feel competent understanding and utilizing systemsbased practices
1
Pre
2
3
25%
75%
Post Understands role within the multidisciplinary team
1
2
Pre
75%
25%
3
4
5
75%
25%
Post Can define NSQIP, SCIP and AHRQ; understand significance to surgical training and patient care
1
2 75%
Pre
3
75%
25%
4
5 25% 100%
Post
Figure 2B. 12-week pre and post SMDR resident survey results.
Abbreviations: AHRQ, Agency for Healthcare Research and Quality; NSQIP, National Surgical Quality Improvement Program; SCIP, Surgical Care Improvement Program; SMDR, surgical multidisciplinary rounds.
SCIP was a national partnership established in 2005 to reduce surgical morbidity and mortality by 25% over a 5-year period. Many of these measures have been incorporated into CMS Value-Based Purchasing. Although compliance with individual SCIP measures has not correlated with improved outcomes, higher SCIP All-or-None composite scores have been associated with a lower probability of postoperative infection.7,15 Tracking compliance with SCIP measures can be labor intensive, and the SMDR format has assisted with both monitoring and trending compliance, and it has allowed the surgical program at the study institution to achieve and maintain excellence in this important area. The administrative data collected from 2008 to 2011 showed the positive effects of SMDR on AHRQ patient safety data such as postoperative DVT and respiratory
failure. The data also revealed that implementation of SMDR decreased length of stay and complications. Furthermore, SMDR allowed real-time effect on patient care by allowing dialogue about quality measures, systemsbased practice, and evidence-based medicine between the departments responsible for the care of the patient. Although having improvement in publically reported measures is critical to any organization, one of the limitations to administrative data is that improvement in results could be related primarily to better documentation and coding and not related to actual improvement in outcomes. This fact led the study group to also use NSQIP to evaluate the results. The ability to carry out quality improvement programs based solely on administrative data has been challenged by several authors.16,17 To validate this study’s findings,
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the study team used NSQIP, a high-fidelity, nationally validated, prospective database containing patient preoperative risk, intraoperative events, and 30-day postoperative morbidity and mortality. Details of the NSQIP data abstraction, data quality, sampling strategy, variables collected, and outcomes measured have been described previously.18-20 When risk adjusted, improvement in outcomes was still observed in patients at the study institution. The Press Ganey employee survey measures employee attitudes toward their organization, leadership, job performance, and satisfaction. These reports are often utilized by health care systems to develop strategies to enhance workplace cohesiveness, communication, and overall organizational performance. Comparison of the surgical team with the rest of the institution and nationwide data looking at questions related to professional satisfaction suggested that employees who were members of the SMDR team reported enhanced job satisfaction among SMDR participants when compared to their colleagues. This positive effect is critical if an organization wants ongoing, meaningful participation in SMDR. The ACGME has outlined in detail the requirements for successful transition from resident to practicing physician, providing core competencies that must be mastered prior to completion of residency training. The core competency systems-based practice is defined as “an awareness of and responsiveness to both the larger context and system of healthcare as well as the ability to effectively call on system resources to provide care that is of optimal value.”21 Given the multidisciplinary and quality improvementfocused nature of SMDR, the survey results in the present study suggest that participation provides an efficient method to enhance knowledge of systems-based practice. There is great interest in expanding knowledge in this area by trainees22,23; however, duty hour restrictions have negatively affected these desires.24 Efforts to teach this specific core requirement reported in one study were labor intensive, spanning several months as an independent research project.23 Others have been less comprehensive, consisting of weekly morbidity and mortality conferences,25,26 or daily “running the list” with a nursing supervisor and case manager.27 However, given the time and resource constraints placed on both clinical practice and resident work hours, the study team chose to try and teach systems-based practice within the framework of their actual continuous quality improvement process. SMDR seems to be the best format to reconcile these needs. The residency review committee in surgery also recently mandated surgical resident involvement in quality improvement programs. The SMDR has enhanced resident understanding of quality improvement initiatives and introduced multidisciplinary, comprehensive, evidence-based care into the daily clinical practice of trainees.
This study has several limitations that must be taken into account. Variability, bias, and even error in the coding of hospital administrative data is well reported,16,28,29 leaving the utility of such databases controversial in clinical quality improvement.17,29 Although national collaborative databases such as the National Inpatient Sample, national trauma registries, and even NSQIP have provided much needed standardization to address many of these variables, a growing number of limitations of these databases have been reported and must be considered.30 Using NSQIP to validate the administrative data when possible helped mitigate the potential weaknesses of the study team’s administrative data. Furthermore, SMDR does not have the ability to affect outcomes that occur because of preoperative factors such as adequate risk modifications (eg, smoking cessation, cardiac optimization). SMDR also cannot affect many of the AHRQ Patient Safety Indicators such as hemorrhage, organ laceration, iatrogenic pneumothorax, or wound dehiscence because they occur at the time of a procedure.
Conclusion Twice-weekly surgical multidisciplinary rounds are an effective instrument to improve surgical care. SMDR has helped change the culture, improved coordination of care, and facilitated rapid and sustained process improvement in an efficient and reproducible format. As an integral part of a comprehensive quality program, SMDR contributed to improved patient safety indicators, core measures, and the reduction of length of stay and complications in surgical inpatients. Furthermore, inherent in its format lie many “teachable moments” to ensure that surgical residents master ACGME core competencies without requiring additional time, projects, or resources. Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
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