Wednesday, June 03, 2009

Trite but True

I must admit that the idea of sifting through reams of data makes me slightly nauseated. And antsy. And irritated. Let's just say it ain't my thing. But, as they say, somebody has to do it, and I'm all for that. Because sometimes sifting yields a little golden nugget --- the trick is to figure out if it is real gold or only pyrite.

A lotta data has been generated by the American College of Surgeons' NSQIP program --- the National Surgical Quality Improvement Program. While I have quibbles with some aspects of NSQIP, particularly about patient risk stratification, it is a laudable attempt to gather enough clinical information to steer patient care in the right direction. With the data that has been rounded up to date, the data analyzers have been able to start identifying hospitals that are outliers in certain areas, basically those with higher than or lower than expected complication and mortality rates. Figuring out what makes those facilities tick in a positive or negative direction is the whole goal of the program, so that every facility gets information to improve patient care delivery.

At the most recent Academic Surgical Congress, NSQIP data analysis of Medicare patients undergoing colectomy from 2005-2006 was presented. A total of 12,688 patients in 123 hospitals undergoing colectomy were included (article in ACS Surgery News). The reviewers looked at not only specific complication rates and risk-adjusted mortality rates, but also at the mortality rates following those complications -- what they termed as "failure to rescue."

High-mortality hospitals were found to have a 1.5-fold greater risk of postsurgical complications --- that stands to reason. However, there was not a linear association with increasing rates of complications and increasing mortality ---- the higher mortality facilities had a rate of mortality associated with postsurgical complications that was more than twice that of low mortality facilities (26% versus 11%).

What, exactly, does that mean? It means that a certain percentage of patients are going to have complications, and that complications are more frequent in higher-mortality hospitals. But it also means that if a patient has a complication in a higher-mortality hospital, their likelihood of mortality is greater than if they had a complication at a lower-mortality hospital. An unwelcome double whammy, to say the least

Why might that be the case? Here is where the trite but true saying comes into play --- it takes teamwork to get patients successfully through a hospitalization. Avoidance of postoperative complications starts well before surgery, with appropriate preoperative evaluation and testing; this includes the assistance of other physicians (cardiologists, pulmonologists, etc.) and staff (following protocols for preop lab and EKGs, initiation of DVT prophylaxis, etc.). In the OR, having a team approach is critical to minimize the risks for excess blood loss, prolonged OR time, avoidance of temperature loss, etc., ad infinitum. Postoperative care is crucial, with nurses, physical and respiratory therapists, and physicians being attentive to mobilization, pulmonary toilet, glucose get the picture.

"Failure to rescue" then may occur with any person or department involved in a patient's care --- the nurse who doesn't recognize that a patient's low blood pressure may indicate bleeding; the respiratory therapist who thinks a patient with worsening respiratory function will do OK through the night; the physician who doesn't see a patient who is doing a bit more poorly than expected in a timely fashion; the blood bank that doesn't get needed products to the patient's bedside quickly enough; failure to implement protocols to deal with DVT prophylaxis, antibiotic prophylaxis, ventilator management, etc.

To draw on the current phraseology of hospital management-types, it boils down to culture. Hospitals with lower mortality rates, I suspect, aggressively engender a culture of high expectations, where everyone down the line understands how important of a role they play on the team. High expectations come with accountability, and the squishiness of some administrators when it comes to meting out that accountability can lead to poor outcomes. That accountability must also apply to the physicians, and a physician culture that demands the best for our patients in our hospitals --- from the physicians and staff alike --- pays big dividends.