Effects on Clinical Outcomes of a 5-Year Surgical Safety Checklist Implementation Experience: A Large-scale Population-Based Difference-in-Differences Study.
ABSTRACT: The adoption of a surgical checklist is strongly recommended worldwide as an effective practice to improve patient safety; however, several studies have reported mixed results and a number of issues are still unresolved. The main objective of this study was to explore the impact of the first 5-year period of a surgical checklist-based intervention in a large regional health care system in Italy (4 500 000 inhabitants). We conducted a retrospective longitudinal study on 1 166 424 patients who underwent surgery in 48 public hospitals between 2006 and 2014. The adherence to the checklist was measured between 2011 and 2013 through a computerized database. The effects of the intervention were explored through multivariable logistic regression and difference-in-differences (DID) approaches, based on current administrative data sources. In-hospital and 30-days mortality, 30-days readmissions and length-of-stay (LOS) ?8?days were the observed outcomes. Adherence to the checklist showed marked variations across hospitals (0%-93.3%). A pre/post analysis detected statistically significant differences between surgical interventions performed in hospitals with higher adherence to the checklist (?75% of the surgeries) and those performed in other hospitals, as for the 30-days readmissions rate (odds ratio [OR]: 0.96; 95% confidence interval [CI]: 0.94-0.98) and LOS ? 8?days rate (OR: 0.88; 95% CI: 0.87-0.89). These findings were confirmed after risk adjustment and DID analysis. No association was observed with mortality outcomes. On the whole, our study attained mixed results. Although a protective effect of the surgical checklist use could not be proved over the first 5?years of this regional implementation experience, our research offers some methodological insights for practical use in the evaluation process of large-scale implementation projects.
Project description:Background and purpose - Fast-track care programs in elective total hip and knee replacement (THR/TKR) have been introduced in several countries during the last decade resulting in a significant reduction of hospital stay without any rise in readmissions or early adverse events (AE). We evaluated the risk of readmissions and AE within 30 and 90 days after surgery when a fast-track program was introduced in routine care of joint replacement at 8 Swedish hospitals. Patients and methods - Fast-track care programs were introduced at 8 public hospitals in Västra Götaland region from 2012 to 2014. We obtained data from the Swedish Hip and Knee Arthroplasty Registers for patients operated with THR and TKR in 2011-2015. All readmissions and new contacts with the health care system within 3 months with a possible connection to the surgical intervention were requested from the regional patient register. We compared patients operated before and after the introduction of the fast-track program. Results - Implementation of the fast-track program resulted in a decrease in median hospital length of stay (LOS) from 5 to 3 days in both THR and TKR. The total readmission rate <90 days for THR was 7.2% with fast-track compared with 6.7% in the previous program, and for TKR 8.4% in both groups. Almost half of the readmissions occurred without any AE identified. There was no statistically significant difference concerning readmissions or AE when comparing the programs. Interpretation - Implementation of a fast-track care program in routine care of elective hip and knee replacement is effective in reducing hospital stay without increasing the risk of readmissions or adverse events within 90 days after surgery.
Project description:OBJECTIVE:Patient handovers are often delayed, patients are hardly involved in their discharge process and hospital-wide standardised discharge procedures are lacking. The aim of this study was to implement a structured discharge bundle and to test the effect on timeliness of medical and nursing handovers, length of hospital stay (LOS) and unplanned readmissions. DESIGN:Interrupted time series with six preintervention and six postintervention data collection points (September 2015 to June 2017). SETTING:Internal medicine and surgical wards PARTICIPANTS: Patients (≥18 years) admitted for more than 48 hours to surgical or internal medicine wards. INTERVENTION:The Transfer Intervention Procedure (TIP), containing four elements: planning the discharge date within 48 hours postadmission; arrangements for postdischarge care; preparing handovers and personalised patient discharge letter; and a discharge conversation 12-24 hours before discharge. OUTCOME MEASURES:The number of medical and nursing handovers sent within 24 hours. Secondary outcomes were median time between discharge and medical handovers, LOS and unplanned readmissions. RESULTS:Preintervention 1039 and postintervention 1052 patient records were reviewed. No significant change was observed in the number of medical and nursing handovers sent within 24 hours. The median (IQR) time between discharge and medical handovers decreased from 6.15 (0.96-15.96) to 4.08 (0.33-13.67) days, but no significant difference was found. No intervention effect was observed for LOS and readmission. In subgroup analyses, a reduction of 5.6 days in the median time between discharge and medical handovers was observed in hospitals with high protocol adherence and much attention for implementation. CONCLUSION:Implementation of a structured discharge bundle did not lead to improved timeliness of patient handovers. However, large interhospital variation was observed and an intervention effect on the median time between discharge and medical handovers was seen in hospitals with high protocol adherence. Future interventions should continue to create awareness of the importance of timely handovers. TRIAL REGISTRATION NUMBER:NTR5951; Results.
Project description:Enhanced recovery protocols (ERPs) are standardized care plans of best practices that can decrease morbidity and length of stay (LOS). However, many hospitals need help with implementation. The Enhanced Recovery in National Surgical Quality Improvement Program (ERIN) pilot was designed to support ERP implementation.To evaluate the association of the ERIN pilot with LOS after colectomy.Using a difference-in-differences design, pilot LOS before and after ERP implementation was compared with matched controls in a hierarchical model, adjusting for case mix and random effects of hospitals and matched pairs. The setting was 15 hospitals of varied size and academic status from the National Surgical Quality Improvement Program. Preimplementation and postimplementation colectomy cases (July 1, 2013, to December 31, 2015) were collected using novel ERIN variables. Emergency and septic cases were excluded. A propensity score match identified a 2:1 control cohort of patients undergoing colectomy at non-ERIN hospitals.Pilot hospitals developed and implemented ERPs that included expert guidance, multidisciplinary teams, data audits, and opportunities for collaboration.The primary outcome was LOS, and the secondary outcome was serious morbidity or mortality composite.There were 4975 colectomies performed by 15 ERIN pilot hospitals (3437 before implementation and 1538 after implementation) compared with a control cohort of 9950 colectomies (4726 before implementation and 5224 after implementation). The mean LOS decreased by 1.7 days in the pilot (6.9 [interquartile range (IQR), 4-8] days before implementation vs 5.2 [IQR, 3-6] days after implementation, P?<?.001) compared with 0.4 day in controls (6.4 [IQR, 4-7] days before implementation vs 6.0 [IQR, 3-7] days after implementation, P?<?.001). Readmission did not differ pre-post for the pilot or controls. Serious morbidity or mortality decreased for pilot participants (485 [14.1%] before implementation vs 162 [10.5%] after implementation, P?<?.001), with no difference in controls, and remained significant after risk adjustment (adjusted odds ratio, 0.76; 95% CI, 0.60-0.96). After adjusting for differences in case mix and for clustering in hospitals and matched pairs, the adjusted difference-in-differences model demonstrated a decrease in LOS by 1.1 days in the pilot over controls (P?<?.001).Participating ERIN pilot hospitals achieved shorter LOS and decreased complications after elective colectomy, without increasing readmissions. The ability to implement ERPs across hospitals of varied size and resources is essential. Lessons from the ERIN pilot may inform efforts to scale this effective and evidence-based intervention.
Project description:Importance:Checklists have been shown to improve patient outcomes in surgery. The intraoperatively used World Health Organization surgical safety checklist (WHO SSC) is now mandatory in many countries. The only evidenced checklist to address preoperative and postoperative care is the Surgical Patient Safety System (SURPASS), which has been found to be effective in improving patient outcomes. To date, the WHO SSC and SURPASS have not been studied jointly within the perioperative pathway. Objective:To investigate the association of combined use of the preoperative and postoperative SURPASS and the WHO SSC in perioperative care with morbidity, mortality, and length of hospital stay. Design, Setting, and Participants:In a stepped-wedge cluster nonrandomized clinical trial, the preoperative and postoperative SURPASS checklists were implemented in 3 surgical departments (neurosurgery, orthopedics, and gynecology) in a Norwegian tertiary hospital, serving as their own controls. Three surgical units offered additional parallel controls. Data were collected from November 1, 2012, to March 31, 2015, including surgical procedures without any restrictions to patient age. Data were analyzed from September 25, 2018, to March 29, 2019. Interventions:Individualized preoperative and postoperative SURPASS checklists were added to the intraoperative WHO SSC. Main Outcomes and Measures:Primary outcomes were in-hospital complications, emergency reoperations, unplanned 30-day readmissions, and 30-day mortality. The secondary outcome was length of hospital stay (LOS). Results:In total, 9009 procedures (5601 women [62.2%]; mean [SD] patient age, 51.7 [22.2] years) were included, with 5117 intervention procedures (mean [SD] patient age, 51.8 [22.4] years; 2913 women [56.9%]) compared with 3892 controls (mean [SD] patient age, 51.5 [21.8] years; 2688 women [69.1%]). Parallel control units included 9678 procedures (mean [SD] patient age, 57.4 [22.2] years; 4124 women [42.6%]). In addition to the WHO SSC, adjusted analyses showed that adherence to the preoperative SURPASS checklists was associated with reduced complications (odds ratio [OR], 0.70; 95% CI, 0.50-0.98; P?=?.04) and reoperations (OR, 0.42; 95% CI, 0.23-0.76; P?=?.004). Adherence to the postoperative SURPASS checklists was associated with decreased readmissions (OR, 0.32; 95% CI, 0.16-0.64; P?=?.001). No changes were observed in mortality or LOS. In parallel control units, complications increased (OR, 1.09; 95% CI, 1.01-1.17; P?=?.04), whereas reoperations, readmissions, and mortality remained unchanged. Conclusions and Relevance:In this nonrandomized clinical trial, adding preoperative and postoperative SURPASS to the WHO SSC was associated with a reduction in the rate of complications, reoperations, and readmissions. Trial Registration:ClinicalTrials.gov Identifier: NCT01872195.
Project description:Surgical checklists are increasingly used to improve compliance with evidence-based processes in the perioperative period. Although enthusiasm exists for using checklists to improve outcomes, recent studies have questioned their effectiveness in large populations.We sought to examine the association of Keystone Surgery, a statewide implementation of an evidence-based checklist and Comprehensive Unit-based Safety Program, on surgical outcomes and health care costs.We performed a study using national Medicare claims data for patients undergoing general and vascular surgery (n=1,002,241) from 2006 to 2011. A difference-in-differences approach was used to evaluate whether implementation was associated with improved surgical outcomes and decreased costs when compared with a national cohort of nonparticipating hospitals. Propensity score matching was used to select 10 control hospitals for each participating hospital. Costs were assessed using price-standardized 30-day Medicare payments for acute hospitalizations, readmissions, and high-cost outliers.Keystone Surgery implementation in participating centers (N=95 hospitals) was not associated with improved outcomes. Difference-in-differences analysis accounting for trends in nonparticipating hospitals (N=950 hospitals) revealed no differences in adjusted rates of 30-day mortality [relative risk (RR)=1.03; 95% confidence intervals (CI), 0.97-1.10], any complication (RR=1.03; 95% CI, 0.99-1.07), reoperations (RR=0.89; 95% CI, 0.56-1.22), or readmissions (RR=1.01; 95% CI, 0.97-1.05). Medicare payments for the index admission increased following implementation ($516 average increase in payments; 95% CI, $210-$823 increase), as did readmission payments ($564 increase; 95% CI, $89-$1040 increase). High-outlier payments ($965 increase; 95% CI, $974decrease to $2904 increase) did not change.Implementation of Keystone Surgery in Michigan was not associated with improved outcomes or decreased costs in Medicare patients.
Project description:Aim:In 2014, Memorial Sloan Kettering Cancer Center was identified as an outlier for increased length of stay (LOS) after colorectal surgery. We subsequently implemented a comprehensive Enhanced Recovery After Surgery (ERAS) program in January 2016, which is continually monitored to target areas for improvement. The primary aim of this study was to evaluate the impact of a newly established ERAS program in a high-volume colorectal center over time. Method:This was a retrospective cohort study, comparing 3000 sequential cancer patients who underwent elective colorectal surgery before and after ERAS implementation. Patients were divided into three groups (Pre-, Early, and Late ERAS). Adherence to ERAS process measures and outcomes (LOS, complications, and 30-day readmission) were compared among the three time periods. Results:Adherence to ERAS metrics significantly increased over time, from a median of 25% Pre-ERAS to 67% Early and 75% Late ERAS (p < 0.0001). Mean LOS decreased from 5.2 days Pre-ERAS to 4.5 Early and 4.0 Late ERAS (p < 0.0001). There were no differences in rates of complications or readmissions, and patients with shorter LOS had lower readmission rates. With ERAS, the readmission rate was 4.4% for patients discharged within 3 days, versus >10% for LOS ?5 days (p < 0.0001). Conclusion:Initiation of an ERAS program at a high-volume colorectal center was associated with decreased LOS, without increasing morbidity. Increased ERAS adherence was associated with a further decrease in LOS. Multidisciplinary monitoring to promote protocol adherence is necessary for maintaining a safe and effective ERAS program.
Project description:Importance:As prospective payment transitions to bundled reimbursement, many US hospitals are implementing protocols to shorten hospitalization after major surgery. These efforts could have unintended consequences and increase overall surgical episode spending if they induce more frequent postdischarge care use or readmissions. Objective:To evaluate the association between early postoperative discharge practices and overall surgical episode spending and expenditures for postdischarge care use and readmissions. Design, Setting, and Participants:This investigation was a cross-sectional cohort study of Medicare beneficiaries undergoing colectomy (189?229 patients at 1876 hospitals), coronary artery bypass grafting (CABG) (218?940 patients at 1056 hospitals), or total hip replacement (THR) (231?774 patients at 1831 hospitals) between January 1, 2009, and June 30, 2012. The dates of the analysis were September 1, 2015, to May 31, 2016. Associations between surgical episode payments and hospitals' length of stay (LOS) mode were evaluated among a risk and postoperative complication-matched cohort of patients without major postoperative complications. To further control for potential differences between hospitals, a within-hospital comparison was also performed evaluating the change in hospitals' mean surgical episode payments according to their change in LOS mode during the study period. Exposure:Undergoing surgery in a hospital with short vs long postoperative hospitalization practices, characterized according to LOS mode, a measure least sensitive to postoperative outliers. Main Outcomes and Measures:Risk-adjusted, price-standardized, 90-day overall surgical episode payments and their components, including index, outlier, readmission, physician services, and postdischarge care. Results:A total of 639?943 Medicare beneficiaries were included in the study. Total surgical episode payments for risk and postoperative complication-matched patients were significantly lower among hospitals with lowest vs highest LOS mode ($26?482 vs $29?250 for colectomy, $44?777 vs $47?675 for CABG, and $24?553 vs $27?927 for THR; P?<?.001 for all). Shortest LOS hospitals did not exhibit a compensatory increase in payments for postdischarge care use ($4011 vs $5083 for colectomy, P?<?.001; $6015 vs $6355 for CABG, P?=?.14; and $7132 vs $9552 for THR, P?<?.001) or readmissions ($2606 vs $2887 for colectomy, P?=?.16; $3175 vs $3064 for CABG, P?=?.67; and $1373 vs $1514 for THR, P?=?.93). Hospitals that exhibited the greatest decreases in LOS mode had the highest reductions in surgical episode payments during the study period. Conclusions and Relevance:Early routine postoperative discharge after major inpatient surgery is associated with lower total surgical episode payments. There is no evidence that savings from shorter postsurgical hospitalization are offset by higher postdischarge care spending. Therefore, accelerated postoperative care protocols appear well aligned with the goals of bundled payment initiatives for surgical episodes.
Project description:BACKGROUND:Hospital length of stays (LOS) for incident of hip fracture are decreasing, but it is unknown if these changes have negative impacts on vulnerable older patient populations, like those with Alzheimer's disease (AD). We aimed to assess if persons with and without AD have different hospital LOS for hip fracture, and is the LOS associated with hospital readmissions. METHODS:Utilizing register-based data for a matched cohort study nested in the Medication use and Alzheimer's disease study (MEDALZ), we collected all community-dwelling persons in Finland diagnosed with AD during 2005-2012, had incident of first hip fracture between 2005 and 2015 after AD diagnosis, and were discharged alive from an acute care hospital. Hospital LOS and hospital readmissions within 30-days and 90-days were compared between those with and without AD and risk of readmission was assessed using binary logistic regression analysis. RESULTS:In this matched cohort study of 12,532 persons (mean age 84.6?years (95% CI: 84.5-84.7), 76.8% women), the median LOS in an acute care hospital was 1 day shorter for those with AD (median 4?days, IQR 3-7) than those without AD (median 5?days, IQR 3-7) (P?<?0.001). However, the AD cohort had respectively 6?days and 5?days longer median LOS in a community hospital, and total hospital stay compared to the non-AD cohort (P?<?0.001 for all comparisons). Those with AD had fewer readmissions within 30-days (10.7%) and 90-days (16.9%) compared to those without AD (13.3% 30-days and 20.7% 90-days) (P?<?0.001 for all comparisons). Both cohorts had a reduced readmission risk within 30-days when the LOS in an acute care hospital was 4-14?days, compared to a LOS less than 4?days. CONCLUSIONS:Persons with AD had shorter acute care hospital LOS, but had longer LOS in a community hospital setting compared to those without AD, which is similar to other findings when comparing total hospital LOS. These findings imply that short LOS in acute care hospitals may be associated with poor health outcomes for vulnerable older populations after hip fracture.
Project description:Importance:Ambulatory surgery in geriatric populations is increasingly prevalent. Prior studies have demonstrated the association between frailty and readmissions in the inpatient setting. However, few data exist regarding the association between frailty and readmissions after outpatient procedures. Objective:To examine the association between frailty and 30-day unplanned readmissions after elective outpatient surgical procedures as well as the potential mediation of surgical complications. Design, Setting, and Participants:In this retrospective cohort study of elective outpatient procedures from 2012 and 2013 in the National Surgical Quality Improvement Program (NSQIP) database, 417 840 patients who underwent elective outpatient procedures were stratified into cohorts of individuals with a length of stay (LOS) of 0 days (LOS = 0) and those with a LOS of 1 or more days (LOS ≥ 1). Statistical analysis was performed from June 1, 2018, to March 31, 2019. Exposure:Frailty, as measured by the Risk Analysis Index. Main Outcomes and Measures:The main outcome was 30-day unplanned readmission. Results:Of the 417 840 patients in this study, 59.2% were women and unplanned readmission occurred in 2.3% of the cohort overall (LOS = 0, 2.0%; LOS ≥ 1, 3.4%). Frail patients (mean [SD] age, 64.9 [15.5] years) were more likely than nonfrail patients (mean [SD] age, 35.0 [15.8] years) to have an unplanned readmission in both LOS cohorts (LOS = 0, 8.3% vs 1.9%; LOS ≥ 1, 8.5% vs 3.2%; P < .001). Frail patients were also more likely than nonfrail patients to experience complications in both cohorts (LOS = 0, 6.9% vs 2.5%; LOS ≥ 1, 9.8% vs 4.6%; P < .001). In multivariate analysis, frailty doubled the risk of unplanned readmission (LOS = 0: adjusted relative risk [RR], 2.1; 95% CI, 2.0-2.3; LOS ≥ 1: adjusted RR, 1.8; 95% CI, 1.6-2.1). Complications occurred in 3.1% of the entire cohort, and frailty was associated with increased risk of complications (unadjusted RR, 2.6; 95% CI, 2.4-2.8). Mediation analysis confirmed that complications are a significant mediator in the association between frailty and readmissions; however, it also indicated that the association of frailty with readmission was only partially mediated by complications (LOS = 0, 22.8%; LOS ≥ 1, 29.3%). Conclusions and Relevance:These findings suggest that frailty is a significant risk factor for unplanned readmission after elective outpatient surgery both independently and when partially mediated through increased complications. Screening for frailty might inform the development of interventions to decrease unplanned readmissions, including those for outpatient procedures.
Project description:Background and purpose - Fast-tracking shortens the length of the primary treatment period (length of stay, LOS) after total knee replacement (TKR). We evaluated the influence of the fast-track concept on the length of uninterrupted institutional care (LUIC) and other outcomes after TKR. Patients and methods - 4,256 TKRs performed in 4 hospitals between 2009-2010 and 2012-2013 were identified from the Finnish Hospital Discharge Register and the Finnish Arthroplasty Register. Hospitals were classified as fast track (Hospital A) and non-fast track (Hospitals B, C and D). We analyzed length of uninterrupted institutional care (LUIC), LOS, discharge destination, readmission, revision, manipulation under anesthesia (MUA) and mortality rate in each hospital. We compared these outcomes for TKRs performed in Hospital A before and after fast-track implementation and we also compared Hospital A outcomes with the corresponding outcomes for the other 3 hospitals. Results - After fast-track implementation, median LOS in Hospital A fell from 5 to 3 days (p < 0.001) and (median) LUIC from 7 to 3 (p < 0.001) days. These reductions in LOS and LUIC were accompanied by an increase in the discharge rate to home (p = 0.01). Fast-tracking in Hospital A led to no increase in 14- and 42-day readmissions, MUA, revision or mortality compared with the rates before fast-tracking, or with those in the other hospitals. Of the 4 hospitals, LOS and LUIC were most reduced in Hospital A. Interpretation - A fast-track protocol reduces LUIC and LOS after TKR without increasing readmission, complication or revision rates.