MBSC Meeting

1. MBSC Meeting October 1st, 2010

2. Welcome/updates John Birkmeyer, MD

3. Updates Move to NCRC New hospitals joining collaborative - Doctor�s Hospital of Michigan - Ingham Regional Medical Center - St. Joseph Mercy Oakland Hospital - William Beaumont Hospital, Grosse Pointe JAMA clip BliNDS IRB approval

4. MBS Update Wayne English, MD

5. Coordinator Updates Amanda O�Reilly, RN

6. Orientation to Meeting Binder

7. - Calling patients using locator web site- Obtain new addresses, phone numbers from the sites- Gather weights at site visits- Sites participate in asking patients to complete the surveys during the annual follow-up appointments Follow-up Rates

11. Problems recognized during site visitsAreas most commonly abstracted incorrectly: - Smoking - VTE prophylaxis - Graded complicationsMeasures to improve accuracy: - repeated site visits - educating data abstractors  - refresher course - providing sites with reports, asking them to go back and abstract the data after education has occurred during the site visit Data Accuracy Issues:

12. Nancy Birkmeyer, PhD Highlights from Reports New Analyses

13. MBSC Clinical Registry

14. Trends in Procedure Mix

15. Risk Factors for Serious Complications

16. Ideas for analyses from June meeting What specific complications are related with surgeon and hospital volume? Do surgeons that operate at different hospitals have similar rates of complications in each of the hospitals? What is the relationship between the length of the case (OR time) and risk of complications?

17. What specific complications are related with surgeon and hospital volume?

18. Procedure Volume Categories

19. Relationship between surgeon volume and surgical site complications

20. Relationship between hospital volume and surgical site complications

21. Relationship between surgeon volume and medical complications

22. Relationship between hospital volume and medical complications

23. Relationship between surgeon and hospital volume and specific complications

24. Do surgeons that operate at different hospitals have similar rates of complications in each of the hospitals? 17 (24%) of MBSC surgeons operate at more than one hospital 15 at two hospitals 3 at three hospitals Calculated risk and reliability adjusted rates for each surgeon at each hospital

25. Risk and reliability adjusted serious complication rates for surgeons that operate in more than one hospital

26. What is the relationship between the length of the case (OR time) and risk of complications? Analytic challenges Cases are harder for higher risk patients so they take longer Surgeons may get faster with experience, is it just a volume effect? Cases that aren�t going well take longer

27. Patient Level Analysis:Relationship between OR Time and rates of serious complications among patients undergoing Lap-RYGB procedures

28. Variability in median Lap-RYGB OR times by surgeon

29. Surgeon Level Analysis:Relationship between surgeon median OR time and rates of serious complications

30. Pay for PerformanceJohn Birkmeyer, MD Proposed measures Scoring/straw man Located under tab 7

31. BCBSM Pay for Performance �Straw Man�

32. Plans for Studying Technical QualityJohn Birkmeyer, MD Technical skills Technique

33. Measuring and improving technical quality Over half of serious complications and deaths involve the surgical site Leak, obstruction, bleeding Strong interest among MBSC surgeons in exploring technical quality Substantial scientific value

34. Assessing Technical Quality 3 domains OR environment Technique Technical skill We need a plan Closure on approach / instruments Short-term plan for getting started Long-term plan for comprehensive study and improvement

35. 1. OR Environment

37. Technical Quality: OR Environment and Safety Culture Goals Short term: gather some pilot information using a survey of the surgeons � other members of the bariatric clinical team Long term: use trained observers in the OR to collect more detailed data

38. Pilot Instrument 4 Sections: For 1-3 we selected items: Hospital Survey on Patient Safety Culture Safety Attitudes Questionnaire (OR version) Overall safety rating Hospital safety culture OR safety culture OR disruptions-developed questions based on MBSC focus groups

41. 2. Technique

42. Technical Quality Surgeon Survey Laparoscopic Sleeve Gastrectomy (Located under Tab 7) Jonathan Finks, MD

43. Please characterize your usual practices with regard to the following: Who most often assists you? Another attending/ staff surgeon PA/ Certified first assistant Resident Fellow

44. 2. How far from the pylorus do you begin your gastrectomy? _______ cm 3. What do you use to calibrate your sleeve? Bougie type dilator, �������________ Fr size Endoscope Other ________________ Nothing

45. 4. What stapler manufacturer do you use for sleeve gastrectomy? Covidien Ethicon � 5. Do you use staple-line reinforcement (buttress) during the gastrectomy? Yes, for the distal portion of the gastrectomy only Yes, for the proximal portion of the gastrectomy only Yes, for both proximal and distal portions of the gastrectomy Depends upon tissue thickness Do not use staple-line reinforcement

46. 6. What thickness staple cartridge do you use when performing the distal portion of the gastrectomy? If you use Covidien staplers 3.5 millimeter (blue) 4.8 millimeter (green) Depends upon tissue thickness If you use Ethicon staplers (closed staple height) 1.0 millimeter 1.5 millimeter 2.0 millimeter 2.5 millimeter Depends upon tissue thickness

47. 7. What thickness staple cartridge do you use when performing the proximal portion of the gastrectomy? If you use Covidien staplers 3.5 millimeter (blue) 4.8 millimeter (green) Depends upon tissue thickness If you use Ethicon staplers (closed staple height) 1.0 millimeter 1.5 millimeter 2.0 millimeter 2.5 millimeter Depends upon tissue thickness

48. 8. Do you oversew the staple line? Yes, the proximal portion only Yes, the distal portion only Yes, for both the proximal and distal portion I do not oversew the staple line. 9. How do you test your staple line intraoperatively for leaks? Endoscopy Methylene blue (or other dye) I do not routinely test the staple line for leaks

49. 10. Do you obtain a routine postoperative upper GI or esophagram? Yes No � 11. Do you routinely leave a drain? Yes No

50. 12. Do you routinely leave a nasogastric tube in place postoperatively? Yes No � 13. Do you veer laterally with the most proximal staple fire? Yes No

51. 3. Technical skill

52. Assessing Technical Skills Peer rating Surgeons rates other surgeons� operations using modified OSATS instrument

54. Assessing Technical Skills Peer rating Surgeons rates other surgeons� operations using modified OSATS instrument Simulator assessment Avoid bias and �noise� introduced by variation in technique Provides detailed, quantitative information about pure videoscopic skills The �Lap-Sim�

57. Other observations Quantitative measures of precision, speed, and path efficiency would definitely discriminate among surgeons Link to clinical outcomes uncertain But might be interesting even if null

58. Straw Man

59. ED Visit rates Nancy Birkmeyer, PhD

60. ED Visits Why focus on this? Vary widely Vast majority for non-urgent complaints Expensive (add $11k on average) What we did Identify and implement best practices Post-discharge call Pre- and post-op patient education Post bariatric triage

61. ED Visit Rates Over Time

62. ED Visit Rates by Site

63. QI activity Amanda O�Reilly, RN

64. Strategies to Reduce Unnecessary ED Visits Gratiot Medical Center

65. Pre-Operative Education:PAST PROCESS Provided pre-operative instructions -written form (patient education notebook) -reinforced information at office visits, consultations, support groups and pre-op nutrition/education classes Clinical pathway-understanding when to call surgeon Verbal instructions to call bariatric coordinator as needed with questions

66. Pre-Operative Education:PROCESS IMPROVEMENTS Updated discharge instructions that patient receives both pre-operatively and post-operatively Includes contact numbers for the clinic, hospital, surgeon and coordinator Emphasis placed on typical post-op complaints/symptoms vs. emergent post-op complications

67. Post-Op Education:PAST PROCESS Instructed patient to present to ER with any complications Stressed importance of attendance to post-operative educational/support groups Post-operative phone call made by Bariatric RN to patient within 2 days of discharge Patient instructed to contact bariatric coordinator with any questions/concerns

68. Post-Op Education:PROCESS IMPROVEMENTS Patient educated that bariatric surgeons are on-call 24/7 Patients urged to call Gratiot Medical Center to have bariatric surgeon on-call paged after-hours Addition of emergency discharge instructions to the binder provided to all patients

69. Staff Education:PROCESS IMPROVEMENTS ED staff educated on new process when patient presents to ED ED staff to contact bariatric surgeon on-call when patient presents to ED PRIOR to patient ED admission Surgeon based training for the Gratiot Medical Center nursing staff ED Competencies in QI Protocol CME Symposium for the Primary Care/Allied Health Professionals-specific to the bariatric program

70. Staff Education:PROCESS IMPROVEMENTS CONTINUED Multi-Disciplinary Management Team Meeting -presentation given to key department managers in facility specific to MBSC ED QI Initiative Staff competency training sessions specific to staff associated with bariatrics -4 hour training blocks

71. Nancy Birkmeyer, PhD VTE Prophylaxis

72. VTE Adherence Low Risk: Pre and post-operative (except LB patients discharged same day) heparin No post-discharge LMW (except for patients with post-op VTE) No IVC filter Med/High Risk: Pre and post-operative heparin Post-discharge LMW heparin

73. Adherence with VTE Prophylaxis Guidelines by Site

74. Rates of VTE among sites with and without high rates of adherence with VTE prophylaxis guidelines

75. Adherence with VTE Prophylaxis Guidelines Over Time

76. Oakwood Bariatric Options VTE Risk Calculator Patient Education Daniel Bacal, MD FACS

77. Oakwood Bariatric Options Patient assessed at the time of initial consult, given score Score/VTE Treatment reviewed at educational sessions Patient actively participates in VTE Treatment

78. Oakwood Bariatric Options

79. Oakwood Bariatric Options

80. Oakwood Bariatric Options

81. Oakwood Bariatric Options Page two of H&P Asked and Answered by the Surgeon at the time of Surgical Assessment Standard orders in preop and postop areas

82. Oakwood Bariatric Options Changes performed since MSCORE More Accurate Assessment and Planning Pre-op VTE No Greenfield Filters Inserted Assist with Pre-operative Education of Patients requiring LMWH VTE score put in the EMR

83. VTE Risk Prediction Michael H. Wood, MD MBSC Meeting October 1, 2010

84. High Risk for VTE

86. 650 lbs.

87. VTE Risk Predictor(MBSC October 2009) Procedure Type Age (per 10y) BMI > 50 Gender (Male) Any smoking history OR Time > 3 hours Prior history of VTE

88. Risk Post-Discharge

89. Hospital VolumeHarper University Hospital, October 2009 through April 2010 Total Volume - 408 patients 231 Band patients (56.65%) 114 RYGB patients (27.90%) 63 Sleeve patients (15.45%) Low Risk - 395 Patients Qualified for Out Patient Treatment - 13 Patients (Score =15; 13 Medium Risk, 0 High Risk) Patients sent home on Lovenox - 151 Patients (138 did not meet the Medium / High Risk criteria) % of patients who qualified (from total volume) 3.2% (13 � 408) � (0 patients were High Risk) % of patients who qualified & were sent home on Lovenox 61.5% (8 � 13, 8 of the patients qualified were sent home on Lovenox) 38.5% (5 � 13, 5 of the patients qualified were not sent home on Lovenox) Surgeons In this review - 8

90. Barriers Multiple practices Rotating residents & medical students Staff awareness & education Communication

91. Action Plans Greater distribution / access / availability / use of �VTE Risk Prediction Tool� Padded (x25 ) and available At surgeon practices On bariatric inpatient unit In Post-op (PACU) New Hospital EMR �Bariatric Order Sets� EMR enhancement Automatically calculate patient risk score based on �VTE Risk Prediction Tool� Provider alerted during patient departure process Patient qualifies Patient does not qualify Revise current program �Management Operating Directive� (MOD) Bariatric MOD 9015, DVT Management of a Bariatric Surgical Patient MOD revision for approval on �Bariatric Surgery Committee� agenda,10-13-2010

92. Summary VTE Risk Calculator Tool in use by the Harper Bariatric Program needs to be expanded Will continue to assess patients utilizing the available tool Will continue to look for solutions to our program�s barriers Harper�s �Risk Group� (medium to high) fall in <4.0% of our patient population

93. Revisional Bariatric Procedures Steve Poplawski, MD

94. Complication or Ineffective Weight Loss Is the complication related to the primary bariatric procedure or a chronic problem? If done for a complication, was the procedure revisional?

95. URGENT / EMERGENT A) Return to operation room after initial bariatric operation 1. <30 days post op 2. <90 days>30 days 3. >90 days B) Description of initial procedure C) Condition of the patient at return to operating room 1. Requiring ventilator support 2. on-going sepsis 3. Vasopressor support D) Diagnosis of complication E) Days in ICU F) Total hospital stay G) Discharge to home, rehab hospital, death

96. CHRONIC PROBLEMS Original procedure: Vertical banded gastroplasty a) Stricture/ pouch outlet obstruction b) GERD c) gastro-gastric fistula / staple line dehiscence d) Ulcer disease �

97. CHRONIC PROBLEMS cont. Original procedure: Gastric bypass a) Anastamotic GJ ulcer (cause bleeding, obstruction, or pain) b) Small bowel obstruction 1. Internal hernia (causing pain or obstruction) 2. Adhesive disease 3. Obstruction at entero-enterostomy 4. Intussecception c) Gastro-gastric fistula d) Non-healing leak from initial procedure e) Recurrent stricture gastro-jejunal anastomosis f) Uncontrolled symptomatic hypoglycemia/ Neuroglycopenia g) Acid -peptic disease distal gastric remnant h) Malnutrition �

98. CHRONIC PROBLEMS cont. Original procedure: Adjustable gastric band a) Band slippage b) Band erosion c) Band infection d) Port infection e) Tubing injury/ breakage f) Food Intolerance g) Unacceptable lifestyle restrictions h) Ineffective weight loss or weight regain

99. CHRONIC PROBLEMS cont. Original procedure: Sleeve gastrectomy a) non-healing leak from original procedure b) stricture/obstruction c) Poorly controlled reflux d) Chronic nausea e) Ineffective weight loss or weight regain

100. CHRONIC PROBLEMS cont. Original procedure: DS-BPD a) non-healing leak from original procedure b) stricture/obstruction c) Small bowel obstruction 1. Internal hernia (causing pain or obstruction) 2. Adhesive disease 3. Obstruction at entero-enterostomy 4. Intussecception d) Nutritional complications

101. Other information: Hospital stay for elective revisional operation 1. Days in ICU 2. Total hospital stay 3. Discharge to home, rehab hospital, death

102. Weight loss failure of original procedure 1. Original procedure 2. Interval in months from primary operation 3. Original weight/BMI 4. Nadir 5. Interval in months to nadir 6. Weight /BMI at evaluation for revision 7. Date at revisional operation 8. Description of revisional operation a. name of procedure b. hospital stay c. Complications d. transfusion e. condition at discharge *** Was the revisional operation a "weight loss" procedure or a return to "normal" anatomy?

103. New priorities ? John Birkmeyer, MD

104. Thank You for AttendingThe next meeting is February 4th, 2010