Exploring Variation in Emergent Surgical Outcomes in the Michigan Surgical Quality Collaborative: a Fertile Area for Quality Improvement

ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONS—ABSTRACTS immunofluorescence and Terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) were used to detect apoptosis. Male Sprague-Dawley rats underwent carotid balloon injury followed by intraluminal infection with adenovirus expressing Smad3; or GFP control and arteries harvested at 3 days were subject to TUNEL staining and immunohistochemistry for cleaved Caspase-3. Akt activation was measured with phospho-Ser473 Akt (p-Akt). SIS3 was used to inhibit Smad3 activation. Results: in vitro, stimulation of SMCs withTGFb reduced the number of TUNEL positive cells (Control ¼ 35.0 vs TGF-b ¼ 22.6%, p < 0.05) and diminished activation of Caspase-3 (31.4 vs 21.8%, p < 0.01) suggesting that TGF-b has an anti-apoptotic or protective effect on vascular SMCs. These protective effects were reversed by knockdown (siRNA) of TGF-b’s primary signaling protein, Smad3 (cleaved Caspase-3, p < 0.05). Moreover, overexpression of Smad3 in SMCs further enhanced TGF-b’s antiapototic effect (cleaved Caspase-3, p < 0.05). TGF-b phosphorylation of Akt was time-dependent and significantly enhanced when Smad3 was overexpressed. Both chemical inhibition and knockdown of Smad3 prevented phosphorylation of Akt (n ¼ 3, p < 0.01). in injured carotid arteries, overexpression of Smad3 resulted in a dramatic inhibition of apoptosis but increased phosphorylation of Akt in the medial layer of the arterial wall: cleaved Caspase-3 (GFP ¼ 35.2 vs Smad3 ¼ 4.9, p < 0.01), TUNEL (32.1 vs 8.5, p < 0.01) and p-Akt (6.2 vs 22.4 p < 0.05). Conclusions: Our data show that TGF-b promotes SMC survival both in vitro and in vivo. This anti-apoptotic effect may well be one of the primary mechanisms through which TGF-b enhances intimal hyperplasia. Knockout and overexpression studies suggest that TGF-b’s inhibitory effect on apoptosis is mediated through the signaling protein Smad3. the correlation with Akt activation suggests that this may be mediated by the Akt-cell survival pathway. 16.2. Assessment of the Implementation of a Surgical Preoperative Checklist. C. E. Senter,1,2,3,5 R. B. Hawkins,1,2,3,5 S. M. Levy,1,2,3,5 J. Y. Zhao,1,2,3,5 K. A. Doody,1,2,3,5 K. P. Lally,1,2,3,5 L. S. Kao,1,2,4,5 K. Tsao1,2,3,5; 1University of Texas Medical School at Houston, Houston, TX; 2Children’s Memorial Hermann Hospital, Houston, TX; 3Department of Pediatric Surgery, Houston, Texas; 4Department of General Surgery, Houston, Texas; 5Center for Surgical Trials and Evidence Based Practice, Houston, Texas Introduction: Peri-operative checklists are mandated by many hospitals based on the reduction in morbidity and mortality seen with utilization of the World Health Organization’s (WHO) ‘‘Surgical Safety Checklist.’’ Although an adapted peri-operative checklist was implemented within our hospital system without formal system-wide training, compliance with the checklist is reported to be 100%. We hypothesize that compliance does not measure fidelity of implementation, in that all items on the checklist are not performed as intended. Methods: Over a 10 week period, a prospective study was performed evaluating the completion of the 12 pre-incision components of the surgical checklist. Pediatric surgical operations, occurring in the operating room or in neonatal and pediatric intensive care units, were randomly selected for direct observation. Emergent cases were excluded. the evaluated checkpoints include essential parties present, team members identified, patient name/procedure verified, incision site confirmed, team member concerns addressed, administration of appropriate antibiotics (if applicable), essential imaging displayed (if applicable), anticipated case length stated, anticipated risk of blood loss stated, and sterility indicator confirmed. Essential parties included anesthesiology attending or fellow, pediatric surgical attending or fellow, circulating nurse, and scrub technologist. Results: 142 pediatric surgical cases were observed. Hospital data demonstrated 100% compliance with the pre-incision phase of the checklist for these cases. Our observation revealed that in 3.5% of cases the checklist was not performed at all. None of the cases completely executed all items on the checklist, and the average number of checklist items performed in the observed cases was five. the most commonly performed checkpoints were the confirmation of patient name and

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procedure (99.3%) and administration of antibiotics (88.1%). the rest of the checkpoints were performed in less than 60% of cases (figure). Conclusions: These data show that despite the 100% documented completion of the pre-incision phase of the checklist, most of the individual checkpoints are not routinely performed. These findings demonstrate lack of fidelity in implementing the checklist, which may be a reflection of the poor strategy in disseminating and implementing this patient safety practice. Failure of the system to measure the appropriate implementation metrics and to fully adopt the evidence-based intervention could lead to failure to achieve the intended outcomes. the impact and etiology of non-compliance with all components of the surgical checklist requires further investigation.

16.3. Exploring Variation in Emergent Surgical Outcomes in the Michigan Surgical Quality Collaborative: a Fertile Area for Quality Improvement. M. E. Smith,1 D. R. Cummings,1 A. Hussain,1 K. O. Olugbade,1 H. G. Reddy,1 W. D. Scheidler,1 J. Xiao,1 D. A. Campbell,2 M. J. Englesbe2; 1 University of Michigan Medical School, Ann Arbor, MI; 2 University of Michigan Medical Center, Ann Arbor, MI Introduction: Within a large, statewide collaborative, significant improvement in surgical quality have been appreciated (9.0% reduction in morbidity for elective general and vascular surgery). Our group has not noted such quality improvement in the care of patients who had emergent operations. With this work, we aim to describe the scope of emergency surgical care within the MSQC, variations in outcomes among hospitals, and variations in adherence to evidence based process measures. Overall, these data will form a basis for a broad based quality improvement initiative within Michigan. Methods: We report morbidity, mortality, and costs of emergency and elective general and vascular surgery cases (n¼ 211,903) within 34 hospitals participating in the MSQC from 2005 to 2010. Adjusted hospital specific outcomes were calculated using a step-wise multivariable logistic regression model. Adjustment covariates included patient specific comorbidities, and case complexity. Hospitals were also compared based on their adherence to evidence based process measures (measures at the patient level for each case – SCIP 1 and 2 compliance). Results: Emergent procedures accounted for approximately 10% of total cases, yet they represented 32.0% of mortalities and 40.4% of surgical complications. the complication-specific costs to payers was $208 million for the emergent cases and $307 million for the elective cases. Adjusted patient outcomes varied widely within MSQC hospitals; morbidity and mortality rates ranged from 3.1% to 28.0% and 0% to 13.6%, respectively.The variation among hospitals was not correlated with volume of emergent cases and case complexity. for emergent colectomies, there was wide variation in compliance with SCIP 1 and 2 measures, and overall compliance (42.0%) was markedly lower than elective colon surgery (81.7%). Conclusions: Emergent surgical procedures are an important target for future quality improvement efforts within Michigan. Future work will identify best practices within high-performing hospitals and disseminate these practices within the collaborative.