Ayurvedic Spine Treatment in kerala | Medical Tourism In India
Spine Center of Excellence - Medical School
Transcript of Spine Center of Excellence - Medical School
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Spine Center of Excellence
First Joint Commission Designated
Spine Center of Excellence in MN
Since 11/17
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Why A Community Hospital
Would Want to Pursue
Joint Commission Designation
As A Center of Excellence
for Spine
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Joint Commission
Provides a framework for
organizational structure and management
for compliance with National evidence-
based clinical practice guidelines
with ordersets, protocols and
outcome analysis
For best quality of patient care
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WHY
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HealthEast Neurosurgery & Spine
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SPINE COUNCIL
4 Practices 15 Surgeons
Neurosurgery & SpineHealthEast
Neurosurgery and Spine
Midwest Brain and Spine
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HealthGrades Hospital Compares
Comparison of Complication Rate for Spine Fusion *
Complications Actual Predicted # of cases
St. Joes 12.12% 10.86 66 +++
St Johns 21.02 13.67 176 +
Woodwinds 13.00 9.12 100 +++
Natl. Average 11.15 11.17 185
*data from medicare.gov 2012-13
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Medicare’s listed complications
Surgical Site Infections
Pressure sores (pressure ulcers)
Collapsed lung that results from medical treatment (Iatrogenic
pneumothorax)
Infections from a large venous catheter (central venous
catheter-related blood stream infection)
Broken hip from a fall after surgery (postoperative hip fracture)
Blood clots, in the lung or a large vein, after surgery
(perioperative pulmonary embolism or deep vein thrombosis)
Blood stream infection after surgery (postoperative sepsis)
A wound that splits open after surgery (postoperative wound
dehiscence)
Accidental cuts and tears (accidental puncture or laceration)
8
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SPINE COUNCIL
VBI PROJECT ON SSI 4 Practices 15 Surgeons
HealthEast
Neurosurgery and Spine
Midwest Brain and Spine
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Project Parameters
Reported Data: July through December of 2014
SSI within 30 days of spine surgery at Joes/Johns
639 inpatient spine surgeries
341 fusions (lumbar, cervical, thoracic)
298 nonfusions
Chart reviews conducted by Kathy Miller and
Annette Lund With Dr. Boyd
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Project Parameters
Reported Data: July through December of 2014
SSI within 30 days of spine surgery at Joes/Johns
639 inpatient spine surgeries
341 fusions (n=7) 2.0%
298 nonfusions (n=2) 0.7%
Chart reviews conducted by Kathy Miller and
Annette Lund
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Organisms Among Infections
0
1
2
3
4
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6
7
8
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Outcome of 9 Infected Patients
0123456789
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Distribution of Infections by
Number of Levels Fused
0 1 2 3 4 5 6 7
lumbar
thoracolumbar
cervicalthoraco
cervical
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Age Distribution of Surgical Spine
Patients with Infections
0
1
2
3
4
30 35 40 45 50 55 60 65 70 75 80 85 90
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Age Distribution of Inpatient
Spine Cases
3 4
34
69
128
171
119
63
40
20
40
60
80
100
120
140
160
180
10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90-99
Inpatient Age Range Distribution July 2014-December 2014
Volume
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Age Distribution of Surgical Spine
Patients with Infections
0
1
2
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30 35 40 45 50 55 60 65 70 75 80 85 90
Cases 34 69 128 171 119 63 4
Rate % 0 0.8 1.2 1.7 4.8 0
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Comorbidites of Elective Surgical
Patients with Infections
0
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30
40
50
60
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80
90
100
Diabetes BMI > 40 BMI 38 BMI 25-30 D/C to TCU recent MI
% total cases 19 23.4
% infections 38 25Infection rate 3.5% 4.1%
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Of the 7 fusion cases with Infections
Intra-Operative Prep
0
1
2
3
4
5
6
7
Duraprep Scrub
Prep Type
6/212
2.8%
1/52
1.9%
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Distribution of Infections By
Surgeons in 2014
0
1
2
3
4
5
A B C D E F G H I J K L M
Total Infections 7/341 Cervical Lumbar/Thoracic Fusion Cases
surgeon specific infection rate
P-value 0.0033 for Surgeon B
Cases 54 37 79 0 11 12 13 24 23 30 49 0 14
Rate 1.9 10.8 1.3 0 9
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Number of Patients Returned to OR
for I/D 1/15 – 6/15
0
1
2
3
4
5
6
7
Cases 3 71 93 61 68 64 118
Rate 4.2 1 9.8 1.5 1.6 1.7
•Now 9 cases from 3/15 – 9/15,
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National Healthcare Safety
Network
Analysis of 49,120 cases Operation Risk Index* Pooled
Mean
Median T value
Minute
Spinal Fusion 0 0.72 0.37 240
1 1.95 1.54 240
2, 3 4.13 4.0 240
Lami 0 0.73 0.56 167
1 1.11 0.98 167
2, 3 2.44 1.67 167
Risk Index: 1 if ASA 3,4,5; 1 if time > T value; 1 if contaminated wound
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Quality Goal
Reduce complications and readmissions
Increase quality of care
Build a team with common purpose
Provide the best patient care
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Joint Commission Certification
Provides a framework for
organizational structure and management
compliance with National evidence-based
clinical practice guidelines
with ordersets, protocols and
outcome analysis
Team - staff recruitment and development
12 new CNRNs in first year of classes
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Joint Commission
Site of Distinction for Spine
Selected + Monitored 4 Criteria for Improvement
Surgical Site Infections
Early Mobilization (Day of surgery)
Pain Management
Indwelling Catheters
Established Protocols, Enlisted Stakeholders,
Collected Data Presented at Site Visit 8/2017
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Surgical Site Infection
Preop Hibiclens shower x 2 prior to surgery
Preop Sage Wipe and Nasal Swab
Abx Irrigation for higher risk patients
(diabetes, obesity etc.) when hardware placed
All others dilute betadine or saline
Infection rate (goal < 1 %)
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Surgical Site Infection
Providine Iodine SSI Prevention
Nasal decolonization + sage cloth
in Preop
Both Nasal Swab and Sage Wipe in Preop
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18
SJ 88% 93% 94% 92% 96% 92%
JN 57% 94% 100% 90% 100% 92%
WW 100% 95% 95% 84% 88% 88%
% SAU Povidone Iodine Nasal Swab
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CAUTI Watch
Nurse driven protocol on Floor and Postop
to Recognize and Manage Postop
Retention with Straight Cath
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Indwelling Urinary Catheter
% Pts w/ Documented reason for retention of foley
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18
SJ 100% 75% 100% 100% 100% 100%
JN 67% 100% 100% 100% 100% 0%
WW 100% 100% 100% 100% 100% 100%
Nursing Protocol for bladder scan and straight cath
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Ambulation Watch
OT/PT Video seen by pt in Preop Area
‘just in time’ repetition for adult learners
PT scheduled on Day of surgery
Goal ambulate 30 feet by 12 hours postop
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Early Mobilization
Ambulate 30 feet within 12 hours after PACU
0%
20%
40%
60%
80%
100%
Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18
SJ 81% 71% 60% 81% 87% 67%
JN 50% 44% 44% 50% 33% 22%
WW 68% 74% 63% 70% 59% 67%
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PAINStandard Orders for
Preop Protocols for Pain Cocktails
(oral Tylenol, Neurontin, oxycodone)
Anesthesia Engagement for Intraop Methadone for
inpatients with surgeries >3 hours
Surgeon Engagement Injections of Marcaine
Presently Monitoring ER - 30 day returns for pain
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Multimodal Pain Management
0%10%20%30%40%50%60%70%80%90%
100%
Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18
SJ 98% 100% 100% 100% 100% 100%
JN 100% 100% 100% 100% 100% 100%
WW 100% 100% 100% 100% 100% 100%
% Patients offered pharm and 2 non-pharm forms of pain management
Future – Protocol for Preop and Intra-Operative Pain Interventions
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Associated Watch Measures
Readmission
Use of ER for Postop Issues
Preop Patient Education
(constructed 6 videos preop education-
awaiting implementation on web site)
Nursing Education CNRN
(2 day class put on by neuro providers)
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Spine Center of Excellence
First Joint Commission Designated
Spine Center of Excellence in MN
Since 11/17
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Is Quality Better?
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Rate of SSI for Fusions
0
0.5
1
1.5
2
2.5
2014 2015 2016 2017
percent SSI
N=341 N=384
N=622 N=471
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HealthGrades 2015
Comparison of Complication Rate for Spine Fusion *
Complications Actual Predicted # of cases
St. Joes 12.12% 10.86 66 +++
St Johns 21.02 13.67 176 +
Woodwinds 13.00 9.12 100 +++
Natl. Average 11.15 11.17 185
*data from medicare.gov 2012-13
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HealthGrades 2016
Comparison of Complication Rate for Spine Fusion
Complications Actual Predicted # of cases
St. Joes 13.79% 11.10 58 ***
St Johns 25.36 13.51 209 *
WoodWinds 17.50 9.59 120 ***
United 9.0 11.18 100 ***
Natl. Average 11.15 11.17 185
data from medicare.gov 2012-14
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HealthGrades 2017
Comparison of Complication Rate for Spine Fusion
Complications Actual Predicted # of cases
St. Joes 12.00% 10.00 75 ***
St Johns 26.97 13.39 241 *
WoodWinds 18.47 9.24 157 *
Natl. Average 11.15 11.17 185
data from medicare.gov 2013-15
Regions *, U of M * Mayo ***, United ***
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HealthGrades 2018-2019
Comparison of Complication Rate for Spine Fusion
Complications Actual Predicted # of cases
St. Joes 19.74% 10.01 76 *
St Johns 31.53 11.35 222 *
WoodWinds 12.98 8.41 208 *
Natl. Average 10.8
data from medicare.gov 2015-17
Regions *, U of M * , United *
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Data lags
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QUALITY
OUTCOMES
ANALYSIS
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HealthEast
Neurosurgery and Spine
Outcomes Analysis
With Structured Patient Education
Individualized, Classes, Videos
Patient Surveys pre and postop by surgery
(ODI, NDI as outcomes measures)
Redcaps Statistical Analysis 2017 -present
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Follow-up Data by Year
2017
268 patients completed pre-op and at least one follow-up
427 follow-up records
2018
261 patients completed pre-op and at least one follow-up
326 follow-up records
2019
36 patients completed pre-op and at least one follow-up
40 follow-up records
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0.0
10.0
20.0
30.0
40.0
50.0
60.0
All Lumbar(n=313)
Laminectomy(n=185)
Microdiscectomy(n=97)
Fusion (n=50)
ODI Pre and Post Lumbar Surgery
Pre-op 6 weeks 3 months 6 months 1 year
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0.0
10.0
20.0
30.0
40.0
50.0
60.0
Laminectomy (n=185) Artifical disk (n=97)
p=0.0001 p=0.0003
Patient Disability Ratings Pre and Post SurveyFollow-up to 1 year
Pre-op Post-op
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0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
45.0
50.0
Lumbar Fusion (n=50) Cervical Fusion (n=28) Mobi-c (n=41)
p = .0004 p = 0.0001 p = 0.001
Patient Disability Ratings Pre and Post SurgeryFollow-up to 1 year
Pre-op Post-op
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0
5
10
15
20
25
30
35
Yes definitely Probably No Not sure
Knowing what you know now, would you have this surgery again?
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0
10
20
30
40
50
60
70
80
90
100
5-Completelyprepared
4 3 2 1-Not at allprepared
How prepared did you feel for your surgery?
Average: 4.7 out of 5
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SPINE COUNCIL
VBI I – Surgical Site Infections
VBI II – Center of Excellence
VBI III – Value - Cost and Quality
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Spine Center of Excellence
First Joint Commission Designated
Spine Center of Excellence in MN
Since 11/17
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