Leapfrog Dashboard Tracking of Postoperative Sepsis: An Opportunity for Quality Improvement

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This article describes the new Leapfrog quality metrics and their methodology, focusing on postoperative sepsis identification and the potential impact of dashboard performance tracking moving forward. Critical care professionals routinely encounter patients with sepsis and play an integral role in the formulation and implementation of management plans for postoperative sepsis, making them key participants in this effort.

Leapfrog Hospital Safety Grade is a national rating system of U.S. hospitals developed in the 1990s by a healthcare quality improvement coalition. Hospitals participating in an inpatient prospective payment system of the Centers for Medicare and Medicaid Services (CMS) are surveyed on more than 30 performance measures and graded on a scale of A to F to reflect the hospitals’ infrastructure and performance on patient safety measures,¹ including healthcare-associated infections (HAIs). In 2009, the U.S. Department of Health and Human Services (HHS) released a national action plan focused on preventing HAIs in acute care hospitals, including central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), surgical site infection (SSI), methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections, and Clostridiodes difficile infection (CDI). In 2011 CMS mandated reporting HAI data through the National Healthcare Safety Network (NHSN).² Despite these efforts, HAIs continue to affect 4% of all hospitalized patients with device-associated infections, together accounting for 25.6% of cases, and SSI alone accounting for 21.6% of cases.³ Leapfrog uses reduction in HAIs as a quality metric in its latest web-based fall 2021 dashboard.⁴

The updated Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021, published by the Society of Critical Care Medicine (SCCM) and the European Society Intensive Care Medicine (ESICM), included recommendations on source control in sepsis.⁵ Given the high prevalence of SSIs, the implementation of this recommendation, among others, is likely to influence Leapfrog Hospital Safety Grade by directly affecting the rates of postoperative sepsis, which are now part of a composite patient safety indicator (PSI).
 
In this article, we describe the new Leapfrog quality metrics and their methodology, focusing on postoperative sepsis identification and the potential impact of dashboard performance tracking moving forward. Critical care professionals routinely encounter patients with sepsis and play an integral role in the formulation and implementation of management plans for postoperative sepsis, making them key participants in this effort.

Leapfrog Methodology as the Performance Measure for U.S. Hospitals

Guided by an expert panel, the Leapfrog methodology focuses on patient safety, defined as “freedom from harm.” It uses an open-access online dashboard⁴ that helps visualize safety measures in individual hospitals and helps comparison across hospitals. The concept of clinical dashboards as a tool to demonstrate current progress toward specific goals has a long history in the business arena; more recently clinical dashboards have been adopted within healthcare to improve interconnectivity and patient care knowledge among clinicians, healthcare administrators, information technology specialists, quality officers, and nursing and other ancillary department leaders. The dashboards also support transparency, decision-making, and dissemination of information, aiding the formulation of new hospital polices.
 
Leapfrog places equal weight on 1) process and structural measures and 2) outcome measures. Process measures include hospital staff responsiveness and adherence to the CMS/Joint Commission Surgical Care Improvement Project (SCIP). Structural measures include computerized physician order entry for medications. Outcome measures include several PSIs, of which HAIs form the largest percentage.⁶ In fall of 2021, the composite PSI-90, which combines 10 PSIs and accounts for 15% of the overall grade, was introduced (Figure 1).
 

PSI-90 includes rates of pressure ulcer (PSI-3), iatrogenic pneumothorax (PSI-6), in-hospital fall with hip fracture (PSI-8), perioperative hemorrhage and hematoma (PSI-9), postoperative acute kidney injury (PSI-10), postoperative respiratory failure (PSI-11), perioperative pulmonary embolism or deep venous thrombosis (PSI-12), postoperative sepsis (PSI-13), postoperative wound dehiscence (PSI-14), and unrecognized abdominopelvic accidental puncture/laceration (PSI-15).

Continuous, concurrent tracking of these measures with tools such as dashboards provides the foundation for transformative discussion that can guide innovative process management⁷ and tracking of intervention effects. When developing a dashboard, facilities should examine the complete report from their most recent Leapfrog evaluation and identify underperforming measures. Data sources for each of the measures should be clearly identified so that the concurrent dashboard can be populated with updated information at regular intervals, typically monthly. Most of the process and structural measures can be manually extracted from the electronic medical record, staffing systems, facility hand hygiene observation process, or the Leapfrog survey. Outcome measures can typically be obtained by manual chart extraction or with a claims-based quality management system such as Premier or Vizient using CMS and NHSN reports as the data source.
 
Ideally, every facility would create a custom dashboard that would allow for accurate visualization of trends and practice patterns. On one hand, this would increase accountability for individual and group practices; on the other hand, it would predict overall facility Leapfrog grading. For key metrics or areas of focus, it may be helpful to include front line drivers (FLD),⁸ which are actions that staff can take to affect specific outcome measures. Figure 2 depicts a hospital safety grade dashboard wherein FLD for PSI-13 (postoperative sepsis) were identified as handwashing and CMS Sep-1 bundle compliance in the surgical ICU. In the example, improvement in FLD corresponds with improvement in PSI-13 and PSI-90 scores. Once dashboards have been created and the data population has been delineated, it is essential to identify a plan for dissemination to all stakeholders either electronically or at a hospital committee with strong multidisciplinary leadership attendance.
  Figure 2. Example of Hospital Safety Grade Dashboard with Frontline Drivers
 
Facility leaders should use the dashboards to help direct decision-making regarding targeted resource allocation;¹⁰ implementation of measure-specific action plans, including pertinent clinical practice guidelines; and real-time tracking of the effects of such interventions, allowing for immediate modifications and long-term planning. For example, an increase in CLABSI at a facility would be reflected in the dashboard and would trigger an analysis of the cases, with possible identification of common risk factors (e.g., catheter insertion by the same clinician or team). Thus, knowledge and skill assessment of the clinician or team could occur, regarding infection prevention measures, provision of education, and tracking their future practices as reflected by their future rates of CLABSI. The real-time analysis would allow for early identification and corrective measures, which could prevent overall performance from being significantly affected, resulting in maintenance and improvement of patient safety scores.

Source Control for Postoperative Sepsis in Light of the Surviving Sepsis Campaign

The Agency for Healthcare Research and Quality (AHRQ) defines postoperative sepsis rate (PSI-13) as the number of cases of postoperative sepsis as a secondary diagnosis per 1000 elective surgical discharges for patients aged 18 years and older. This encompasses sepsis from all causes, including shock, and of any severity in the postoperative period. The presence of sepsis on admission as a principal or secondary diagnosis is a criterion for case exclusion from this rate calculation, as is postoperative infection without evidence of sepsis.
 
In the United States, around 1.2% of all elective surgery patients develop sepsis in the postoperative period. Hospital length of stay (18 days vs. 6 days, P < 0.0001) and hospital mortality (25.88% vs. 0.81%, P < 0.0001) for postoperative sepsis are substantially higher than in those without sepsis.¹¹ This trend toward higher mortality continues for up to 1 year after hospital discharge.¹² Abdominal procedures involving the gastrointestinal tract other than the colon (esophageal, gastric, small bowel, pancreatic) are associated with the highest mean risk-adjusted incidence rates of more than 2.75%. Despite lower incidence, sepsis after noncardiac thoracic procedures was associated with the highest risk-adjusted hospital mortality, approaching 46%. Moreover, there is a substantial monetary cost. In the 2002-2006 cohort from the AHRQ-sponsored nationwide inpatient sample, the median total hospital stay cost was substantially more for those with postoperative sepsis ($57,032 vs. $17,229, P < 0.0001).¹¹ These numbers do not consider the morbidity associated with such severe illness and the cost of ongoing out-of-hospital care for subsequent infections and complications. This imposes a significant and potentially reducible burden on healthcare systems. A 10% reduction in postoperative sepsis from general surgical procedures alone could reduce healthcare costs by $421 million.¹³
 
Early (1-3 days) postoperative infections may be community-acquired preoperatively, but late (4-30 days) postoperative infections are largely site-specific SSIs and may be superficial, deep incisional, or deep space/organ related. HAIs can occur at any time in the postoperative course and are more likely to be associated with multidrug-resistant (MDR) organisms and postoperative critical illness when indwelling catheters and devices are used.
 
The Surviving Sepsis Campaign adult guidelines⁵ emphasize early and definitive control of the source of infection, defined as “identification of a specific anatomical diagnosis contributing to infection and subsequent intervention to remove it,” as a best practice recommendation. Included in this recommendation is definitive removal of a source of ongoing microbial contamination such as infected skin and soft tissue; infected indwelling catheters or intracardiac devices; infected fluid collections such as intra-abdominal abscess, empyema, or superinfected seroma or hematoma; and, in dire circumstances, amputation or removal of vital organs such as in traumatic or spontaneous necrotizing infections. Also included in the recommendation is limiting the introduction of otherwise site-specific normal flora into a relative sterile space such as the peritoneum in the case of bowel perforation by correction of anatomical derangements. Such efforts often also establish the microbial diagnosis and help guide optimal antimicrobial strategies.
 
Because of the varied nature of such infection sources, definitive data about the effect of source control measures on clinical outcomes is primitive at best. The least invasive and most effective strategy is recommended and, the earlier the intervention, the better. For critically ill patients, open surgical drainage may be precluded by hemodynamic instability, favoring percutaneous or endoscopic approaches or suboptimal drainage procedures referred to as damage control. For necrotizing fasciitis, earlier source control, within 6 to 12 hours, is associated with substantially reduced mortality.¹⁴ Such a time cutoff has not been identified in other sites or infection types, although increasing data suggest that, for severe sepsis or septic shock, delays are associated with higher mortality,¹⁵ especially in those with an intra-abdominal source.^16-19 However, adequate source control is associated with improved clinical outcomes and survival, even if performed later in the course of illness.^15,17,20,21 In the case of MDR organisms, adequate source control has been independently associated with improved clinical outcomes.²²
 
We strongly advocate for the three-pronged approach of appropriate antimicrobial therapy, adequate source control, and supportive care for the treatment of all patients with sepsis or septic shock. The key, however, to decreasing the rate of postoperative sepsis is in the adequate implementation of guideline-directed preventative measures that have been proven to decrease HAIs,^23-27 such as strict adherence to hand hygiene measures, appropriate indication for devices and removal when no longer necessary, appropriate insertion and maintenance techniques, and strong antibiotic stewardship interventions.

Conclusion

Data are scarce on the impact of implementing Leapfrog Hospital Safety Grade on overall clinical outcomes. However, using dashboards to track specific parameters allows for objective assessment and better resource utilization and monitoring progress, ultimately improving patient care and hospital performance.

References
 

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Posted: 3/10/2022 | 0 comments