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Table 3: 2016 Performance Measures: Outcome Results of SUL Unit’s Surgical and Medical Cases 4

30-day 30-day re- ED Visit rate
Types of In-Hospital SSI Infection MDRA
Cases Mortality rate CAUTI rate rate Readmission Operation w/in 48 hrs of
rate rate surgery
Shoulder 0 0 0 0 0 0.2% (b) 1.1% (c)
(a)
Elbow/Wrist/Hand 0 0.2% 0 0 0 0 0
Other 0 0 0 0 0 0 0

Each variation in performance measure is explained below along with the team’s process improvement initiatives:

(a) 1 surgical case of a superficial Surgical Site Infection (SSI) after the surgical reduction of a fracture which represents less than 0.2% of all
surgeries. Root cause analysis was conducted and process improvement was put in place which involved educating nursing providers. The
International Benchmark for SSI rates in Orthopedics is 2.6%. (CDC). Although SUL’s performance is far lower than benchmark rates (lower is
better) , a root cause analysis of every SSI is conducted to determine if it could have been prevented. Not all SSIs are preventable.

(b) 1 surgical case of arthroscopy for the fracture of gleno-humeral joint required a second surgery within 30 days. Root Cause: during the
first surgery, the operating theatre did not have a C-Arm available, resulting in limitations in visualizing all bone fragments. This resulted in an
incomplete reduction, so the patient underwent a second surgery. As part of SUL’s multi-disciplinary process improvement process (CQI),
a change of protocol was implemented: All arthroscopic-assisted fracture reductions now require the use of a C-Arm. There is no established
benchmark for re-operation rates in shoulder surgeries; lower is better.

(c) 5 patients out of 439, or 1.2% of our cases, returned to the Emergency Department (ED) within 48 hours of day surgery due to pain complaints.
Although there is no published benchmark, that number was deemed to be unacceptably high. Clearly, there was a common root cause to be
determined, and an improvement plan (CQI) initiated. As a result of the CQI project, post-surgery E.D. visits dropped dramatically. Only one
has occurred since the CQI steps were implemented.

Please see Figure 1 at the back of this report for an example of our CQI process using the “ED Visit Rate within 48 hours” outcomes measure.
Process Improvement steps can include protocol changes, modifications in process, and/or education.

- 4 In-Hospital Mortality: rate of patient mortality prior to discharge for cases in 2016.
- SSI Infections: Rate of surgical site infections; CAUTI: Rate of Catheter-associated urinary tract infections; MDRA: Rate of Multi-drug resistant Acinetobacter.
- 30-Day Readmission: # of readmission cases for all causes as an inpatient within 30 days of discharge in 2016.
- 30-Day Reoperation: # of rate reoperation on the same joint/site within 30 days of discharge in 2016.
- ED (Emergency department) visits within 7 days of surgery: # of patients who visited the ED 7 days after surgery.
The Shoulder and Upper Limb Unit