Clinical FOCUS
Moran Eye Center
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Patient Outcomes & Quality Improvement
AT A GL A NCE Moran Eye Center July 1, 2020 — June 30, 2021
2 02 1 R A NK INGS U.S. NEWS & WORLD REPORT
D OX IM I T Y
No. 11 Nationwide Best Hospitals for Ophthalmology
O P H T H A L M O L O GY T IM E S
No. 6 Nationwide No. 2 in the West Best Residency Education
No. 11 Nationwide Best Overall Program No. 10 Nationwide Best Residency Program
Publications: 170+
No. 11 Nationwide Best Clinical Care Program
Grants and Contracts: $10.4 Million Clinical Trials/Studies: 100+
PAT IE N T V ISI T S By Specialty Neuro-Ophthalmology: 4,549 Cornea/Refractive: 19,282
Comprehensive Ophthalmology/ Cataract: 32,750
Glaucoma: 14,084
Low Vision: 1,009
15 7,17 7 TOTA L PAT IE N T S V ISI T S
Other: 12,911
(includes telehealth) Pediatric: 16,802 Oculoplastics: 6,110
Retina: 19,146
Optometry: 25,337 Uveitis: 5,197
Our Commitment to Quality The John A. Moran Eye Center at the University of Utah is routinely recognized for its exceptional care and has been ranked among the best eye centers in the nation by U.S. News & World Report and Ophthalmology Times. We’re part of an amazing health system that, for 12 years in a row, has been ranked in the Top 10 of participating medical centers nationwide in the Vizient Quality and Accountability Ranking system. Moran’s Quality Improvement (QI) Program, led by Judith E.A. Warner, MD, developed this publication and will launch a website in early 2022 to share information about the quality of our care and how we’re always working to improve it. We are initially sharing patient outcomes from cataract surgeries and endophthalmitis complications and will continue to expand the data sets in the future. The Moran Eye Center is committed to transparency, and we hope this publication assists physicians, our patients, and the public. Sincerely,
RANDALL J OLSON, MD Distinguished Professor and Chair, Department of Ophthalmology and Visual Sciences, CEO, John A. Moran Eye Center, University of Utah
Improving patient outcomes, safety, or other operational issues requires an understanding of the processes involved. Measuring processes to establish baseline data can, at times, be a challenge. Yet since I joined Moran’s Quality Improvement Committee in 1994, I have seen our institution rise to meet these challenges. Our surgery program is a good example. The first goal was to establish a rigorous process to measure surgical complications. Documenting the entire surgical event in the operative note has long been the gold standard, but as our surgical volume increased to more than 7,000 a year, we could no longer read each note to extract data. Instead, we developed a surgical complication
reporting sheet several years ago. This evolved into a form documenting the absence or presence of a complication for every surgery. The process is now second nature to our surgeons and is creating a database second to none in the country. Now we are joining respected colleagues in a process of transparency for the benefit of our field and, most importantly, of our patients.
JUDITH E.A. WARNER, MD Vice-Chair of Quality and Value, John A. Moran Eye Center Professor, Department of Ophthalmology and Visual Sciences, John A. Moran Eye Center, University of Utah
Notable Patient Outcomes Recent outcomes reflect Moran’s dedication to providing exceptional care while fulfilling its teaching role as part of an academic medical center. Moran’s cataract surgery and endophthalmitis complication rates include cases performed with fellows or residents, or both. Moran researchers have also published some of the most influential studies about cataract surgery techniques, safety, and intraoperative complications.1 These complication rates for cataract surgery2 and endophthalmitis, a potentially blinding infection of the tissues or fluids inside the eye following surgery or ophthalmic injections, are among the lowest when compared to known national and international benchmarks.
Cataract Surgery Complications
Cataract Surgery Complications by Type
1.03% with complications
35 cataract extraction procedures with complications
98.97% complications free
Data collected in 2020 shows cataract surgery complications were rare, occurring in only 35 of 3,378 surgeries.
Capsular Breakage (Vitreous Loss) 20 Capsular Breakage 7
Lens Damage 1 Zonular Dehiscence (Vitreous Loss) 3 Zonular Dehiscence 3 Anterior Capsular Tear 1
1. Among the studies: “Cataract Surgery Complications in 1 Year at an Academic Institution.” MF Pingree, AS Crandall, RJ Olson. Journal of Cataract & Refractive Surgery.1999 May;25(5):705-8. 2. Available benchmark data includes a reported 2020 cataract surgery intraoperative complication rate by Cleveland Clinic Cole Eye Institute of 0.85%. Massachusetts Eye and Ear reported a 2019 cataract surgery intraoperative complication rate of 1.6%; comparable 2020 data from the institution was not available at time of printing. 3. Multiple studies in the U.S., Europe, and Asia, put the incidence of post-cataract-surgery endophthalmitis from 0.03% to 0.07%, with the mean at about 1 in 1,500.
Cataract Surgery-Induced Endophthalmitis There were no cases of culture-positive endophthalmitis following uncomplicated cataract surgery in 2020. One possible case investigated in a complicated cataract surgery procedure returned with a negative culture. It was atypical in that it occurred more than five weeks after surgery. Visual outcome was excellent, improving from 20/150 best corrected, to 20/30 uncorrected. This results in an incidence of 0.018% for cataract surgery in 2020.3
All-Specialties Endophthalmitis Data Surgery-Induced Endophthalmitis
0.07% Surgery-induced endophthalmitis
99.93% endophthalmitis free cases
5,551 surgeries (4 cases: 1 positive culture, 3 negative)
Injection-Induced Endophthalmitis
0.11% Injection-induced endophthalmitis
99.89% endophthalmitis free cases
8,690 intravitreal injections (10 cases: 5 infectious endophthalmitis, 5 non-infectious endophthalmitis)
C OMP R E HE NSI V E DATA C OL L EC T ION Casting a wide net, Moran’s QI group and division representatives, University of Utah Health Infection Prevention Department, and others review every potential case of endophthalmitis in the U of U Health hospital system. The team reviews all ocular specimens submitted for culture, all patients receiving intraocular antibiotics, and all cases coded as endophthalmitis. Because Moran is part of a large referral hospital system, there were numerous “external” cases of endophthalmitis, not related to Moran’s facility, reviewed in 2020. Moran’s review of 255 total potential endophthalmitis cases in 2020 detected 8 positive external referral cases, including 1 with post-operative endophthalmitis, 1 with indolent endophthalmitis,
and 6 with endogenous endophthalmitis. There were 4 external cases of traumatic endophthalmitis. Of the 4 internal Moran post-operative cases reviewed, 3 came back with negative cultures. Because of the possibility of falsenegative culture results, Moran includes negative cultures in final complication rate totals for comprehensive data analysis. The 1 positive culture surgery-induced endophthalmitis case occurred following a vitreoretinal procedure. By seeking cases from numerous sources and locations, Moran is rigorous in including not only potential surgical complications, but also traumatic and endogenous cases.
Quality Improvement:
Adopting Best Practices for Exceptional Outcomes
University of Utah Health has led the way as health care systems nationwide pursue process and policy improvements. For the past 12 years, U of U Health has placed among the Top 10 nationally in the Vizient Quality and Accountability Ranking system. At the Moran Eye Center, this commitment extends to a broad range of measures to provide the best possible procedural outcomes. Rigorous Data Monitoring
Moran employs an extensive data monitoring system and communicates well-established expectations to ensure the highest quality of care in clinics and operating rooms. To objectively and prospectively collect information on surgical complications, Moran digitally records every surgery and uses an “every-case-every-time” philosophy for reporting. Every surgeon is expected to attest that there was or was not a complication for every case. This assures surgical complications are reported in all instances. Moran reviews and verifies the reports, comparing them with independent data points, such as equipment or supplies used in surgical cases with complications. For example, every case of endophthalmitis is reviewed by Moran’s QI group and division representatives, U of U Health Infection Prevention Department, and others in the hospital system. A weekly review of intraocular antibiotic injections assures monitors can discover any potential worrisome trends. Infection Prevention Moran adheres to top-rate infection prevention standards set by the Association for the Advancement of Medical Instrumentation, International Association of Healthcare Central Service Materiel Management, Association of periOperative Registered Nurses, Association for Professionals in Infection Control and Epidemiology, and American Society of Ophthalmic Registered Nurses. These organizations are vital in helping Moran maintain current evidencebased best practices. They also provide critical resources for continuing education and certification for ophthalmic medical employees that go beyond state requirements.
Moran sets its high standards in collaboration with U of U Health and its Infection Prevention Department, partners that share the same mission of patient safety and quality care. Moran’s Sterile Processing Department was the first in the U of U Health system to achieve zero percent immediate-use steam sterilization (IUSS), a remarkable achievement for the past four years. IUSS is no longer an acceptable practice, and all instrumentation is now completely reprocessed before it goes back into service. Moran is a national leader in developing infection prevention protocols, including participation in a national task force addressing Toxic Anterior Segment Syndrome (TASS), a rare but potentially sight-threatening condition. Led by Nick Mamalis, MD, co-director of the Intermountain Ocular Research Center based at Moran, the task force helped develop national guidelines for cleaning and sterilizing intraocular surgical instruments to protect eye surgery patients from TASS. Individualized Training and Mentoring Faculty monitor the advancing skill levels of Moran residents and fellows, who gradually perform more complex surgeries as their skill levels increase. Moran faculty members also identify each trainee’s strengths and tailor mentoring to their unique needs—all part of an ophthalmology education program consistently ranked as one of the best in the nation. Residents and fellows train virtually on Moran’s in-house surgical simulator. Moran also recently became a test center for a unique small-incision cataract surgery simulator-based training system by HelpMeSee. Research Projects and Studies Residents and faculty are actively engaged in an extensive QI and clinical studies program. (See boxes below and at right for a few examples.)
Resident QI Projects Moran’s residents are required to design and implement QI projects as part of their training. Recent projects include:
Establishing the Underrepresented Minorities in Medicine (URiM) Scholarship to encourage URiM applicants.
Designing and implementing a revamped reverse-classroom curriculum that stresses interactive blended learning over traditional lectures.
Expanding processes and experiences for the ophthalmology-incorporated intern year.
Providing nocturnal intraocular pressure-measuring devices for Salt Lake City Veteran’s Administration Hospital glaucoma patients.
Developing a protocol for exposure keratopathy in ICU patients.
Faculty Study: Expanding Access to Visual Field Testing Meagan D. Seay, DO, recently led a quality improvement study that found use of a virtual visual field (VVF) device improves patient care in acute hospital settings. The team introduced the virtual visual field devices to inpatient and on-call settings to improve access to formal visual field testing, which is typically only available in comprehensive eye care clinics. While physicians use the device for patients with all types of visual symptoms, the team was particularly interested in the potentially improved outcome for patients admitted for lumbar spine drains placed to treat vision-threatening optic nerve edema. They found the VVF devices to be especially beneficial for patients in the ICU to avoid difficult and potentially dangerous transport to an eye clinic for the testing. The team presented its findings at the 2021 North American Neuro-Ophthalmology Society meeting.
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Coming Soon
Look for our Patient Outcomes & Quality Improvement website in early 2022 at moraneyecenter.org.
Resources for Physicians Refer a Patient 801-213-2001 healthcare.utah.edu/moran/refer-patient.php
Moran CORE Clinical Ophthalmology Resource for Education morancore.utah.edu
John A. Moran Eye Center
Moran Eye Center Annual Reports
NOVEL Neuro-Ophthalmology Virtual Education Library novel.utah.edu WEBVISION The Organization of the Retina and Visual System webvision.med.utah.edu
Subscribe to the monthly Moran Update email by sending your email address to us at moran.info@hsc.utah.edu
CME Information medicine.utah.edu/cme
