Three new studies on reducing surgical site infections (SSIs) were reported at the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) conference in July.
Researchers at three different institutions identified several process changes that, once implemented, brought down SSI rates. Each study used different methodology, but all noted the need for teamwork. Findings from each are described in this article.
“How do you get your SSI rate as low as possible? By doing everything you know how to do to lower the risk,” says E. Patchen Dellinger, MD, FACS, professor of surgery, associate medical director, University of Washington Medical Center, Seattle.
“It’s better to work on one thing at a time,” he advised. “Pick something you want to change, and do it. When you succeed on item one, go to item two, and so on.”
He noted that an SSI should be treated like an accident investigation.
“Look into what was done before and during the procedure to prevent an infection. If you did not do everything you intended to do to lower risk, you have a potentially preventable SSI. But if the investigation shows you did everything you know to lower risk, you have an apparently unpreventable SSI,” he says.
“We’ll never get to zero SSIs, but it would be great if we could get to zero potentially preventable SSIs,” Dr Dellinger says.
Preventing potentially preventable SSIs. Dr Dellinger recommended starting with a simple definition of actions to take when a patient gets an SSI, and then adding to it.
• First action: Look to see if the patient got the right antibiotic and the right dose at the right time. If not, this is a potentially preventable SSI.
• Second action: Check to see if the patient came out of the OR hypothermic. If so, this is a potentially preventable SSI.
• Third action: Find out if the patient was hyperglycemic the day of surgery or the day after. If so, this is a potentially preventable SSI.
Preoperative preventive actions. Preoperative preventive actions that should be taken include evaluation of the patient’s:
• stabilized physiology
• blood glucose level and if the patient is at risk for hyperglycemia
• nutritional status.
Patients also should be cautioned to stop smoking and instructed on the bowel preparation and oral antibiotics for colorectal surgery.
Operative day preventive actions. On the day of surgery, patients should be prewarmed in the holding area, and their blood glucose levels should be checked.
In the OR, the surgical team should:
• use a checklist
• ensure the prophylactic antibiotic is given and repeated if the procedure is long
• warm the patient
• use sterile technique for the skin prep
• use double gloving
• administer a high fraction of inspired oxygen (FiO2).
Not all of these elements have level-one evidence showing their value, but all of them are reasonable and rational, and most are not difficult to do, he says.
“Teamwork, communication, and discipline are critical to preventing SSIs, just as they are critical for every other aspect of safe patient care,” Dr Dellinger says. Using this process, the University of Washington Medical Center dropped their potentially preventable SSI rate in colorectal patients appreciably within 3 years.
The clean wound SSI rate was 0.83% in 2005, 0.59% in 2008, and 0.33% in 2014, and the potentially preventable SSI rate was 46% in 2005, 14% in 2008, and 39% in 2014.
“We started with a simple definition of potentially preventable SSIs. After we got that down we increased the definition, thus increasing potentially preventable SSIs again, but all the while lowering the clean wound infection rate,” says Dr Dellinger.
SSIs add from $10,000 to $25,000 to the cost of care, double the length of stay, are an independent risk factor for mortality, and are the most common reason for unplanned readmissions. SSIs are very high in colorectal surgical patients, occurring in 15% to 30% of patients.
In early 2012, Thomas Jefferson University Hospital, Philadelphia, was identified as a high outlier for colorectal SSIs in NSQIP descriptive data. At the same time, the Pennsylvania Consortium and Pennsylvania Patient Safety Authority were looking at low outliers and what these organizations were doing well that others could learn from.
“We tried to implement what these organizations were doing at Thomas Jefferson, but we were unable to sustain a cultural change,” says surgical resident Daniel Brock Hewitt, MD, MPH.
Resident involvement key. A year later, a hospital program was developed to increase resident involvement in quality improvement projects. Dr Hewitt and his group took on the challenge of colorectal SSIs.
The group did an extensive literature review and found out what successful institutions were doing to lower their colorectal SSI rates. They took the data to the attending surgeons, and developed a colorectal surgical bundle.
Among the highlights of the bundle were:
• checklist for the patient’s chart to be filled in pre-, intra-, and postoperatively
• preoperative smoker cessation program
• preoperative oral antibiotics
• intraoperative barrier wound protection, wound irrigation, and wound closure tray
• intraoperative and postoperative glycemic control.
Within a year’s time, the superficial SSI rate decreased from 8% to less than 2%.
This was the driving factor that lowered the overall SSI rate from 14% to 6.3%, and the hospital is now a low outlier.
Success not without challenges. “We faced significant resistance from a number of people, including residents, fellows, nurses, and faculty,” says Dr Hewitt. “However, with good data, we were able to show them that change was indeed needed, not just for our institution, but for the benefit of our patients,” he says.
One of the first challenges was how to record compliance, which is why the checklist was instituted, he says.
Antibiotic prescriptions were another challenge—how to ensure that patients got the oral antibiotics they had to take the day before surgery.
Dr Hewitt and his group decided on prewritten antibiotic prescriptions that just needed to be signed by the physician and given to the patient during an office visit before the surgery.
Implementing the closing tray proved challenging. There was concern regarding how to incorporate it into the flow of the procedure for both surgeons and supporting staff. However, over time, it was appropriately implemented and is not lengthening operative times.
Takeaway. “What we learned from this experience is to get as many people involved as possible from all of the different levels—administration to scrub technicians,” says Dr Hewitt.
“If they get involved and feel like they have a serious stake in the success of a program, they’re more likely to work for that success,” he says.
In 2012, the NSQIP semi-annual report identified Sacred Heart Medical Center, River Bend, Oregon, as a high outlier with an overall infection rate of 6.05. The major cause of the high rate was a high colorectal SSI rate of 20.71.
“Surgical site infections are the plague of our profession,” says David R. DeHass, MD, FACS, a general, vascular, and colorectal surgeon who is chairman of the quality committee at Sacred Heart. “They’re the most common type of nosocomial infection that we encounter, and colorectal cases account for approximately 38%, by some reports.”
Enhanced recovery pathway. Dr DeHass and members of his quality team developed an enhanced recovery colorectal pathway and incorporated a best practice SSI prevention bundle with pre-, intra-, and postoperative measures. The multidisciplinary team consisted of representatives from the anesthesia department, infection control, pharmacy, nursing, and surgical leadership, along with NSQIP surgical clinical reviewers.
Perioperative measures in the bundle included:
• emphasis on patient education with discharge planning
• bowel prep with oral antibiotics
• preoperative analgesia and nausea prophylaxis
• carbohydrate loading
• judicious use of epidural catheters
• minimally invasive approach when appropriate
• maintenance of intra- and postoperative euvolemia
• avoidance of nasogastric tubes and drains
• minimal intra- and postoperative narcotics
• feeding patients and ambulation immediately after surgery.
Process improvement plan. In early 2012, the general surgeons met, reviewed their NSQIP results, and committed to a process improvement plan, notes Dr DeHass.
The first intervention included chlorhexidine showers the night before and the morning of surgery. Chlorhexidine wipes were implemented in the preoperative holding area, and chlorhexidine preps were standardized in the OR.
In the third quarter of 2012, they standardized the mechanical bowel preparation with oral antibiotics, standardized the use of wound protectors, protocolized their Surgical Care Improvement Project (SCIP) bundle compliance, and introduced a colorectal order set.
The fourth quarter of 2012 brought implementation of Bear Paws for postoperative warming.
In the first quarter of 2013, the full colorectal enhancement recovery pathway was implemented, and a SCIP reviewer was hired to provide surgeons with immediate feedback if they missed one of the key SCIP measures.
In addition, it was decided to institute gown changes before wound closure.
For quarter two of 2013, the clean closure process was reviewed and reintroduced to staff and surgeons. In addition, carbohydrate loading was added to the colorectal pathway.
In the first quarter of 2014, members of the quality team and the general surgeons group met and reevaluated the colorectal pathway and assessed whether there were areas where further gains could be made.
From 2011 to the last quarter of 2014, the colorectal SSI rate decreased from 17.32% to 0 infections, and the cost savings was conservatively estimated at $1.6 million. ✥