NEW YORK – Facing an “unacceptably high” rate of surgical site infections associated with colorectal surgery at their community hospital, surgeons searched for solutions. They created a perioperative bundle of interventions that ultimately dropped their infection rates enough to achieve the highest ranking in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP).
“The Centers for Disease Control and Prevention recommends we use a robust surveillance program to monitor surgical site infection data. The system gives us feedback, and that will [help us] reduce surgical site infection (SSI) risk,” said Christopher Wolff, MD, a PGY4 resident at the Cleveland Clinic Akron General Hospital. “NSQIP and the National Healthcare Safety Network from the CDC are two programs that do just that.”
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The effort paid off, with the number of SSIs going from 16 cases in 2013 to 10 cases in 2014 and then 5 cases in 2015. Since the bundle was implemented in the last quarter of 2014, “we’ve seen a consistent downtrend since that point in our total infections, and we kept that in the background of a consistent number of cases.
“We have good outcomes by incidence, but that is not the whole story,” Dr. Wolff said. “With respect to colorectal infections, we are now performing in the ‘exemplary’ category, compared with our peers” according to the ACS NSQIP data. In addition, “we are performing at or below the SIR [standardized infection ratio] or expected number consistently since the implementation.”
The bundle addresses actions in five domains: preoperative, anesthesia, operating room, post–anesthesia care unit, and postoperative floor interventions. Preoperative elements include patient education, use of chlorhexidine wipes before surgery, and antibiotics noted on the chart, for example. Additional features include prewarming preoperatively and maintaining normothermia, requiring all surgeons scrub traditionally instead of “foaming,” use of wound protectors in the OR, and close monitoring of blood glucose in diabetics postoperatively. “There also is education of floor nurses on how to take care of these patients specifically,” Dr. Wolff noted.
To identify these areas for improvement, Dr. Wolff and his colleagues initially reviewed the literature to find individual and bundle elements demonstrated to improve outcomes. Then, a surgeon group “think tank” discussed the possibilities. However, reaching agreement was not easy, Dr. Wolff said. “They had a hard time agreeing on best practices, even within our own specialty. We did finally come to a consensus.
“We took those bundled protocols through to other areas and said ‘here are the things we want you to work on, things we want you to improve.’ That did not necessarily go over so well,” Dr. Wolff said. Because of resistance from their colleagues, they changed strategies. “We brought other people to the table and changed our work groups from being surgeons only to [being] a multidisciplinary team.”
The process took months and months of deliberation. It’s important to have a champion behind the project, said Dr. Wolff. “I have to thank my chairman, Mark C. Horattas, MD, FACS, who had the vision to see this through.
“We implemented tried-and-true measures to reduce surgical site infections. We did so in a team manner and had multidisciplinary buy-in, and that created a culture change in our program over time,” Dr. Wolff said.
This study also shows, Dr. Wolff added, that “a successful multidisciplinary quality improvement program can be implemented in a community hospital setting.”
Going forward, continuous monitoring will identify any areas that need improvement over time. The preoperative bundle also will be integrated into an Enhanced Recovery After Surgery protocol.
The Akron Hospital is now ranked by ACS NSQIP in the top 10% of hospitals for their colorectal SSI rate. “It’s nice to meet someone in the first decile,” session moderator Timothy D. Jackson, MD, FACS, of the University of Toronto said after Dr. Wolff’s presentation. “I’ve never done that before, and I took notes for what to do at my hospital.”
Dr. Wolff had no relevant financial disclosures.