A new program being spearheaded by surgeons at Johns Hopkins University, Baltimore, and patient safety experts aims to dramatically reduce surgical site infections, which occur in almost a third of colorectal procedures and are a major reason for readmissions.
According to a fact sheet on the Surgical Unit-Based Safety Program (SUSP), each year about 50 million people undergo surgery in the United States. Of those, 1 million develop serious complications and more than 150,000 die within 30 days.
The goals of SUSP are to reduce surgical site infections (SSIs), to document use of checklistlike methods to improve safety, and to document the culture of safety through use of the Hospital Survey of Patient Safety Culture.
SUSP is designed to build on the success of the Comprehensive Unit-Based Safety Program (CUSP), which was developed by the Johns Hopkins Armstrong Institute for Patient Safety and Quality. Results of the CUSP program were recently reported in the Journal of the American College of Surgeons.
The CUSP Study
After CUSP was adopted in 2009 by colorectal surgeons at Johns Hopkins, colorectal surgical site infections were reduced by a third in the first year and saved the hospital $168,000-$280,000, according to the study (J. Am. Coll. Surg. 2012;215:193-200).
Surgical site infections occur in 15%-30% of colorectal procedures and lead to as much as $1 billion in costs for longer admissions, readmissions, and treatment.
"Until now, there’s been little evidence on how to effectively address SSIs among this group of patients," said Dr. Elizabeth Wick of the department of surgery at Johns Hopkins, who was the lead investigator.
Dr. Wick and her associates analyzed outcomes after implementation of CUSP, which was developed by Dr. Peter Pronovost, director of the Armstrong Institute at Hopkins
The Hopkins colorectal CUSP team of 36 people included a representative from surgery, nursing, and anesthesia; a team coach; and a hospital executive who was committed to helping the project, according to the researchers.
After attending a lecture on patient safety, all members of the team completed an anonymous two-question assessment that asked how an SSI might develop in the next patient and what could be done to prevent it.
The team identified 95 areas of concern and picked six interventions to focus on to improve care: standardization of skin preparation and prescription of chlorhexidine showers; restricted use of oral bowel-cleansing solution before a procedure; warming of patients in the preanesthesia area; adoption of enhanced sterile techniques for bowel and skin; and addressing lapses in preoperative prophylactic antibiotics.
The team met monthly, using checklists and monitoring progress to address problems quickly. "The benefits of a bottom-up vs. a top-down approach to patient safety were immediately obvious," said Dr. Wick in a statement.
The study consisted of all consecutive colorectal surgery patients who were included in the American College of Surgeons’ NSQIP (National Surgical Quality Improvement Program) from July 2009 to July 2011. Procedures included open and laparoscopic colectomies and proctectomies, but not abdominal perineal resections. SSI rates that were collected using NSQIP were compared from the first year (2009-2010) to the second year (2010-2011); there were 278 patients in the first cohort and 324 in the second.
During that first year, the 27% (76) of patients had an SSI. By the second year, only 18% (59) of patients had an infection, for a decrease of 33%.
The authors said that CUSP seems to be effective, in part because it bridges the divide between frontline staff and senior leaders. The NSQIP outcome measures also helped the team to effectively monitor SSI rates, said the authors.
CUSP/SUSP in Practice
The CUSP model has been applied successfully to decrease central line–associated bloodstream infections in the intensive care unit, as well as to cut mortality and length of stay in a statewide program, the MHA (Michigan Health and Hospital Association) Keystone Intensive Care Unit project.
The elements of CUSP are not well validated in the operating room, however, and there’s little data on how the program could potentially impact other types of infections or complications – even though the program is in use at 1,200 ICUs in 47 states, said Dr. Sean M. Berenholtz, physician director of inpatient quality and safety at the Armstrong Institute. The aim of the SUSP is to adapt the CUSP practices to the OR, Dr. Berenholtz said in an interview.
Project teams consisting of experts from the Agency for Healthcare Research and Quality (AHRQ), the Armstrong Institute, the American College of Surgeons, the University of Pennsylvania in Philadelphia, and the World Health Organization’s Patient Safety Programme will assist SUSP participants.