FOCUS ON INFECTION PREVENTION Successful Strategies for Prevention of Bariatric and Colectomy Surgical Site Infections Sharon M. Bradley, RN, CIC INTRODUCTION Senior Infection Prevention Analyst Healthcare-associated infections (HAIs) have a significant impact on patients and Regina M. Hoffman, RN, BSN, CPHRM, CPPS healthcare organizations. According to the Centers for Disease Control and Preven- Patient Safety Liaison tion, the socioeconomic impacts of HAIs are divided into three categories: direct Pennsylvania Patient Safety Authority medical costs, indirect costs, and intangible costs (loss of quality of life). Annual direct medical cost benefits after adjusting for infection prevention strategies are estimated at a low of $5.7 billion to a high of $31.5 billion. Annual attributable inpatient hospital ABSTRACT costs for surgical site infections (SSIs) are estimated at $3.45 billion to $10.07 billion.1 The Pennsylvania Patient Safety In December 2010, the Pennsylvania Patient Safety Authority and the Pennsylvania Authority and Pennsylvania hospitals National Surgical Quality Improvement Project (PA-NSQIP) initiated a collaboration participating in the American College targeting reduction of SSIs in the collaborative member group. By June 2013, the of Surgeons (ACS) National Surgi- success of the project was demonstrated by the substantial reduction of SSIs for a sus- cal Quality Improvement Program tained period, improvement in implementation of SSI evidence-based best practices, (NSQIP) entered into a joint quality and improvement in the NSQIP decile place. improvement collaboration to reduce surgical site infections (SSIs) among GOALS Pennsylvania NSQIP member hospitals and to share successful strategies and The collaborative’s short-term goal was performance improvement related to the lessons learned with other Pennsylva- evidence-based process measures in each of the hospitals with high SSI rates (outliers). nia hospitals. Using an SSI prevention The long-term goal was to reduce bariatric and colectomy surgery SSIs in the outlier assessment tool based on the ACS hospitals. This would be demonstrated by a reduction in the SSI rate for each facility, best practices relevant to bariatric and as well as an improvement in the decile place on the American College of Surgeons colectomy surgery, analysts identified (ACS) NSQIP national observed-versus-expected (O/E) ratio. The decile rank is a com- variances between implementation of parative rank by which individual hospital surgical outcome performance is compared best practices in hospitals with high SSI with those of peer hospitals and with national averages in the ACS NSQIP national rates (outliers) and hospitals with low database. ACS NSQIP considers decile 1 to be “exemplary” performance, deciles 2 SSI rates. The outlier hospitals moni- through 9 indicate a hospital is performing “as expected,” and decile 10 is flagged as tored and documented their process “needs improvement.” steps, barriers, successes, and outcome In addition to the reduction of SSIs in the outlier facilities, the lessons learned from measures for implementation of SSI the process and outcome successes would be shared with other Pennsylvania hospitals. prevention practices in bariatric and Other hospitals would then be able use this information when implementing improve- colectomy procedures selected from ment plans to reduce SSIs. the variance assessment. Both the col- ectomy and the bariatric outlier sites METHODS demonstrated substantial improvement in their SSI rates from the 2010 baseline In the first phase of the project, each of the eight PA-NSQIP member hospitals pro- period to March 2013. This improve- vided SSI data from two ACS NSQIP sources—the 2009 ACS NSQIP annual report ment was accompanied by enhanced and a completed survey on the O/E ratio and decile ranking for the surgical categories implementation of best-practice systems listed in that report. Those surgical categories included general surgery, vascular sur- and processes. (Pa Patient Saf Advis gery, and colorectal surgery. Authority analysts identified two high-performer hospitals 2014 Jun;11[2]:82-7.) (with SSI rates lower than expected) and two outlier hospitals (with SSI rates higher than expected) in the general surgery category. Facilities were selected based on their Corresponding Author reported O/E ratio, decile ranking, and individual performance in the selected catego- Sharon M. Bradley ries. Authority staff conducted a secondary analysis of the two outlier hospitals with the highest SSI rates in the general surgery category and established that the highest Scan this code rate of SSIs was in colectomy surgery for one outlier and in bariatric surgery for the with your mobile second outlier. device’s QR On-site visits were conducted at each of the two high-performer hospitals and the two reader to access outlier hospitals to determine if there were differences in implementation of surgical the Authority's best practices in bariatric and colectomy surgery. On-site visits were conducted by two toolkit on this topic. separate bariatric and colectomy teams consisting of key Authority and PA-NSQIP Page 82 Pennsylvania Patient Safety Advisory Vol. 11, No. 2—June 2014 ©2014 Pennsylvania Patient Safety Authority staff. The on-site visits were conducted Collaborative teams from each of the for collaborative leadership and team using the framework of an SSI preven- two outlier hospitals selected process members. The Patient Safety Knowledge tion assessment tool that was based on measures for implementation and mea- Exchange (PassKey), a password-protected, the ACS comprehensive list of existing surement from the on-site assessment dedicated website created and maintained evidence-based guidelines. The practices analysis of the differences between the by the Authority, provided a virtual most relevant to bariatric and colectomy high performers’ and the outliers’ imple- collaboration forum to post tools, bibliog- surgery were selected for the assessment mentation of best practices. raphies, and data analysis information. tool. Interviews with nursing staff, sur- The bariatric outlier initially selected the The two outlier hospitals in bariatric geons, and anesthesia providers were following process measures: and colectomy surgery SSIs developed conducted during the on-site visits. hospital-specific implementation strate- Authority staff analyzed the on-site assess- —— Number of patients who have glyco- sylated hemoglobin A1c drawn prior gies based on their selected process ment results and determined that the measures identified from the variance high-performing facilities (those with the to surgery assessment. The Authority developed a low SSI rates) had stricter adherence to —— Number of patients with a hemo- facility-specific, three-part data collection the best-practice guidelines. globin A1c level over 8% who tool that provided the two outlier hospi- had surgery The on-site assessment interviews iden- tals with a secure, web-based location to tified major differences between the —— Number of patients who received document, track, and measure progress. high-performer and the outlier hospitals chlorhexidine gluconate (CHG) wipes The tool included data on monthly for bariatric and colectomy procedures. on the morning of the procedure implementation of selected process mea- These differences were published in a —— Number of patients who received sures, SSI rates over time, a comparison December 2012 Pennsylvania Patient Safety a Peridex swish on the morning of of ACS NSQIP decile placement, and a Advisory article. The Advisory article and the procedure monthly narrative of steps and barriers to assessment tool are available on the The colectomy outlier initially selected the implementation. Confidential PA-NSQIP Authority’s website at http://patient following process measures: internal hospital reports provided infor- safetyauthority.org/EducationalTools/ mation on wound class and SSI category. —— Number of patients who have docu- PatientSafetyTools/ssi/Pages/home.aspx. Outcome measures included raw numbers mentation that the surgical bundle Both provider-specific and organizational was fully implemented of SSIs, rate of SSIs per 1,000 patient- variations in practice were observed when —— Number of patients who have skin days, and the ACS NSQIP decile ranking high performers were compared with edge protection used during surgery based on the O/E ratio for SSIs data outliers in both bariatric and colectomy from the available national ACS NSQIP —— Number of patients who have antibi- surgeries. Bariatric outlier interviews reports. Authority staff analyzed process otic redosing for a procedure lasting revealed variation in preoperative measure implementation based on the more than four hours measurement of arterial blood gas and number of processes correctly imple- hemoglobin A1c, postoperative upper gas- In the second phase of the project, from mented for each surgical procedure trointestinal studies, and the involvement July 2012 through March 2013, the two during the same period. Results were of residents in the procedure. Colorectal outlier hospitals monitored and docu- further quantified by the specific type outlier interviews revealed variation in mented steps, barriers, successes, and of SSI (superficial, deep incisional, or history of steroid use, albumin checks, outcome measures for implementation of organ/space) and by wound category patient and site preparation, decisions the selected SSI prevention practices in (clean, clean/contaminated, contami- of diversion versus colostomy, wound bariatric and colectomy procedures. nated, or dirty/infected). protection and closure methods, antibi- Key Authority staff provided the collabo- otic timing with prolonged procedures, ration with overall coordination, project RESULTS operating room (OR) cleaning, traffic management, and technical support. The baseline period for measuring control, and handoffs. Provider-specific The Authority served as an independent SSI rates was calendar year 2010. The variation in bowel preparation was identi- facilitator to analyze facility-level SSI data, baseline process measurement period was fied in both groups. In addition, on-site to collect any additional data provided July through August 2012, followed by interviews identified organizational varia- directly by the participating hospitals, the process implementation measurement tions in both the bariatric and colectomy and to produce reports for the collab- period of September 2012 through March outliers regarding communication, safety orative. The Authority hosted monthly 2013. The SSI rate outcome period was briefings, and transport. topic-specific coaching and content calls Vol. 11, No. 2—June 2014 Pennsylvania Patient Safety Advisory Page 83 ©2014 Pennsylvania Patient Safety Authority FOCUS ON INFECTION PREVENTION July 2012 through March 2013. The ACS Figure 1. Bariatric and Colectomy Surgical Site Infection Outcomes NSQIP national 2010 and 2012 decile reports with O/E ratios for SSIs were used SSIs PER 100 CASES to determine improvement in the O/E 20 19.4 ratio for SSIs compared with ACS NSQIP hospitals nationwide. Bariatric SSI Outcome 15 Improvement In the baseline period, the bariatric 12.2 outlier hospital’s SSI rate was 2.3 per 100 cases of bariatric surgery. Further 10 baseline measures included the following: —— Superficial SSIs accounted for 66.7% (6 of 9) of the SSIs in the baseline period. Organ/space SSIs accounted 5 for 33.3% (3 of 9) of the SSIs. —— All 9 SSIs were in the clean/contami- 2.3 MS14249 nated wound category. 0.3 —— The hospital was in the 10th decile 0 according to the ACS NSQIP national O/E ratio for SSIs. Bariatric Colectomy At the end of the implementation period, TYPE OF PROCEDURE the bariatric outlier hospital’s SSI rate decreased from 2.3 per 100 cases to Baseline period (2010) 0.3 per 100 cases (p value = 0.036). See Figure 1. Additional findings are Implementation period (July 2012 through March 2013) as follows: —— The 1 SSI in the implementation period was a superficial SSI in the —— 71.9% of patients (46 of 64) received morning of the procedure increased clean/contaminated wound category. CHG wipes the morning of the to 90.8% (207 of 228). —— There were no deep incisional or procedure. —— The percentage of patients who organ space SSIs. At the end of the implementation period, received CHG wipes the morning —— The hospital improved to the eighth analysis of the bariatric outlier hospital’s of the procedure increased to 81.6% decile according to the ACS NSQIP implementation of the selected process (186 of 228 patients). national O/E ratio for SSIs. measures demonstrated the following (see Figure 2): Colectomy SSI Outcome Bariatric Surgery Process —— The percentage of patients who took Improvement Improvement a CHG bath the night before surgery In the 2010 baseline period, the colectomy In the baseline period, analysis of the increased to 72.8% (166 of 228). outlier hospital’s SSI rate was 19.4 SSIs bariatric outlier hospital’s process This measure was added in response per 100 cases of colectomy surgery. implementation of the selected process to the decision to not implement the Further baseline measures included measures demonstrated that hemoglobin A1c measure within the the following: project time frame due to multiple —— Superficial SSIs accounted for 73.1% —— 62.5% of patients (40 of 64) took a system issues. (19 of 26) of the SSIs in the baseline CHG bath the night before surgery, —— The percentage of patients who period. Of those, 78.9% (15 of 19) —— 68.8% of patients (44 of 64) received received a Peridex oral swish the were clean/contaminated wounds, a Peridex oral swish the morning of 5.3% (1 of 19) were contaminated the procedure, and Page 84 Pennsylvania Patient Safety Advisory Vol. 11, No. 2—June 2014 ©2014 Pennsylvania Patient Safety Authority Figure 2. Bariatric Process Measure Implementation —— 77.8% of patients (21 of 27) were either nonsmokers or quit smoking PROCESS MEASURE more than two weeks prior to surgery, Patients who took a 62.5 —— 70.4% of patients (19 of 27) had chlorhexidine gluconate (CHG) CHG wipes the morning of surgery, bath the night before surgery 72.8 and —— 63.0% of patients (17 of 27) had intraoperative normothermia. Patients who received a Peridex oral 68.8 At the end of the implementation period, swish the morning of the procedure 90.8 analysis of the colectomy outlier hospital’s implementation of the selected process measures demonstrated the following (see 71.9 Figures 3 and 4): Patients who received CHG wipes the morning of the procedure 81.6 —— The percentage of patients with sur- gery time over four hours who had an antibiotic redosed increased to 0 20 40 60 80 100 59.1% (13 of 22). PERCENTAGE —— The percentage of patients who used CHG wipes the night before the sur- Baseline period (July through August 2012) gery increased to 26.4% (34 of 129). MS14250 Implementation period (September 2012 through March 2013) —— The percentage of patients who had skin edge protection during surgery increased to 27.1% (35 of 129). —— There were no improvements in the wounds, and 15.8% (3 of 19) were —— Organ/space SSIs accounted for percentages of patients who were dirty/infected wounds. 36.8% (7 of 19) of the implementa- either nonsmokers or quit smok- —— Organ/space SSIs accounted for tion period SSIs. Of those, 100% ing more than two weeks prior to 26.9% (7 of 26) of the SSIs in the (7 of 7) were clean/contaminated surgery, who had CHG wipes the baseline period. Of those, 71.4% wounds. morning of surgery, or who had (5 of 7) were clean/contaminated —— The hospital improved to the eighth intraoperative normothermia. and 28.6% (2 of 7) were dirty/ decile according to the ACS NSQIP infected wounds. national O/E ratio for SSIs. DISCUSSION —— The hospital was in the 10th decile In phase 2 of the project, the bariatric and according to the ACS NSQIP Colectomy Surgery Process colectomy outlier hospitals documented national O/E ratio for SSIs. Improvement their monthly progress toward imple- At the end of the implementation period, In the baseline period, analysis of the mentation of the process measures they the colectomy outlier hospital’s SSI rate colectomy outlier hospital’s process selected from the comparison document. decreased from 19.4 per 100 cases to implementation of the selected process Recommendations for the use of preoper- 12.2 per 100 cases (p value = 0.047). measures demonstrated that ative CHG wipes and Peridex mouthwash See Figure 1. Additional findings are —— 33.3% of patients (2 of 6) with for all bariatric patients were discussed as follows: surgery time over four hours had an with infection control staff and with the antibiotic redosed, bariatric surgery director. All bariatric —— Superficial SSIs accounted for 63.2% surgeons agreed to order CHG wipes and (12 of 19) of the SSIs in the imple- —— 18.5% of patients (5 of 27) used Peridex oral swish preoperatively, and mentation period. Of those, 83.3% CHG wipes the night before the these were added to the standard bariatric (10 of 12) were clean/contaminated surgery, order sets. Documentation of both pro- wounds, 8.3% (1 of 12) were con- —— 25.9% of patients (7 of 27) had skin cess measures was discussed with the OR taminated wounds, and 8.3% (1 of edge protection during surgery, director of education. The surgical staging 12) were dirty/infected wounds. Vol. 11, No. 2—June 2014 Pennsylvania Patient Safety Advisory Page 85 ©2014 Pennsylvania Patient Safety Authority FOCUS ON INFECTION PREVENTION Figure 3. Colectomy Process Measure Implementation—Improvement area staff were instructed to document Peridex on the medication record and PROCESS MEASURE CHG wipes on the “ticket to the OR.” All patients were given a prescription for Patients with surgery time over four 33.3 a CHG bath at their preoperative admis- hours who had an antibiotic redosed sion testing visit. All bariatric surgeons 59.1 had also implemented wound edge protec- tion in March 2010. This strategy was not Patients who used chlorhexidine 18.5 selected as a new process measure, as com- gluconate (CHG) wipes the pliance with this practice was tracked at night before the surgery 26.4 100% for the entire baseline and process implementation periods. Patients who had skin edge 25.9 Information on differences in imple- protection during surgery 27.1 mentation of best practices between the outlier and the high-performing colec- tomy hospitals identified during the site 0 20 40 60 80 100 visits was shared with the colectomy sur- geons. Process measures that were agreed PERCENTAGE upon to monitor actual compliance included the bundle components (i.e., the Baseline period (July through August 2012) percentages of patients who used CHG MS14251_A wipes the night before the surgery, who Implementation period (September 2012 through March 2013) quit smoking within two weeks of sur- gery, who had CHG wipes the morning of surgery, and who had intraoperative Figure 4. Colectomy Process Measure Implementation—No Improvement normothermia), antibiotic redosing in cases lasting more than four hours, and PROCESS MEASURE wound edge protection. The implementa- tion team identified discrepancies in the Patients who were either 77.8 documentation of these practices and nonsmokers or quit smoking more coordinated with the OR staff to provide than two weeks prior to surgery 67.4 education and to identify and overcome barriers to accurate and complete docu- 70.4 mentation of these measures. Patients who had CHG wipes Surgeon champions presented the chief the morning of surgery 58.9 of colorectal surgery and members of the colorectal surgery division with their 63.0 most recent hospital-specific NSQIP SSI Patients who had data. They also compared their results intraoperative normothermia 56.6 with the ACS NSQIP national average. A review was done of the colectomy best 0 20 40 60 80 100 practices, derived from the site visits, and contrasted the implementation of dif- PERCENTAGE ferent processes of the high-performing and outlier hospitals in colectomy SSI Baseline period (July through August 2012) prevention. The chief of colorectal surgery MS14251_B presented a standardized data sheet to the Implementation period (September 2012 through March 2013) attending surgeons to manually collect this data to ensure compliance. The data sheets were compared with the data input Page 86 Pennsylvania Patient Safety Advisory Vol. 11, No. 2—June 2014 ©2014 Pennsylvania Patient Safety Authority into the “Surgical Care Bundle” screen The outlier hospitals were encouraged in Health Care in a poster titled “Using by the OR nurses. Both outlier hospitals to select three process measures from Cross-Institutional Learning to Reduce continue outcome and process improve- the phase 1 variance assessment. This Surgical Site Infection Rates in Pennsyl- ment beyond the scope of this project by strategy was suggested to ensure sufficient vania.” These activities demonstrated virtue of their continued participation resource allocation to implementation the lessons learned from the process in ACS NSQIP, a nationally validated, activities. The colectomy outlier hospital implementation and outcome successes risk-adjusted, outcomes-based program to endeavored to implement all four ele- and facilitated the goal of sharing of the measure and improve the quality of surgi- ments in the hospital’s SSI prevention successes in implementation of improve- cal care across surgical specialties. bundle, including use of CHG wipes ment plans to reduce SSIs with other the night before and the morning of Pennsylvania hospitals. Cross-institutional Limitations surgery, smoking cessation, and normo- learning about bariatric and colectomy The original project end point was sched- thermia, as well as skin edge protection SSI prevention was facilitated by arrang- uled for June 2013, at which time only and antibiotic redosing for a procedure ing site visits and interactions among the June 2012 through March 2013 cases lasting more than four hours. There was clinical teams from facilities struggling were available for process and outcome initial inconsistency in the colectomy with implementation and their colleagues measurement. This was due to the ACS surgeons’ acceptance of the selected col- from institutions that have achieved and NSQIP data abstraction process, which ectomy process measures. This cultural sustained low SSI rates. begins 60 to 90 days after the case barrier affected the timing and progress The dedication and commitment of is completed. of implementation of systems to achieve PA-NSQIP leadership and teams from compliance with the process measures. each participating facility and col- The bariatric surgical staging area docu- Information technology issues were found mentation process was revised to begin laboration with the Authority resulted in that affected determining which cases substantial beneficial outcomes in the pre- online documentation. It was unclear if lasting more than four hours required documentation was absent or was not vention of bariatric and colectomy SSIs. antibiotic redosing. This took several Those outcomes included the substantial scanned into the chart. Medical records months to correct. was contacted to follow up on documenta- reduction of bariatric and colectomy SSIs tion in the paper medication records. The for a sustained period, the creation of a CONCLUSION collaborative learning network for the surgical staging area educator was con- tacted to remind staff to document on the In November 2013, the project’s suc- prevention of SSIs, and the creation of paper form. Implementation of the hemo- cessful outcome was shared with all comparison reports to measure progress. globin A1c measure was affected by the PA-NSQIP consortium member hospitals Acknowledgments extended time frame between the blood and presented to the American College The authors and the Pennsylvania Patient Safety draw at the initial visit and the date of the of Surgeons’ administrative director of Authority thank the PA-NSQIP collaboration procedure, which is up to 24 months from the Division of Research and Optimal project leaders, staff, and administrators at the Patient Care (Quality Programs). The hospitals who participated in the project and enrollment to the surgery date, as well as invited the Authority to review their data and by inconsistent ordering and multiple phy- project was also selected for poster pre- observe their practices to prevent SSIs. Jonathan sician and nurse practitioner changes in sentation at the December 2013 Institute R. Treadwell, PhD, associate director, Evidence- based Practice Center, ECRI Institute, consulted the facility’s weight management center. for Healthcare Improvement 25th Annual on and contributed to statistical testing for National Forum on Quality Improvement this article. NOTES 1. Scott RD 2nd. The direct medical costs of healthcare-associated infections in U.S. hospitals and the benefits of prevention [online]. 2009 Mar [cited 2013 Dec 27]. http://www.cdc.gov/HAI/pdfs/hai/ Scott_CostPaper.pdf Vol. 11, No. 2—June 2014 Pennsylvania Patient Safety Advisory Page 87 ©2014 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 11, No. 2—June 2014. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2014 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. 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