ORIGINAL CONTRIBUTION
Implementation of Surgical Quality Improvement: Auditing Tool for Surgical Site Infection Prevention Practices Elizabeth M. Hechenbleikner, M.D.1 • Deborah B. Hobson, R.N.1,2 Jennifer L. Bennett, B.A.1 •Elizabeth C. Wick, M.D.1 1 Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland 2 Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, Maryland
BACKGROUND: Surgical site infections are a potentially preventable patient harm. Emerging evidence suggests that the implementation of evidence-based process measures for infection reduction is highly variable. OBJECTIVE: The purpose of this work was to develop an
auditing tool to assess compliance with infection-related process measures and establish a system for identifying and addressing defects in measure implementation. DESIGN: This was a retrospective cohort study using electronic medical records. SETTING: We used the auditing tool to assess compliance with 10 process measures in a sample of colorectal surgery patients with and without postoperative infections at an academic medical center (January 2012 to March 2013). PATIENTS: We investigated 59 patients with surgical site
infections and 49 patients without surgical site infections. MAIN OUTCOME MEASURES: First, overall compliance
rates for the 10 process measures were compared between patients with infection vs patients without infection to assess if compliance was lower among patients with surgical site infections. Then, because of the burden of data collection, the tool was used exclusively to evaluate quarterly compliance rates among patients with Financial Disclosures: None reported. Presented at the meeting of The American Society of Colon and Rectal Surgeons, Hollywood, FL, May 17 to 21, 2014. Correspondence: Elizabeth C. Wick, M.D., Johns Hopkins University School of Medicine, Blalock Room 618, 600 N Wolfe St, Baltimore, MD 21287. E-mail: [email protected] Dis Colon Rectum 2015; 58: 83–90 DOI: 10.1097/DCR.0000000000000259 © The ASCRS 2014 Diseases of the Colon & Rectum Volume 58: 1 (2015)
infection. The results were reviewed, and the key factors contributing to noncompliance were identified and addressed. RESULTS: Ninety percent of process measures had lower compliance rates among patients with infection. Detailed review of infection cases identified many defects that improved following the implementation of systemlevel changes: correct cefotetan redosing (education of anesthesia personnel), temperature at surgical incision >36.0°C (flags used to identify patients for preoperative warming), and the use of preoperative mechanical bowel preparation with oral antibiotics (laxative solutions and antibiotics distributed in clinic before surgery). Quarterly compliance improved for 80% of process measures by the end of the study period. LIMITATIONS: This study was conducted on a small surgical cohort within a select subspecialty. CONCLUSIONS: The infection auditing tool is a useful strategy for identifying defects and guiding quality improvement interventions. This is an iterative process requiring dedicated resources and continuous patient and frontline provider engagement. KEY WORDS: Quality improvement; Infection; Colorectal surgery; Outcomes; Public reporting; National Surgical Quality Improvement Program.
S
urgical site infection (SSI) is a leading publically reported surgical outcome and is now being tied to hospital payment determinations. As a result, hospitals are devoting significant resources to reducing SSIs. Colorectal surgery has emerged as a particular area of focus because it has some of the highest infection rates among abdominal surgery cases, ranging from 3% to 25%.1 Despite the extensive focus on SSI prevention in national quality initiatives like the Surgical Care Improvement 83
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Project (SCIP), emerging evidence suggests that adherence to perioperative SCIP guidelines alone is not enough to prevent SSIs.2 New guidelines for effective surgical antimicrobial prophylaxis have recently been published,3 and the Healthcare Infection Control Practices Advisory Committee guidelines for SSI prevention are presently under revision. Integrating advanced SSI prevention practices or process measures from new guidelines into practice represents an opportunity for further quality improvement in established processes of care. Although new guidelines and studies support the implementation of additional processes, translating this research into practice has been a challenge, and wide variation in practice exists throughout the country. In the primary care setting, a recent study demonstrated that physician prescribing habits did not change after implementing a comprehensive, multifaceted educational program for improving adherence with updated guidelines for antihypertensive drug management.4 Among surgical patients, investigating the ability to translate non-SCIP SSI process measures into everyday practice is an important part of understanding potential lapses in perioperative care and should be performed with a structured, organized approach. To identify and address defects in daily practices, we created an auditing tool to assess compliance with SSI process measures that go beyond SCIP. The purpose of this study was to provide a systematic framework for investigating compliance with SSI process measures, implement targeted quality improvements to prevent recurrence of defects identified, and evaluate the overall impact on SSI reduction.
MATERIALS AND METHODS Background
Johns Hopkins Hospital has participated in the targeted colectomy and proctectomy procedure module of the American College of Surgeons’ National Surgical Quality Improvement Program (ACS-NSQIP) since 2009. Colon and rectal resections are identified by the following Current Procedural Terminology codes: colon – 44: 140–141, 143–147, 150–151, 155–158, 160, 204–208, 210–212; rectal – 45: 110–114, 116, 119–121, 123, 126, 130, 135, 160, 395, 397, 402, 550. ACS-NSQIP data collection methodologies have been previously described in detail.5,6 In this study, all patients undergoing emergent surgery were eliminated because standard process measures may not be applicable in an emergent situation. Participation in the colorectal surgery module brought to light a very high SSI rate (27%) among this patient population. To address the higher-than-expected SSI rate, we used the Comprehensive Unit-Based Safety Program (CUSP) methodology.7 In brief, a group of frontline anesthesiology, surgery, and nursing providers partnered
Hechenbleikner et al: Surgical Site Infection Auditing Tool
with a senior hospital executive to reduce the colorectal SSI rate. This group was trained in the science of safety and systems-level thinking. All providers were asked to complete a brief questionnaire as follows: 1) How will the next patient be harmed or develop an SSI? and 2) How can we prevent the next patient from being harmed or developing an SSI? Based on the results of this questionnaire and further discussion, the CUSP group identified 5 key areas of perioperative patient care for improvement including the development of a consistent team of anesthesia and nursing providers, intravenous antibiotic selection, temperature management, surgical site skin preparation, and preoperative bowel preparation. Despite an initial 33% reduction in the NSQIP colorectal SSI rate from 27% (2009–2010) to 18% (2010–2011) during the 12 months following CUSP implementation, SSI rates subsequently plateaued and continued to be higher than expected. Interestingly, a self-reported survey of patients on the day of surgery demonstrated significant noncompliance with the mechanical bowel preparation (MBP) (data not shown). This prompted further systemic evaluation of the processes. SSI Auditing Tool Development and Data Collection
Instead of addressing the refractory SSI rate with additional interventions, the group focused on measuring and improving compliance with current process measures. In January 2012, the CUSP team developed an auditing tool for key process measures spanning the 5 areas of patient care improvement related to SSI prevention as previously described (Fig. 1). Ten specific measures were collected with the tool as follows: 1) consistent anesthesia team member in the operating room (OR), 2) consistent nursing team member in the OR, 3) correct gentamicin dosing (5 mg/kg), 4) correct cefotetan redosing (every 6 hours), 5) use of forced air warming device in preoperative area, 6) temperature at time of surgical incision >36.0°C, 7) temperature immediately postoperatively >36.0°C, 8) chlorhexidine washcloth used preoperatively, 9) standardized skin preparation of the surgical site by trained personnel, and 10) MBP with oral antibiotics before surgery. All compliance data were available in the electronic medical record. Two clinicians (D.H., J.B.) conducted a retrospective chart review with the auditing tool to collect data for the SSI process measures. Because of the burden of data collection, the tool was to be used just to audit compliance in patients in whom SSIs developed under the assumption that this group of patients would likely have lower compliance than the overall group of patients. To validate this approach, the tool was used for 2 months to audit all patients (with and without SSIs). After this initial period, data collection was exclusively done on patients who developed an SSI.
Diseases of the Colon & Rectum Volume 58: 1 (2015)
Figure 1. Surgical site infection (SSI) process measures auditing tool. ABX = antibiotic; CUSP = Comprehensive Unit-Based Safety Program.
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Interpretation of Tool and Analysis
The auditing tool provided a structured, deeper look into SSI cases and helped identify defects in the new SSI process measures. Any defects identified via tool measures were then directly discussed with the providers responsible for implementing those measures to understand the contributing factors, increase awareness, and allow for the correction of those gaps in patient care. First, overall compliance rates for each of the 10 individual SSI process measures were compared between all SSI vs non-SSI cases to determine if SSI cases had lower rates and where to focus our quality improvement interventions. Next, we measured the quarterly compliance rates for all 10 process measures across the study period for patients with SSIs to evaluate consistency and improved compliance. This study was approved by the Johns Hopkins Hospital Institutional Review Board. Statistical Analysis
Patient characteristics and perioperative factors were compared between SSI and non-SSI cases to assess for significant differences; pairwise t tests were performed for continuous variables, and the Fisher exact test was used for categorical data. Compliance rates for process measures among all SSI vs non-SSI cases were compared by using the Fisher exact test. Groups were considered significantly different at a p value of g rd ne tu 36 ize w re °C d as > M ski hcl 36° BP n ot C + pre h u or pa se al ra an ti tib on io tic s
% Compliance 100 90 80 70 60 50 40 30 20 10
Process measures
Figure 2. Compliance data for process measures in all SSI vs nonSSI cases. SSI = surgical site infection; MBP = mechanical bowel preparation.
ance the need for reliable data with the burden of manual data collection. The tool was effective at identifying multiple defects in process measures among patients with SSIs to allow for focused quality improvement interventions. Key processes with poor compliance based on baseline compliance rates and comparison with non-SSI cases were as follows: 1) correct gentamicin dosing, 2) correct cefotetan redosing, 3) temperature at time of surgical incision >36.0°C, 4) standardized surgical site skin preparation by trained personnel, 5) chlorhexidine washcloth used preoperatively, and 6) MBP with oral antibiotics before surgery. Upon further investigation with front-line providers and patients, contributing factors for the defects in SSI compliance measures and responsible providers were identified and system changes were implemented to prevent recurring defects (Table 2). Compliance Rates With SSI Process Measures
Quarterly compliance rates for all 10 process measures among patients with SSIs are shown in Figure 3. At the beginning of the study period (first quarter (Q1) 2012), correct cefotetan redosing and temperature at the time of surgical incision >36.0°C had the lowest compliance rates at 20% and 22%; in contrast, a consistent nursing team member in the OR and temperature immediately postoperatively >36.0°C had the highest compliance rates at 78% and 100%. All other SSI process measure compliance rates during Q1 2012 fell between 40% and 60%. At the end of the study period (Q1 2013), 8 process measure compliance rates increased by a median of 31% (range,
9%–50%) from Q1 2012, whereas a consistent anesthesia team member in the OR and temperature immediately postoperatively >36.0°C decreased by 4% and 13% (data not shown). Of note, there was great variability in compliance rates among all 10 SSI process measures across the entire study period. Two measures (correct gentamicin dosing, temperature at time of surgical incision >36.0°C) demonstrated consistent quarterly improvement from baseline (Q1 2012) compliance rates, whereas only 1 measure (preoperative forced air warming) had consecutively increased quarterly compliance rates during the study period (Q2 2012 through Q1 2013). Notably, significantly lower compliance rates among all SSI cases (n = 59) compared with all non-SSI cases (n = 49) were found for 2 measures: 1) standardized skin preparation of surgical site by trained personnel (59% vs 82%; p = 0.02) and 2) MBP with oral antibiotics before surgery (49% vs 87.5%; p = 0.001) (Figure 2). Quarterly Colorectal SSI Rates
Before implementing the SSI auditing tool, Q4 2011 colorectal SSI rates were greater than 22% (Fig. 4). A consistent decrease was noted in quarterly SSI rates after implementing the SSI auditing tool in Q1 2012; the largest decreases occurred during Q1 2012 (SSI rate, 14.1%– 15.1%) and Q3 2012 (SSI rate, 11.0%–11.5%).
DISCUSSION The implementation of an auditing tool for colorectal SSI cases was a successful systematic method for tracking compliance with SSI prevention process measures that balanced the need for providing data to drive improvement with the burden of manual data abstraction. This tool was intended to educate and engage the multidisciplinary perioperative team in SSI prevention practices by using empiric evidence from their daily practices. Knowing that compliance was less than 100% drove providers to further investigate and mitigate barriers with system-level interventions. For example, after identifying that patient compliance with the prescribed preoperative bowel preparation was poor, evaluation of the process and interviews with patients revealed that patients were frequently overwhelmed on the day of their office visit and missed some of the preparatory details for surgery. Many of the surgical patients also did not understand the reason for the bowel preparation with oral antibiotics or its role in SSI prevention. In addition, patients in rural areas were frequently not able to obtain the bowel preparation medications from their pharmacy before surgery. To address these gaps and other defects, the team implemented the following interventions: 1. A patient-centered educational curriculum was created on an interactive tablet by using the teach-back method
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Hechenbleikner et al: Surgical Site Infection Auditing Tool
Table 2. Contributing factors, disciplines, and interventions for SSI process measures with poor compliance (SSI cases only) SSI process measures with poor compliance Correct gentamicin dosing (5 mg/kg) Correct cefotetan redosing (every 6 hr) Temperature at time of surgical incision >36.0°C)
Standardized skin preparation by trained personnel Chlorhexidine washcloth used preoperatively
Mechanical bowel preparation with oral antibiotics
Primary discipline involved
Contributing factors Lack of follow-through with appropriate weight-based dosing Lack of understanding of correct antibiotic redosing interval based on updated guidelines Poor designation of patients in the preoperative area for forced air warming Insufficient forced air warming devices in preoperative area Insufficient ambient room temperature in OR Lack of standardized education process and training for attending physicians, residents, and OR staff involved in skin preparation Lack of patient education regarding the importance of using chlorhexidine washcloths before surgery Poor distribution of washcloths in the clinic before surgery Lack of patient education regarding the importance of completing a mechanical bowel preparation with oral antibiotics before surgery Patients had difficulty obtaining bowel preparation and oral antibiotics at local pharmacies
Anesthesia
Targeted interventions Increased awareness and accountability by CUSP champions in OR Increased education and awareness by CUSP champions in OR
Anesthesia Nursing
Electronic flag placed on case schedule to identify patients for preoperative warming Increased number of forced air warming devices in preoperative area Ensured ambient OR temperature > 22.2° C or > 72° F
Surgery and nursing
Dedicated skin preparation team created Individuals participating on team completed a standardized tutorial and training
Surgery
Dedicated patient education materials distributed in clinic along with washcloths before surgery
Surgery
Dedicated patient education materials distributed in clinic along with bowel preparation, oral antibiotics, and directions on usage
CUSP = Comprehensive Unit-Based Safety Program; OR = operating room; SSI = surgical site infection.
% Compliance 100 90 80 70 60 50 40 30 20 10
Q1 2012 Q2 2012 Q3 2012 Q4 2012 Q1 2013
es th e N si Co urs a te rre in am g Pr Co ct g tea me eo rre e m m pe ct nta m be 1s T rat ce mi em r t P em iv fo cin b os pe e f tet d er to ra orc an os pe tu e re in ra re d d g Ch tiv at air w osi lo e te inc a ng St rh m is rm an ex p io in da idi era n > g rd ne tu 36 ize w re °C d as > M ski hcl 36° BP n ot C + pre h u or pa se al ra an tio tib n io tic s
The team was able to improve quarterly compliance with 80% of SSI process measures by the end of the study period but only had consecutively increasing quarterly compliance rates for 1 measure; although these results are only among patients who developed SSIs, this highlights the difficulty of achieving consistent adherence to daily prevention practices. Furthermore, we noted that, in general, providers and patients were less compliant with process measures in SSI vs non-SSI cases. These results can
be interpreted in 2 ways. First, these SSI process measures are directly related to infection, and, in patients where providers were noncompliant with measures, the risk of
An
of adult learning.8 This curriculum was aimed at further educating patients on the importance of the use of a MBP with oral antibiotics and chlorhexidine washcloths before surgery to reduce their risk of a SSI. The curriculum was administered to patients at their preoperative clinic visit. 2. All MBP materials (laxatives and oral antibiotics) were given to the patient in the outpatient clinic when they scheduled their surgery. 3. Phone calls to patients were made by the surgical scheduling office approximately 2 days before surgery to remind patients to begin the MBP with oral antibiotics and to use the chlorhexidine washcloths. 4. Nurses in the preanesthesia area began administering chlorhexidine washcloths to patients who did not use their washcloths at home.
Process measures
Figure 3. Quarterly compliance data for process measures among SSI cases. SSI = surgical site infection; MBP = mechanical bowel preparation; Q1 = first quarter; Q2 = second quarter; Q3 = third quarter; Q4 = fourth quarter.
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Colorectal SSI Cases, % 30.0
25.0
20.0
15.0
10.0
5.0
Risk-adjusted administration data All NSQIP colorectal cases NSQIP CUSP surgeon colorectal cases
Q4 2011 22.4% 24.7% 27.5%
Q1 2012 15.1% 15.1% 14.1%
Q2 2012 22.2% 21.1% 16.4%
Q3 2012 11.5% 11.5% 11.0%
Q4 2012 16.2% 18.2% 19.2%
Q1 2013 18.9% 18.9% 19.2%
Figure 4. Quarterly colorectal SSI rates based on administrative and NSQIP data. SSI = surgical site infection; NSQIP = National Surgical Quality Improvement Program; CUSP = Comprehensive Unit-Based Safety Program; Q1 = first quarter; Q2 = second quarter; Q3 = third quarter; Q4 = fourth quarter.
SSI was greater. Second, in cases where providers were mostly or completely compliant with all process measures, this represented a highly functioning team taking care of an engaged patient such that the execution of perioperative patient care was fully optimized, leading to a reduction in SSI risk. Despite the multidisciplinary approach and significant time investment in weekly meetings toward addressing poor compliance with prevention measures and patient care defects, it was only possible to achieve 100% quarterly compliance on 1 SSI process measure (correct gentamicin dosing) throughout our study period. The processes spanned inpatient and outpatient settings and required both patient and provider engagement for compliance; adherence to these patient care measures is intrinsically complex and challenging and often involves multiple disciplines. Regardless of the inherent challenges, the multidisciplinary operative team should continuously work toward improving care through a critical review of data and continuously evaluating quality improvement initiatives and providing feedback to a team helps achieve greater perceived effectiveness.9 Team-driven rather than hierarchical and bureaucratically driven approaches to quality improvement initiatives promote greater implementation of those initiatives.10 Ultimately, the use of the team that directly cares for the patients is ideal to promote quality improvement. Studies support the use of cross-
departmental teams for introducing quality improvement along with empowering team members to identify patient care defects and taking action to improve on the defects.10,11 We believe the value of our SSI auditing tool cannot be fully appreciated or measured, because, in large part, it is derived from engaging providers in team-based quality improvement processes and sometimes only through this engagement can strides be made toward changing practices and improving patient care. There were several important limitations to this study. First, our SSI auditing tool has only been piloted at 1 hospital among a select population of patients undergoing colorectal surgery reported in ACS-NSQIP data. Second, the tool is based on our institution’s SSI prevention practices, which were identified by a team surgeons, anesthesia providers, and frontline nurses using the tools available as part of the CUSP team and previously published.7 Most interventions are largely supported by the literature (MBP with oral antibiotics, alcohol-based skin preparation, maintenance of normothermia, and antibiotic dosing and redosing) but some reflect local wisdom and adaption of other successful SSI reduction efforts in other service lines at our hospital (chlorhexidine bathing); this may ultimately limit its universal application. Third, we acknowledge the burden of data collection associated with our tool because this requires detailed chart review. To decrease this burden at our institution, we propose using the tool to further explore SSI
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cases only. In addition, the differences noted in patient characteristics and perioperative factors for SSI vs non-SSI cases may have an impact on process measure compliance rates; further prospective cohort studies are required to evaluate the effectiveness of the targeted quality improvement interventions for defects identified by our auditing tool.
CONCLUSIONS The use of an auditing tool to investigate compliance with process measures related to SSI reduction is a good systematic strategy for identifying defects, providing feedback to the operative team, and rallying providers around actionable items for improvement; however, this is a time-consuming, iterative process that requires continuous engagement of providers across multiple disciplines. As a result of our auditing tool initiative, we were able to implement some key perioperative practices toward SSI reduction. Dedicated resources and staff will be required to sustain this initiative and provide ongoing feedback to the multidisciplinary operative team. We believe that ongoing efforts to achieve 100% compliance in key process measures and develop high-performing patient care teams will be essential for high-quality colorectal surgery; auditing practices is one element of this process. ACKNOWLEDGMENTS The authors thank Lucy Mitchell, R.N., M.A., QI Specialist, and SCNR ACS NSQIP, for assistance with acquisition and interpretation of data. REFERENCES 1. Wick EC, Hirose K, Shore AD, et al. Surgical site infections and cost in obese patients undergoing colorectal surgery. Arch Surg. 2011;146:1068–1072.
Hechenbleikner et al: Surgical Site Infection Auditing Tool
2. Hawn MT, Vick CC, Richman J, et al. Surgical site infection prevention: Time to move beyond the surgical care improvement program. Ann Surg. 2011;254:494–501. 3. Bratzler DW, Dellinger EP, Olsen KM, et al; American Society of Health-System Pharmacists; Infectious Disease Society of America; Surgical Infection Society; Society for Healthcare Epidemiology of America. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70:195–283. 4. Sipilä R, Helin-Salmivaara A, Korhonen MJ, Ketola E. Change in antihypertensive drug prescribing after guideline implementation: a controlled before and after study. BMC Fam Pract. 2011;12:87. 5. Khuri SF, Henderson WG, Daley J, et al; Principal Investigators of the Patient Safety in Surgery Study. Successful implementation of the Department of Veterans Affairs’ National Surgical Quality Improvement Program in the private sector: the Patient Safety in Surgery study. Ann Surg. 2008;248:329–336. 6. Khuri SF, Daley J, Henderson W, et al. The Department of Veterans Affairs’ NSQIP: the first national, validated, outcomebased, risk-adjusted, and peer-controlled program for the measurement and enhancement of the quality of surgical care. National VA Surgical Quality Improvement Program. Ann Surg. 1998;228:491–507. 7. Wick EC, Hobson DB, Bennett JL, et al. Implementation of a surgical comprehensive unit-based safety program to reduce surgical site infections. J Am Coll Surg. 2012;215:193–200. 8. Bedra M, Wick E, Brotman D, Finkelstein J. Avatar-based interactive ileostomy education in hospitalized patients. Stud Health Technol Inform. 2013;190:83–85. 9. Shortell SM, Marsteller JA, Lin M, et al. The role of perceived team effectiveness in improving chronic illness care. Med Care. 2004;42:1040–1048. 10. Shortell SM, O’Brien JL, Carman JM, et al. Assessing the impact of continuous quality improvement/total quality management: concept versus implementation. Health Serv Res. 1995;30:377–401. 11. Shortell SM, Levin DZ, O’Brien JL, Hughes EF. Assessing the evidence on CQI: is the glass half empty or half full? Hosp Health Serv Adm. 1995;40:4–24.
Implementation of Surgical Quality Improvement: Auditing Tool for Surgical Site Infection Prevention Practices Elizabeth M. Hechenbleikner, M.D.1 • Deborah B. Hobson, R.N.1,2 Jennifer L. Bennett, B.A.1 •Elizabeth C. Wick, M.D.1 1 Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland 2 Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, Maryland
BACKGROUND: Surgical site infections are a potentially preventable patient harm. Emerging evidence suggests that the implementation of evidence-based process measures for infection reduction is highly variable. OBJECTIVE: The purpose of this work was to develop an
auditing tool to assess compliance with infection-related process measures and establish a system for identifying and addressing defects in measure implementation. DESIGN: This was a retrospective cohort study using electronic medical records. SETTING: We used the auditing tool to assess compliance with 10 process measures in a sample of colorectal surgery patients with and without postoperative infections at an academic medical center (January 2012 to March 2013). PATIENTS: We investigated 59 patients with surgical site
infections and 49 patients without surgical site infections. MAIN OUTCOME MEASURES: First, overall compliance
rates for the 10 process measures were compared between patients with infection vs patients without infection to assess if compliance was lower among patients with surgical site infections. Then, because of the burden of data collection, the tool was used exclusively to evaluate quarterly compliance rates among patients with Financial Disclosures: None reported. Presented at the meeting of The American Society of Colon and Rectal Surgeons, Hollywood, FL, May 17 to 21, 2014. Correspondence: Elizabeth C. Wick, M.D., Johns Hopkins University School of Medicine, Blalock Room 618, 600 N Wolfe St, Baltimore, MD 21287. E-mail: [email protected] Dis Colon Rectum 2015; 58: 83–90 DOI: 10.1097/DCR.0000000000000259 © The ASCRS 2014 Diseases of the Colon & Rectum Volume 58: 1 (2015)
infection. The results were reviewed, and the key factors contributing to noncompliance were identified and addressed. RESULTS: Ninety percent of process measures had lower compliance rates among patients with infection. Detailed review of infection cases identified many defects that improved following the implementation of systemlevel changes: correct cefotetan redosing (education of anesthesia personnel), temperature at surgical incision >36.0°C (flags used to identify patients for preoperative warming), and the use of preoperative mechanical bowel preparation with oral antibiotics (laxative solutions and antibiotics distributed in clinic before surgery). Quarterly compliance improved for 80% of process measures by the end of the study period. LIMITATIONS: This study was conducted on a small surgical cohort within a select subspecialty. CONCLUSIONS: The infection auditing tool is a useful strategy for identifying defects and guiding quality improvement interventions. This is an iterative process requiring dedicated resources and continuous patient and frontline provider engagement. KEY WORDS: Quality improvement; Infection; Colorectal surgery; Outcomes; Public reporting; National Surgical Quality Improvement Program.
S
urgical site infection (SSI) is a leading publically reported surgical outcome and is now being tied to hospital payment determinations. As a result, hospitals are devoting significant resources to reducing SSIs. Colorectal surgery has emerged as a particular area of focus because it has some of the highest infection rates among abdominal surgery cases, ranging from 3% to 25%.1 Despite the extensive focus on SSI prevention in national quality initiatives like the Surgical Care Improvement 83
84
Project (SCIP), emerging evidence suggests that adherence to perioperative SCIP guidelines alone is not enough to prevent SSIs.2 New guidelines for effective surgical antimicrobial prophylaxis have recently been published,3 and the Healthcare Infection Control Practices Advisory Committee guidelines for SSI prevention are presently under revision. Integrating advanced SSI prevention practices or process measures from new guidelines into practice represents an opportunity for further quality improvement in established processes of care. Although new guidelines and studies support the implementation of additional processes, translating this research into practice has been a challenge, and wide variation in practice exists throughout the country. In the primary care setting, a recent study demonstrated that physician prescribing habits did not change after implementing a comprehensive, multifaceted educational program for improving adherence with updated guidelines for antihypertensive drug management.4 Among surgical patients, investigating the ability to translate non-SCIP SSI process measures into everyday practice is an important part of understanding potential lapses in perioperative care and should be performed with a structured, organized approach. To identify and address defects in daily practices, we created an auditing tool to assess compliance with SSI process measures that go beyond SCIP. The purpose of this study was to provide a systematic framework for investigating compliance with SSI process measures, implement targeted quality improvements to prevent recurrence of defects identified, and evaluate the overall impact on SSI reduction.
MATERIALS AND METHODS Background
Johns Hopkins Hospital has participated in the targeted colectomy and proctectomy procedure module of the American College of Surgeons’ National Surgical Quality Improvement Program (ACS-NSQIP) since 2009. Colon and rectal resections are identified by the following Current Procedural Terminology codes: colon – 44: 140–141, 143–147, 150–151, 155–158, 160, 204–208, 210–212; rectal – 45: 110–114, 116, 119–121, 123, 126, 130, 135, 160, 395, 397, 402, 550. ACS-NSQIP data collection methodologies have been previously described in detail.5,6 In this study, all patients undergoing emergent surgery were eliminated because standard process measures may not be applicable in an emergent situation. Participation in the colorectal surgery module brought to light a very high SSI rate (27%) among this patient population. To address the higher-than-expected SSI rate, we used the Comprehensive Unit-Based Safety Program (CUSP) methodology.7 In brief, a group of frontline anesthesiology, surgery, and nursing providers partnered
Hechenbleikner et al: Surgical Site Infection Auditing Tool
with a senior hospital executive to reduce the colorectal SSI rate. This group was trained in the science of safety and systems-level thinking. All providers were asked to complete a brief questionnaire as follows: 1) How will the next patient be harmed or develop an SSI? and 2) How can we prevent the next patient from being harmed or developing an SSI? Based on the results of this questionnaire and further discussion, the CUSP group identified 5 key areas of perioperative patient care for improvement including the development of a consistent team of anesthesia and nursing providers, intravenous antibiotic selection, temperature management, surgical site skin preparation, and preoperative bowel preparation. Despite an initial 33% reduction in the NSQIP colorectal SSI rate from 27% (2009–2010) to 18% (2010–2011) during the 12 months following CUSP implementation, SSI rates subsequently plateaued and continued to be higher than expected. Interestingly, a self-reported survey of patients on the day of surgery demonstrated significant noncompliance with the mechanical bowel preparation (MBP) (data not shown). This prompted further systemic evaluation of the processes. SSI Auditing Tool Development and Data Collection
Instead of addressing the refractory SSI rate with additional interventions, the group focused on measuring and improving compliance with current process measures. In January 2012, the CUSP team developed an auditing tool for key process measures spanning the 5 areas of patient care improvement related to SSI prevention as previously described (Fig. 1). Ten specific measures were collected with the tool as follows: 1) consistent anesthesia team member in the operating room (OR), 2) consistent nursing team member in the OR, 3) correct gentamicin dosing (5 mg/kg), 4) correct cefotetan redosing (every 6 hours), 5) use of forced air warming device in preoperative area, 6) temperature at time of surgical incision >36.0°C, 7) temperature immediately postoperatively >36.0°C, 8) chlorhexidine washcloth used preoperatively, 9) standardized skin preparation of the surgical site by trained personnel, and 10) MBP with oral antibiotics before surgery. All compliance data were available in the electronic medical record. Two clinicians (D.H., J.B.) conducted a retrospective chart review with the auditing tool to collect data for the SSI process measures. Because of the burden of data collection, the tool was to be used just to audit compliance in patients in whom SSIs developed under the assumption that this group of patients would likely have lower compliance than the overall group of patients. To validate this approach, the tool was used for 2 months to audit all patients (with and without SSIs). After this initial period, data collection was exclusively done on patients who developed an SSI.
Diseases of the Colon & Rectum Volume 58: 1 (2015)
Figure 1. Surgical site infection (SSI) process measures auditing tool. ABX = antibiotic; CUSP = Comprehensive Unit-Based Safety Program.
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Interpretation of Tool and Analysis
The auditing tool provided a structured, deeper look into SSI cases and helped identify defects in the new SSI process measures. Any defects identified via tool measures were then directly discussed with the providers responsible for implementing those measures to understand the contributing factors, increase awareness, and allow for the correction of those gaps in patient care. First, overall compliance rates for each of the 10 individual SSI process measures were compared between all SSI vs non-SSI cases to determine if SSI cases had lower rates and where to focus our quality improvement interventions. Next, we measured the quarterly compliance rates for all 10 process measures across the study period for patients with SSIs to evaluate consistency and improved compliance. This study was approved by the Johns Hopkins Hospital Institutional Review Board. Statistical Analysis
Patient characteristics and perioperative factors were compared between SSI and non-SSI cases to assess for significant differences; pairwise t tests were performed for continuous variables, and the Fisher exact test was used for categorical data. Compliance rates for process measures among all SSI vs non-SSI cases were compared by using the Fisher exact test. Groups were considered significantly different at a p value of g rd ne tu 36 ize w re °C d as > M ski hcl 36° BP n ot C + pre h u or pa se al ra an ti tib on io tic s
% Compliance 100 90 80 70 60 50 40 30 20 10
Process measures
Figure 2. Compliance data for process measures in all SSI vs nonSSI cases. SSI = surgical site infection; MBP = mechanical bowel preparation.
ance the need for reliable data with the burden of manual data collection. The tool was effective at identifying multiple defects in process measures among patients with SSIs to allow for focused quality improvement interventions. Key processes with poor compliance based on baseline compliance rates and comparison with non-SSI cases were as follows: 1) correct gentamicin dosing, 2) correct cefotetan redosing, 3) temperature at time of surgical incision >36.0°C, 4) standardized surgical site skin preparation by trained personnel, 5) chlorhexidine washcloth used preoperatively, and 6) MBP with oral antibiotics before surgery. Upon further investigation with front-line providers and patients, contributing factors for the defects in SSI compliance measures and responsible providers were identified and system changes were implemented to prevent recurring defects (Table 2). Compliance Rates With SSI Process Measures
Quarterly compliance rates for all 10 process measures among patients with SSIs are shown in Figure 3. At the beginning of the study period (first quarter (Q1) 2012), correct cefotetan redosing and temperature at the time of surgical incision >36.0°C had the lowest compliance rates at 20% and 22%; in contrast, a consistent nursing team member in the OR and temperature immediately postoperatively >36.0°C had the highest compliance rates at 78% and 100%. All other SSI process measure compliance rates during Q1 2012 fell between 40% and 60%. At the end of the study period (Q1 2013), 8 process measure compliance rates increased by a median of 31% (range,
9%–50%) from Q1 2012, whereas a consistent anesthesia team member in the OR and temperature immediately postoperatively >36.0°C decreased by 4% and 13% (data not shown). Of note, there was great variability in compliance rates among all 10 SSI process measures across the entire study period. Two measures (correct gentamicin dosing, temperature at time of surgical incision >36.0°C) demonstrated consistent quarterly improvement from baseline (Q1 2012) compliance rates, whereas only 1 measure (preoperative forced air warming) had consecutively increased quarterly compliance rates during the study period (Q2 2012 through Q1 2013). Notably, significantly lower compliance rates among all SSI cases (n = 59) compared with all non-SSI cases (n = 49) were found for 2 measures: 1) standardized skin preparation of surgical site by trained personnel (59% vs 82%; p = 0.02) and 2) MBP with oral antibiotics before surgery (49% vs 87.5%; p = 0.001) (Figure 2). Quarterly Colorectal SSI Rates
Before implementing the SSI auditing tool, Q4 2011 colorectal SSI rates were greater than 22% (Fig. 4). A consistent decrease was noted in quarterly SSI rates after implementing the SSI auditing tool in Q1 2012; the largest decreases occurred during Q1 2012 (SSI rate, 14.1%– 15.1%) and Q3 2012 (SSI rate, 11.0%–11.5%).
DISCUSSION The implementation of an auditing tool for colorectal SSI cases was a successful systematic method for tracking compliance with SSI prevention process measures that balanced the need for providing data to drive improvement with the burden of manual data abstraction. This tool was intended to educate and engage the multidisciplinary perioperative team in SSI prevention practices by using empiric evidence from their daily practices. Knowing that compliance was less than 100% drove providers to further investigate and mitigate barriers with system-level interventions. For example, after identifying that patient compliance with the prescribed preoperative bowel preparation was poor, evaluation of the process and interviews with patients revealed that patients were frequently overwhelmed on the day of their office visit and missed some of the preparatory details for surgery. Many of the surgical patients also did not understand the reason for the bowel preparation with oral antibiotics or its role in SSI prevention. In addition, patients in rural areas were frequently not able to obtain the bowel preparation medications from their pharmacy before surgery. To address these gaps and other defects, the team implemented the following interventions: 1. A patient-centered educational curriculum was created on an interactive tablet by using the teach-back method
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Table 2. Contributing factors, disciplines, and interventions for SSI process measures with poor compliance (SSI cases only) SSI process measures with poor compliance Correct gentamicin dosing (5 mg/kg) Correct cefotetan redosing (every 6 hr) Temperature at time of surgical incision >36.0°C)
Standardized skin preparation by trained personnel Chlorhexidine washcloth used preoperatively
Mechanical bowel preparation with oral antibiotics
Primary discipline involved
Contributing factors Lack of follow-through with appropriate weight-based dosing Lack of understanding of correct antibiotic redosing interval based on updated guidelines Poor designation of patients in the preoperative area for forced air warming Insufficient forced air warming devices in preoperative area Insufficient ambient room temperature in OR Lack of standardized education process and training for attending physicians, residents, and OR staff involved in skin preparation Lack of patient education regarding the importance of using chlorhexidine washcloths before surgery Poor distribution of washcloths in the clinic before surgery Lack of patient education regarding the importance of completing a mechanical bowel preparation with oral antibiotics before surgery Patients had difficulty obtaining bowel preparation and oral antibiotics at local pharmacies
Anesthesia
Targeted interventions Increased awareness and accountability by CUSP champions in OR Increased education and awareness by CUSP champions in OR
Anesthesia Nursing
Electronic flag placed on case schedule to identify patients for preoperative warming Increased number of forced air warming devices in preoperative area Ensured ambient OR temperature > 22.2° C or > 72° F
Surgery and nursing
Dedicated skin preparation team created Individuals participating on team completed a standardized tutorial and training
Surgery
Dedicated patient education materials distributed in clinic along with washcloths before surgery
Surgery
Dedicated patient education materials distributed in clinic along with bowel preparation, oral antibiotics, and directions on usage
CUSP = Comprehensive Unit-Based Safety Program; OR = operating room; SSI = surgical site infection.
% Compliance 100 90 80 70 60 50 40 30 20 10
Q1 2012 Q2 2012 Q3 2012 Q4 2012 Q1 2013
es th e N si Co urs a te rre in am g Pr Co ct g tea me eo rre e m m pe ct nta m be 1s T rat ce mi em r t P em iv fo cin b os pe e f tet d er to ra orc an os pe tu e re in ra re d d g Ch tiv at air w osi lo e te inc a ng St rh m is rm an ex p io in da idi era n > g rd ne tu 36 ize w re °C d as > M ski hcl 36° BP n ot C + pre h u or pa se al ra an tio tib n io tic s
The team was able to improve quarterly compliance with 80% of SSI process measures by the end of the study period but only had consecutively increasing quarterly compliance rates for 1 measure; although these results are only among patients who developed SSIs, this highlights the difficulty of achieving consistent adherence to daily prevention practices. Furthermore, we noted that, in general, providers and patients were less compliant with process measures in SSI vs non-SSI cases. These results can
be interpreted in 2 ways. First, these SSI process measures are directly related to infection, and, in patients where providers were noncompliant with measures, the risk of
An
of adult learning.8 This curriculum was aimed at further educating patients on the importance of the use of a MBP with oral antibiotics and chlorhexidine washcloths before surgery to reduce their risk of a SSI. The curriculum was administered to patients at their preoperative clinic visit. 2. All MBP materials (laxatives and oral antibiotics) were given to the patient in the outpatient clinic when they scheduled their surgery. 3. Phone calls to patients were made by the surgical scheduling office approximately 2 days before surgery to remind patients to begin the MBP with oral antibiotics and to use the chlorhexidine washcloths. 4. Nurses in the preanesthesia area began administering chlorhexidine washcloths to patients who did not use their washcloths at home.
Process measures
Figure 3. Quarterly compliance data for process measures among SSI cases. SSI = surgical site infection; MBP = mechanical bowel preparation; Q1 = first quarter; Q2 = second quarter; Q3 = third quarter; Q4 = fourth quarter.
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Colorectal SSI Cases, % 30.0
25.0
20.0
15.0
10.0
5.0
Risk-adjusted administration data All NSQIP colorectal cases NSQIP CUSP surgeon colorectal cases
Q4 2011 22.4% 24.7% 27.5%
Q1 2012 15.1% 15.1% 14.1%
Q2 2012 22.2% 21.1% 16.4%
Q3 2012 11.5% 11.5% 11.0%
Q4 2012 16.2% 18.2% 19.2%
Q1 2013 18.9% 18.9% 19.2%
Figure 4. Quarterly colorectal SSI rates based on administrative and NSQIP data. SSI = surgical site infection; NSQIP = National Surgical Quality Improvement Program; CUSP = Comprehensive Unit-Based Safety Program; Q1 = first quarter; Q2 = second quarter; Q3 = third quarter; Q4 = fourth quarter.
SSI was greater. Second, in cases where providers were mostly or completely compliant with all process measures, this represented a highly functioning team taking care of an engaged patient such that the execution of perioperative patient care was fully optimized, leading to a reduction in SSI risk. Despite the multidisciplinary approach and significant time investment in weekly meetings toward addressing poor compliance with prevention measures and patient care defects, it was only possible to achieve 100% quarterly compliance on 1 SSI process measure (correct gentamicin dosing) throughout our study period. The processes spanned inpatient and outpatient settings and required both patient and provider engagement for compliance; adherence to these patient care measures is intrinsically complex and challenging and often involves multiple disciplines. Regardless of the inherent challenges, the multidisciplinary operative team should continuously work toward improving care through a critical review of data and continuously evaluating quality improvement initiatives and providing feedback to a team helps achieve greater perceived effectiveness.9 Team-driven rather than hierarchical and bureaucratically driven approaches to quality improvement initiatives promote greater implementation of those initiatives.10 Ultimately, the use of the team that directly cares for the patients is ideal to promote quality improvement. Studies support the use of cross-
departmental teams for introducing quality improvement along with empowering team members to identify patient care defects and taking action to improve on the defects.10,11 We believe the value of our SSI auditing tool cannot be fully appreciated or measured, because, in large part, it is derived from engaging providers in team-based quality improvement processes and sometimes only through this engagement can strides be made toward changing practices and improving patient care. There were several important limitations to this study. First, our SSI auditing tool has only been piloted at 1 hospital among a select population of patients undergoing colorectal surgery reported in ACS-NSQIP data. Second, the tool is based on our institution’s SSI prevention practices, which were identified by a team surgeons, anesthesia providers, and frontline nurses using the tools available as part of the CUSP team and previously published.7 Most interventions are largely supported by the literature (MBP with oral antibiotics, alcohol-based skin preparation, maintenance of normothermia, and antibiotic dosing and redosing) but some reflect local wisdom and adaption of other successful SSI reduction efforts in other service lines at our hospital (chlorhexidine bathing); this may ultimately limit its universal application. Third, we acknowledge the burden of data collection associated with our tool because this requires detailed chart review. To decrease this burden at our institution, we propose using the tool to further explore SSI
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cases only. In addition, the differences noted in patient characteristics and perioperative factors for SSI vs non-SSI cases may have an impact on process measure compliance rates; further prospective cohort studies are required to evaluate the effectiveness of the targeted quality improvement interventions for defects identified by our auditing tool.
CONCLUSIONS The use of an auditing tool to investigate compliance with process measures related to SSI reduction is a good systematic strategy for identifying defects, providing feedback to the operative team, and rallying providers around actionable items for improvement; however, this is a time-consuming, iterative process that requires continuous engagement of providers across multiple disciplines. As a result of our auditing tool initiative, we were able to implement some key perioperative practices toward SSI reduction. Dedicated resources and staff will be required to sustain this initiative and provide ongoing feedback to the multidisciplinary operative team. We believe that ongoing efforts to achieve 100% compliance in key process measures and develop high-performing patient care teams will be essential for high-quality colorectal surgery; auditing practices is one element of this process. ACKNOWLEDGMENTS The authors thank Lucy Mitchell, R.N., M.A., QI Specialist, and SCNR ACS NSQIP, for assistance with acquisition and interpretation of data. REFERENCES 1. Wick EC, Hirose K, Shore AD, et al. Surgical site infections and cost in obese patients undergoing colorectal surgery. Arch Surg. 2011;146:1068–1072.
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2. Hawn MT, Vick CC, Richman J, et al. Surgical site infection prevention: Time to move beyond the surgical care improvement program. Ann Surg. 2011;254:494–501. 3. Bratzler DW, Dellinger EP, Olsen KM, et al; American Society of Health-System Pharmacists; Infectious Disease Society of America; Surgical Infection Society; Society for Healthcare Epidemiology of America. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70:195–283. 4. Sipilä R, Helin-Salmivaara A, Korhonen MJ, Ketola E. Change in antihypertensive drug prescribing after guideline implementation: a controlled before and after study. BMC Fam Pract. 2011;12:87. 5. Khuri SF, Henderson WG, Daley J, et al; Principal Investigators of the Patient Safety in Surgery Study. Successful implementation of the Department of Veterans Affairs’ National Surgical Quality Improvement Program in the private sector: the Patient Safety in Surgery study. Ann Surg. 2008;248:329–336. 6. Khuri SF, Daley J, Henderson W, et al. The Department of Veterans Affairs’ NSQIP: the first national, validated, outcomebased, risk-adjusted, and peer-controlled program for the measurement and enhancement of the quality of surgical care. National VA Surgical Quality Improvement Program. Ann Surg. 1998;228:491–507. 7. Wick EC, Hobson DB, Bennett JL, et al. Implementation of a surgical comprehensive unit-based safety program to reduce surgical site infections. J Am Coll Surg. 2012;215:193–200. 8. Bedra M, Wick E, Brotman D, Finkelstein J. Avatar-based interactive ileostomy education in hospitalized patients. Stud Health Technol Inform. 2013;190:83–85. 9. Shortell SM, Marsteller JA, Lin M, et al. The role of perceived team effectiveness in improving chronic illness care. Med Care. 2004;42:1040–1048. 10. Shortell SM, O’Brien JL, Carman JM, et al. Assessing the impact of continuous quality improvement/total quality management: concept versus implementation. Health Serv Res. 1995;30:377–401. 11. Shortell SM, Levin DZ, O’Brien JL, Hughes EF. Assessing the evidence on CQI: is the glass half empty or half full? Hosp Health Serv Adm. 1995;40:4–24.
