Original Article

Using Quality Improvement Methods to Change Surgical Practice: A Case Example of Pediatric Soft-Tissue Abscesses Justin B. Mahida, MD, MBA; Jason P. Sulkowski, MD; Kelli J. Kurtovic, BS; Jennifer N. Cooper, PhD, MS; Brian D. Kenney, MD, MPH; Richard J. Brilli, MD; Katherine J. Deans, MD, MHSC; Peter C. Minneci, MD, MHSC Background: Surgical treatments of soft-tissue abscesses (STAs) include packing and ring drain (RD) and straight drain (SD) placement. Potential benefits of SDs include a single incision, less scarring, and no need for a follow-up appointment. We used a multidisciplinary quality improvement (QI) process to promote surgeon adoption of an STA drainage technique to improve efficiency and quality of care. Subjects and Methods: Outcome measures included the proportion of STAs drained using SDs, the number of postoperative clinic visits, the proportion of patients requiring follow-up with a pediatric surgeon and other providers, and the postoperative complication rate, defined as need for an additional drainage procedure. Results: After beginning the QI initiative, the proportion of STAs drained by SDs increased from 23% to 78% (P < .00001) and the proportion of patients requiring a surgical follow-up clinic appointment decreased from 71% to 32% (P < .00001). The mean number of surgical clinic visits per patient decreased from 0.79 to 0.39 visits per patient (P < .00001). Complication rates were similar between drain types (RD: 2.4%; SD: 1.7%; P = .57). This QI initiative produced a rapid sustained shift in surgeon practice with increased use of SDs, decreased number of follow-up visits, and no increase in complications. Key words: abscess [C01.539.830.025], child [M01.060.406], general pediatric surgery [H02.403.810.300], outcome and process assessment (health care) [N04.761.559]

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reatment of pediatric skin and soft-tissue infections is becoming more complex with the emergence of antibiotic-resistant organisms, leading to more patients being admitted to the hospital and undergoing operative management.1-6 In the United States, pediatric soft-tissue abscesses (STAs) accounted for 74 000 inpatient admissions in 2009.3 Traditional surgical treatment of STAs involves open incision and drainage with packing of the abscess and multiple dressing changes that can be painful and leave unpleasant scars.7-9 A number of less invasive surgical techniques are now being used to drain STAs in children.10-12 One technique, ring drain placement, entails drawing a vessel loop or Penrose drain through the abscess by means of 2 smaller incisions and extracorporeally tying it to Author Affiliations: Center for Surgical Outcomes Research, The Research Institute at Nationwide Children’s Hospital (Drs Mahida, Sulkowski, Cooper, Deans, and Minneci), Department of Surgery, Nationwide Children’s Hospital (Drs Mahida, Sulkowski, Kenney, Deans, and Minneci and Kurtovic), and Department of Pediatrics, Division of Pediatric Critical Care Medicine, Nationwide Children’s Hospital (Dr Brilli), Columbus, Ohio. Correspondence: Peter C. Minneci, MD, MHSc, Center for Surgical Outcomes Research, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Dr, JW4914, Columbus, OH 43205 ([email protected]). This project was supported by intramural funding from the Research Institute at Nationwide Children’s Hospital. The authors declare no conflicts of interest. Q Manage Health Care Vol. 24, No. 2, pp. 84–90 C 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright 

DOI: 10.1097/QMH.0000000000000054 84

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itself (Figure 1). Ring drains eliminate the need for repeated wound packing and therefore result in reduced pain and scarring.11 However, ring drain placement results in 2 incisions and requires postoperative outpatient follow-up for removal of the drain. Another option is straight drain placement, in which, after opening and draining the abscess with a small incision, a Penrose drain is placed into the abscess cavity and sewn in place with an absorbable suture. Because an absorbable suture is used, the Penrose drain falls out within a week, eliminating the need for a follow-up clinic visit. Compared with ring drains, potential benefits of straight drains include less scarring, especially for patients who develop repeat abscesses; less pain or irritation from a single-incision drain site; improved patient and referring physician satisfaction; and fewer surgical follow-up appointments with subsequent improvement in clinic workflow. Potential risks of straight drain placement include inadequate drainage requiring additional treatment and decreased healthcare satisfaction. In this article, we present a quality improvement (QI) initiative designed to improve the quality of care of pediatric patients with STAs requiring drainage. We describe the development and implementation of a QI process involving multiple groups of caregivers to encourage voluntary compliance with a newer surgical intervention. METHODS Study design

A prospective QI initiative was undertaken with the mission to improve the quality of care of pediatric patients www.qmhcjournal.com

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Figure 1. Images of soft-tissue abscess drain types. A, A soft-tissue abscess of the thigh of an infant drained using a ring drain. Note the 2 incisions with the drain passed under the skin from one to the other and then sutured to itself, in this case with 3 nonabsorbable sutures. B, A soft-tissue abscess of the buttock drained using a straight drain. Note the single incision and the single absorbable suture.

undergoing drainage procedures for STAs by changing the preferred surgical procedure to decrease patient pain, scarring, and the need for surgical follow-up. Ring drain placement was adopted by the majority of surgeons at our institution in 2009, and straight drain placement was introduced in October 2011. A multidisciplinary improvement team consisting of surgeons, infectious disease physicians, nurses from the operating room, inpatient floor, and outpatient clinic, and a QI coordinator was convened. The team created a process map detailing the current workflow for patients admitted with STAs who underwent operative drainage. From this map, the team identified an aim, key drivers, and targeted interventions (Figure 2).

The aim of the QI initiative was to increase the percentage of abscesses drained with straight drains from 20% to at least 50% within 3 months of initiation. Primary measures were the proportion of abscesses drained using straight drains, the proportion of patients requiring surgery clinic follow-up, and the average number of surgery clinic visits per patient with abscess. Secondary measures were the proportion of abscess cases requiring follow-up with any health care provider and the average number of outpatient follow-up visits per patient with abscess. The balancing measure was the proportion of patients with a postoperative complication defined as inadequate drainage requiring an additional procedure within 30 days of initial abscess drainage.

Figure 2. Process map and key driver diagram. The process map outlines the steps taken in performing an abscess drainage procedure prior to the start of the QI initiative. From this, the multidisciplinary QI team extracted drivers onto which interventions could be performed to reach the specific aim of the QI initiative. QI indicates quality improvement.

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Study setting

This study was performed at Nationwide Children’s Hospital (Columbus, Ohio), a 420-bed freestanding pediatric tertiary care center with 14 pediatric surgeons who operatively drain approximately 350 STAs annually. The institutional review board evaluated the study and waived the need for institutional review board approval. Study population

The study population included all children undergoing operating room drainage of an STA with either straight drain placement or ring drain placement. Rates were followed using control charts with 3 distinct time periods: Preinitiative from September 2010 to September 2011, Straight Drain Introduction from October 2011 to September 2012, and Straight Drain QI Initiative from October 2012 to September 2013. Patients undergoing abscess drainage who did not require a drain were excluded. In addition, patients undergoing abscess drainage with packing were excluded from analysis of primary and secondary measures because this procedure requires several follow-up visits and the 2 surgeons who regularly perform this procedure have not adopted the ring drain procedure into their practice and were resistant to participating in the current initiative. We did, however, include these patients in analysis of our balancing measure. Intervention development

The QI initiative included the following components. First, surgeon education about the potential advantages and disadvantages of both straight and ring drains was performed. In addition, data from the Introduction period were shared to try to solicit participation. Type of drain placement remained at the discretion of the operating surgeon; placement of straight drains was voluntary. Second, the operating room staff was educated and staff members were instructed to have necessary supplies available during all abscess drainage procedures. Practices were reinforced by nurse leadership. Third, key leaders from the infectious disease team and unit nurses were educated regarding the benefits and safety of straight drain placement. Fourth, a standardized set of discharge instructions for families detailing expectations of both the straight and ring drains was developed and reviewed with the family prior to discharge. Finally, the surgery clinic scheduling staff was educated about the various drain types and indications for follow-up for each surgical intervention. Data collection

An electronic operating room record search was performed over the periods of interest to identify the cohort. Each patient’s chart was reviewed by our QI coordinator for evidence of complications and followup visits after the initial surgical intervention. Complications were defined as any indication for an additional drainage procedure to treat the initial abscess. Followup visits were defined as all outpatient visits to the pediatric surgical clinic or to other practitioners within our hospital system within 30 days of the initial surgi-

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cal intervention. Surgical follow-up visits were defined as all outpatient visits to the pediatric surgical clinic with any pediatric surgeon, including but not limited to the surgeon who performed the surgical drainage procedure. All patients undergoing STA drainage at our institution receive at least 2 attempts at telephone follow-up by an outpatient surgical nurse following discharge; telephone communications were not included in our definition of a follow-up visit. Statistical analysis

For the purposes of the control charts, we evaluated each of our outcomes in monthly intervals. P-charts were used to display the monthly proportions of STAs drained using straight drains, the monthly proportions of patients not requiring follow-up with our pediatric surgery group, and the monthly proportions of patients not requiring follow-up with any practitioner in our hospital system including a pediatric surgeon. U-charts were used to display the average number of clinic visits per patient following drainage. Overall proportions of patients with the characteristic of interest were calculated for each of the 3 distinct time periods. For the proportion of straight drains placed and the percentage of patients not requiring outpatient surgery followup, Pearson χ 2 tests for independence were used to compare adjacent testing periods and control limits for each monthly estimate were calculated using the exact binomial distribution.13 Two-sample z tests for incidence rates were used to compare average clinic visits per patient among the 3 study periods and the control limits for monthly estimates were calculated using the exact Poisson distribution. For the comparison of the proportion of patients with a complication between straight drain placement and ring drain placement, regardless of the timing of the procedure, we used a Fisher exact test. We also used a Fisher exact test to compare the proportion of patients with a complication between packing and ring drain placement and packing and straight drain placement. All tests were 2-tailed, and P values less than .0027 were considered statistically significant. RESULTS Study population

A total of 681 patients underwent initial surgical intervention by means of either straight drain placement or ring drain placement between September 2010 and September 2013: 229 in the Preinitiative period, 204 in the Introduction period, and 248 in the QI Initiative period. During the study, a total of 440 ring drains were placed: 228 during the Preinitiative period, 157 during the Introduction period, and 55 during the QI Initiative period. Also, 241 straight drains were placed: 1 during the Preinitiative period, 47 during the Introduction period, and 193 during the QI Initiative period. Primary measures

Straight drain placement increased from 0% during the Preinitiative period to 23% during the Introduction

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period (P < .0001) and further increased to 78% during the QI Initiative period (Figure 3) (P < .0001). Postoperative follow-up visits with pediatric surgery decreased following the QI initiative (Figure 4). The percentage of patients requiring surgery clinic follow-up decreased from 91% during the Preinitiative period to 71% during the Introduction period (P < .0001) and further decreased to 32% during the QI Initiative period (Figure 4A) (P < .0001). The average number of surgery clinic visits per patient decreased from 1.03 visits per patient during the Preinitiative period to 0.79 visits per patient during the Introduction period (P < .0001) and further decreased to 0.39 visits per patient during the QI Initiative period (Figure 4B) (P < .0001). Postoperative follow-up visits with other health care providers in our system also decreased following the QI initiative (Figure 5). The percentage of patients requiring any outpatient follow-up with a practitioner from our hospital system decreased from 92% during the Preinitiative period to 80% during the Introduction period (P = .0003) and further decreased to 42% during the QI Initiative period (Figure 5A) (P < .0001). The average number of outpatient visits per patient did not change from the Preinitiative period to the Introduction period, with 1.12 visits per patient during the Preinitiative period and 1.07 visits per patient during the Introduction period (P = .26). However, the average number of

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patients did decrease from 1.07 visits per patient during the Introduction period to 0.51 visits per patient during the QI Initiative period (Figure 5B) (P < .0001). Balancing measure

Complication rates between straight drain interventions and ring drain interventions were similar when compared over the Introduction and QI Initiative periods. Use of ring drains was associated with a complication rate of 2.4% (5/212), whereas use of straight drains was associated with a complication rate of 1.7% (4/240) (P = .51). Use of packing over this time period was associated with a complication rate of 0.7% (1/137) (P = .24 when compared with ring drains and P = .38 when compared with straight drains). DISCUSSION Implementation of this QI initiative increased the percentage of STAs drained with a straight drain from 23% to 78%. Postoperative follow-up visits decreased and this occurred without a rise in the post–abscess drainage complication rate. As a result, patients receiving care by our surgical group were treated with a less invasive procedure that causes less scarring and was more efficient. In addition, the postoperative period was less disruptive to their families because fewer

Figure 3. Percentage of abscesses treated with straight drains. Diamonds represent straight drains as the percentage of total straight drains and ring drain placements per month. The 3 time periods (Preinitiative, Introduction, and QI Initiative) are separated by dashed lines. Dotted lines represent control limits for each month. The solid line represents baseline means for each period. QI indicates quality improvement.

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Figure 4. Patients requiring postoperative surgical follow-up. A, Diamonds represent patients requiring follow-up with a pediatric surgeon as the percentage of total patients with abscesses treated with straight drains and ring drains per month. B, Diamonds represent the number of postoperative surgical visits per patient for all patients with abscesses treated with straight drains and ring drains per month. For both charts, the 3 time periods (Preinitiative, Introduction, and QI Initiative) are separated by dashed lines. Dotted lines represent control limits for each month. The solid line represents baseline means for each period. QI indicates quality improvement.

Figure 5. Patients requiring postoperative follow-up with any health care provider. A, Diamonds represent patients requiring outpatient follow-up with any health care provider as the percentage of total patients with abscesses treated with straight drains and ring drains per month. B, Diamonds represent the number of outpatient follow-up visits per patient for all patients with abscesses treated with straight drains and ring drains per month. The 3 time periods (Preinitiative, Introduction, and QI Initiative) are separated by dashed lines. Dotted lines represent control limits for each month. The solid line represents baseline means for each period. QI indicates quality improvement.

postoperative visits were required. Changing practice patterns among any physician group is always challenging, and this work has shown that an intensive QI program can be used to influence a group of surgeons to change their practice. Current literature supports the use of ring drains instead of the more traditional open drainage and abscess packing because patients treated with ring drains have comparable abscess resolution rates, acceptably low complication rates, improved cosmetic

results, decreased pain, and reduced postoperative care needs.10,11 The introduction of straight drains into our practice provided data to support their similar effectiveness to ring drains, with the added benefits of reduced need for postoperative clinic follow-up and further improved cosmetic results. Our study presents a model for effective implementation of a QI initiative to voluntarily change surgical practice. Using the process outlined, our surgeons and staff rapidly adopted straight drain placement as the most

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common drainage procedure for STAs and this change was maintained over 1 year. Several key components of the QI process were critical to its success. First, before the QI initiative began, the potential benefit and efficacy of the new drainage technique at our institution could be demonstrated by tracking its use by 2 surgeons who routinely used it in their practice. Data on straight drain use, including its effects on postoperative follow-up and its associated complication rate, were tabulated and presented initially at a staff meeting. This preliminary information added credibility to subsequent individual conversations with the rest of the surgical group and helped persuade others to trial this new technique. Furthermore, the introductory period allowed us to gather preliminary data that demonstrated the reduction in postoperative follow-up visits without an increase in complications. Since there is limited published data on the benefits of straight drains and no published guidelines for STA drainage, those preliminary data were instrumental in persuading our surgeons to adopt the new procedure. Second, involving all key personnel (nonsurgeons) who participate in surgical abscess drainage was essential. Several key constituents, including leaders of the Infectious Disease service and nurse managers in the operating room, inpatient units, and clinic, were enlisted as change team members. This provided “behind the scenes” leverage, as these individuals were leaders and knowledge resources within their respective groups, and their acceptance of the straight drain initiative influenced their colleagues to be more receptive and was essential to the success of this project. These enlisted team members then served as leaders to educate and encourage acceptance of the new practice and reinforce this education with Infectious Disease house staff and nursing. Additional components of the initiative focused on making it easy for the surgeons, house staff, and nursing staff to implement the changes encouraged by the QI initiative. Standardized discharge instructions were incorporated into the electronic health record to make it easy for staff to provide the appropriate discharge instructions to the patients. Finally, surgical clinic nurses were enlisted and educated to champion the QI initiative in the clinic to ensure scheduling of follow-up visits only on an as-needed basis. Each component played a critical role in the success of this QI initiative. One important concern with the adoption of any new surgical procedure is that outcomes may be affected during the “learning curve” period. To minimize the negative effects of this possibility on outcomes after straight drain placement, the steps of the straight drain procedure were reviewed with each surgeon using diagrams before beginning the initiative and a surgeon familiar with the technique was available to assist with the procedure if needed. In this particular initiative, straight drain placement is a comparable procedure with ring drain placement, so the surgeons and operating room nursing staff had minimal difficulty with performing the new procedure. However, this process of providing standardized education, training, and assistance with new procedures is an important component

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of using QI techniques to promote adoption of the procedure and may be critical to improving the measures being monitored. The goal for this QI initiative was to improve the quality of care for patients undergoing STA drainage, which we accomplished by fostering adoption of a STA drainage technique that has similar abscess resolution rates with less scarring and decreased need for followup visits. In addition, the efficiency for drainage of STAs was improved; by reducing the number of follow-up surgical visits per patient, we reduced the number of outpatient visits per surgeon, with no change in reimbursement rates for surgeons, as the postdrainage clinic visit is part of the global fee for reimbursement. Our analysis suggests that this is a true expense savings and not a transfer of responsibility to primary care physicians, as there was also a decrease in the number of patients who required postoperative follow-up with any health care provider. Future steps in this initiative include evaluation of patient satisfaction and further adoption of straight drain use. Our discussions with patients, families, nursing staff, and the Infectious Disease service suggest greater satisfaction among all of these groups with straight drain placement than with ring drain placement. We plan to obtain formal satisfaction data from patients and families as well as the Infectious Disease service to substantiate this. In addition, we would like to demonstrate continued gains and reductions in postoperative follow-up as we continue to encourage straight drain placement. There are several potential limitations of our study. First, there may be unintended consequences related to the decrease in follow-up. Although the evaluation of complication rates serves to reinforce the similar effectiveness of straight drains compared with ring drains, there may be decreased patient or physician satisfaction. A formal assessment of this is planned. Second, despite decreasing surgical clinic visits, there may be increased utilization of primary care for follow-up. We noted a decrease in the number of follow-up visits with practitioners in our hospital system after starting the initiative. It is possible that out-of-network primary care providers or other practitioners are seeing more patients in follow-up; however, this still represents an improvement for patients and their families, as they can see their regular care provider locally rather than travel to the surgical clinic for follow-up. Finally, we did exclude patients who underwent packing as their surgical intervention, which could have led to selection bias. However, these procedures are regularly performed by only 2 surgeons and we found no difference in the reoperation rate for patients who underwent packing and patients who underwent either ring drain placement or straight drain placement. Given that abscess drainage procedures are performed by the on-call surgeon and the on-call schedule is unrelated to patient factors, it is unlikely that excluding these patients biased the study population. Future planned efforts include using our results to try to solicit participation from surgeons still using packing as their drainage procedure of choice.

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CONCLUSION We improved the quality of care for pediatric patients with STAs by implementing a QI initiative that promoted rapid adoption of the straight drain procedure with improvements in efficiency and no change in complication rates. In the ensuing 16 months, the results from this initiative have led to sustained use of the straight drain procedure in more than 80% of abscess drainage cases performed with persistently improved efficiency reflected in consistently lower postoperative followup visit rates. This study demonstrates a successful QI process that can be used as a model to increase voluntary adoption of surgical procedures that have demonstrated benefits for patients and the health care system.

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4. Frei CR, Makos BR, Daniels KR et al. Emergence of communityacquired methicillin-resistant Staphylococcus aureus skin and soft tissue infections as a common cause of hospitalization in United States children. J Pediatr Surg. 2010;45:1967-1974. 5. Lautz TB, Raval MV, Barsness KA. Increasing national burden of hospitalizations for skin and soft tissue infections in children. J Pediatr Surg. 2011;46:1935-1941. 6. Hersh AL, Chambers HF, Maselli JH et al. National trends in ambulatory visits and antibiotic prescribing for skin and soft-tissue infections. Arch Intern Med. 2008;168:1585-1591. 7. Stevens DL, Bisno AL, Chambers HF et al. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis. 2005;41:1373-1406. 8. Kessler DO, Krantz A, Mojica M. Randomized trial comparing wound packing to no wound packing following incision and drainage of superficial skin abscesses in the pediatric emergency department. Pediatr Emerg Care. 2012;28:514-517. 9. Singer AJ, Richman PB, Kowalska A et al. Comparison of patient and practitioner assessments of pain from commonly performed emergency department procedures. Ann Emerg Med. 1999;33:652-658. 10. McNamara WF, Hartin CW Jr, Escobar MA et al. An alternative to open incision and drainage for community-acquired soft tissue abscesses in children. J Pediatr Surg. 2011;46:502-506. 11. Tsoraides SS, Pearl RH, Stanfill AB et al. Incision and loop drainage: a minimally invasive technique for subcutaneous abscess management in children. J Pediatr Surg. 2010;45:606-609. 12. Ladd AP, Levy MS, Quilty J. Minimally invasive technique in treatment of complex, subcutaneous abscesses in children. J Pediatr Surg. 2010;45:1562-1566. 13. Mohammed M, Worthington P, Woodall W. Plotting basic control charts: tutorial notes for healthcare practitioners. Qual Saf Health Care. 2008;17:137-145.

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Using quality improvement methods to change surgical practice: a case example of pediatric soft-tissue abscesses.

Surgical treatments of soft-tissue abscesses (STAs) include packing and ring drain (RD) and straight drain (SD) placement. Potential benefits of SDs i...
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