Joint Commission, collaborating hospitals put problem of colorectal SSIs behind them
The Joint Commission Update for Infection Control
Editor’s note: In this issue of our Joint Commission supplement we complete a two-part series on best practices and proven interventions to reduce surgical site infections, one of the biggest threats to patient safety in the health care system. (See TJC Update for IC inserted in the July 2013 issue.)
Colorectal surgical site infections (SSIs) are among the most common and costly post-op complications, increasing morbidity and mortality and driving up the cost of care. Preventing this type of SSI is difficult hence national colorectal SSI rates in the 15% range. Colorectal surgery is a common procedure across different types of hospitals, can have significant complications, but also presents significant opportunities for improvement. Not exactly low-hanging fruit, but the Joint Commission Center for Transforming Healthcare decided to form an ambitious collaborative to reduce this critical group of SSIs.
"It’s been a challenging project as everybody knows in terms of surgical site infections," says Donise Musheno RN, MS, CPHQ, Robust Process Improvement Black Belt and Project Leader at the TJC Center for Transforming Healthcare. "The reason we tackled it is that it has been a problem for a long time. It was a significant amount of work, but at the end of day the surgeons were really engaged in the process. The nursing staff, the pharmacy staff, everyone was really engaged and pleased with the outcome. We are finding the same as we are now piloting the project."
The final result of the project will be the development of a web-based tool in 2014 that will allow organizations across the country to access the work, the interventions and best practices in prevention of colorectal SSIs.
"The tool itself will do the analysis for them and then guide them on how to implement the solutions for each organization’s specific contributing factors," Musheno says.
While the pilot phase of the project continues, the numbers coming out the earlier phases are impressive. The seven health organizations that volunteered for the project, saved more than $3.7 million in costs for 135 avoided SSIs in the initial data analysis. After the two-and-a-half year project done in collaboration with the American College of Surgeons -- there was an overall reduction in superficial incisional SSIs by 45% and all types of colorectal SSIs by 32%.
No small change
Applying the reduction in SSIs to the annual case load of colorectal surgeries at the participating hospitals suggests that they will experience 384 fewer SSI cases and save $10.6 million per year as the result of this work. The average length of stay for hospital patients with any type of colorectal SSI decreased from an average of 15 days to 13 days. In comparison, patients with no SSIs had an average length of stay of eight days.
"In our hospital our [colorectal] SSI rate — as expected for this population nationally was around 15% to 18%," says Shirin Towfigh, MD, FACS, attending surgeon and surgeon champion at Cedars-Sinai Medical Center in Los Angeles. "That means for every six patients or so one patient will have an SSI. With that in mind, our goal with the Joint Commission was to reduce these SSI rates by at least half towards the end of the project. I’m glad to say that we were able to reduce our SSI rate from an average of about 15.5% down to 5.5%, which is a 65% rate reduction within only 10 months. Since the end of the project we have continued with implementation of all the different steps we made to reduce surgical site infections, and we have been able to sustain that below 5%."
The project addressed preadmission, preoperative, intraoperative, postoperative and post discharge follow-up processes for all surgical patients undergoing emergency and elective colorectal surgery, with the exception of trauma and transplant patients and patients under the age of 18. Project participants studied the potential factors that contribute to all three types of colorectal SSIs — superficial incisional, deep incisional and organ space SSIs, which affect organs and the space surrounding.
"One of the major areas that a lot of the organizations focused on was their closing process — making sure the teams really clearly communicated when they were about to close the case and making sure that they were closing with new sterile instruments," Musheno says. "So they either had a separate closing tray that they used or they kept the closing instruments separate on what we call the back table,’ which was not actively in the field. They would bring those to the field at the time to close."
The strategy was designed to reduce the risk of pathogenic transmission via the instruments used during the operative procedure. It sounds simple, but "the hospitals didn’t have as coordinated of an effort for all of those pieces, so I’m assuming that there is also the potential that it is not being consistently done [at hospitals] across the country," she says.
"Obviously working in the colon is a risk area to begin with, so they used new fresh sterile supplies to close the case," Musheno says. "They would also change their gloves. Some organizations changed gowns if they were visibly soiled -- some of the organizations changed the gowns regardless. They also changed things like the suction catheters to get fresh sterile access or [changed out] anything that would contact the patient prior to closing. Everything would be fresh."
Another big area that organizations focused on was appropriate timing of antibiotic delivery and discontinuation before and after surgery, and they also developed consistent protocols for skin preparation and disinfection with chlorhexidine, she added.
The project addressed the problem of colorectal SSIs using Robust Process Improvement (RPI) methods. "Essentially it’s using Lean Six Sigma and change management tools, " she says.
Using RPI, project participants measured the magnitude of the problem, pinpointed contributing causes, and developed specific targeted solutions that were tested in real-world situations. The hospitals in the SSI project identified 34 unique correlating variables that increase the risk of colorectal SSIs, including patient characteristics, surgical procedure, antibiotic administration, preoperative, intraoperative and postoperative processes, and measurement challenges.
Casting a wide net
"They really started by casting a wide net, looking at data across all different types of contributing factors," Musheno says. "Then they zeroed that down to their list of 34 that they found to be significant in increasing the risk of SSIs. We’re assuming those 34 are the general ones that could come out across the country, but we are still in the pilot testing phase and we are working with four different organizations right now, going through the same process starting with that already honed down list of 34. We are also checking to make sure that there are no other contributing factors or other targeted solutions that we may need to include in the work."
Examples of some of the targeted solutions to reduce superficial incisional colorectal SSIs included establishing specific criteria for the correct management of specific types of wounds, an approach that promotes healing and helps decrease the risk of developing SSIs. Examples of some of the targeted solutions to reduce all types of colorectal SSIs include warming interventions to ensure that the patient’s temperature was consistently maintained at the recommended range for optimal wound healing and infection prevention.
Over the course of the project, it became apparent that the "one size fits all" approach in measuring and reducing the different levels of colorectal SSIs would not have the same success for all types of colorectal SSIs, especially organ space SSIs. These particularly challenging SSIs require more in-depth investigation, especially in surgical techniques and protocols. Further work is being conducted by the pilot organizations to validate measurement tools and identify significant correlating factors that can be improved upon to reduce these more severe types of SSIs.
"I’m glad to say that we were able to reduce our SSI rate from an average of about 15.5% down to 5.5%, which is a 65% rate reduction within only 10 months."
— Shirin Towfigh, MD, FACS, attending surgeon and surgeon champion, Cedars-Sinai Medical Center, Los Angeles
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