Pilot program slashes colorectal SSIs by 33%
Hospital saves $168,000-$280,000 in one year
A patient safety team including researchers in the Johns Hopkins Armstrong Institute for Patient Safety and Quality reported a one-third cut in the rate of costly and potentially lethal surgical site infections (SSIs) following colorectal operations after requiring use of a simple safety checklist and urging caregivers to speak up if they see potentially unsafe practices. [A copy of the checklist is included. For assistance, contact customer service at (800) 688-2421 or [email protected].]
The decreased incidence of SSIs, described by Johns Hopkins researchers in the August issue of the Journal of the American College of Surgeons, suggests that systematic creation of a culture of patient safety in which frontline staff members are encouraged to challenge anyone and anything that puts patients at risk can effectively address complex safety concerns in high-risk patients.
Researchers estimate that, if applied to all types of surgical procedures, locally developed checklists and similar culture change programs could reduce the total number of SSIs by 170,000 and result in a nationwide cost savings of $102 million to $170 million annually.
"Applied to other areas of medicine, that cost savings could make a sizable dent in medical inflation while saving lives," said senior author Martin Makary, MD, MPH, an associate professor of surgery at the Johns Hopkins University School of Medicine.
As the most common complication after colorectal operations, SSIs occur in 15-30% of these patients, resulting in longer hospital stays, frequent readmissions, and subsequent need for treatment, at an estimated cost of $1 billion annually. In addition, disability and quality of life often are affected. Study leader Elizabeth Wick, MD, an assistant professor of surgery at the Johns Hopkins University School of Medicine, said, "We're thrilled to see such a positive outcome in an area where it has traditionally been very tough to move the needle. Until now, there's been little evidence on how to effectively address SSIs among this group of patients." The nature of colorectal procedures — cutting in the bacteria-rich environment of the bowel — lends itself to a high risk of infection, Wick said.
The Johns Hopkins study reflects increasing pressure on hospitals to reduce preventable harm, Wick notes. The Centers for Medicare and Medicaid Services (CMS) already is using SSI rates as a quality indicator and, in some instances, the agency is refusing to reimburse hospitals for the costs associated with treating these infections. But despite heightened attention and required reporting on process measures, SSI rates remain high, even among hospitals with near-perfect compliance with national guidelines, Wick says.
Using a pilot study protocol for high risk patients set by the American College of Surgeons National Surgical Quality Improvement Program, Wick and her colleagues collected baseline SSI rates after colorectal surgeries at The Johns Hopkins Hospital (JHH) for one year leading up to and following the Hopkins safety team's checklist and "speak up" interventions.
In the first year of the study, beginning in July 2009, 76 of 278 patients at JHH, or 27.3%, developed an SSI after colorectal surgery. The rate dropped to 18.2% in the subsequent year after interventions were in place, with 59 of 324 patients contracting an SSI. Procedures for which data was collected include colectomies and proctectomies, removal of part of or the entire colon and rectum, respectively.
Researchers estimate that 28 infections were prevented in 2010 to 2011, which resulted in an estimated cost savings of between $168,000 and $280,000 for the hospital in just one year. This is the reported cost to the hospital/patient of an SSI in the literature. Assuming a nationwide annual incidence of 1.7 million total SSIs per year, researchers estimate widespread application of the Johns Hopkins safety program across all surgical specialties could save more than $100 million annually.
The team's approach is based on a program developed and championed by patient safety experts in Hopkins' Armstrong Institute for Patient Safety and Quality. The Comprehensive Unit-based Safety Program (CUSP) emphasizes careful measurement of a safety issue, research to develop a likely solution, and team-driven culture changes that eliminate barriers to challenging unsafe practice.
Based on an initial safety survey and monthly meetings, a CUSP team of surgeons, nurses, operating room technicians, and anesthesiologists identified six key interventions. Those included standardization of skin preparation, prescription of preoperative chlorhexidine showers, restricted use of by-mouth bowel cleansing solution before procedures, warming of patients in the pre-anesthesia area, adoption of enhanced sterile techniques for bowel and skin portions of the case, and addressing lapses in prophylactic antibiotics. (To see how nurse staffing and burnout can impact SSIs and other infections, see story, below.)
Resource
For more information on the Comprehensive Unit-based Safety Program (CUSP), go to http://bit.ly/lwKn0c.
Nurse staffing, burnout linked to infections (We tweeted about this news on Aug. 1. To receive breaking news as it happens, follow us on Twitter@SameDaySurgery.) Nurse burnout and staffing woes lead to higher healthcare-associated infection rates (HAIs) and costs healthcare providers millions of additional dollars annually, according to a study published in the August issue of the American Journal of Infection Control, the official publication of the Association for Professionals in Infection Control and Epidemiology (APIC). Researchers from the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing analyzed data previously collected by the Pennsylvania Health Care Cost Containment Council, the American Hospital Association Annual Survey, and a 2006 survey of more than 7,000 registered nurses from 161 hospitals in Pennsylvania to study the effect of nurse staffing and burnout on surgical site infections (SSI) and catheter-associated urinary tract infections (CAUTI), two of the most common HAIs. Job-related burnout was determined by analyzing the emotional exhaustion subscale from the Maslach Burnout Inventory-Human Services Survey (MBI-HSS) that was obtained from nurse survey responses. The MBI-HSS filters 22 items on job-related attitudes into emotional exhaustion, depersonalization, and personal accomplishment, identifying emotional exhaustion as the key component to burnout syndrome. More than one-third of survey respondents received an emotional exhaustion score of 27 or greater, the MBI-HSS definition for healthcare personnel burnout. Comparing CAUTI rates with nurses' patient loads (5.7 patients on average), the researchers found that for each additional patient assigned to a nurse, there was roughly one additional infection per 1,000 patients (or 1,351 additional infections per year, calculated across the survey population). Additionally, each 10% increase in a hospital's high-burnout nurses corresponded with nearly one additional CAUTI and two additional SSIs per 1,000 patients annually. The average rate of SSIs across hospitals was 5 per 1,000 patients; for CAUTIs, it was 9 per 1,000 patients. Using the per-patient average costs associated with SSIs ($11,087 to $29,443 each) and CAUTIs ($749 to $832 each), the researchers estimate that if nurse burnout rates could be reduced to 10% from an average of 30%, Pennsylvania hospitals could prevent an estimated 4,160 infections annually with an associated savings of $41 million. "Healthcare facilities can improve nurse staffing and other elements of the care environment and alleviate job-related burnout in nurses at a much lower cost than those associated with healthcare-associated infections," conclude the authors. "By reducing nurse burnout, we can improve the well-being of nurses while improving the quality of patient care." |
A patient safety team including researchers in the Johns Hopkins Armstrong Institute for Patient Safety and Quality reported a one-third cut in the rate of costly and potentially lethal surgical site infections (SSIs) following colorectal operations after requiring use of a simple safety checklist and urging caregivers to speak up if they see potentially unsafe practices.
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