Quality leaders work to reduce surgical infections
Quality managers can have a very visible impact’
(Editor’s note: This is the second of a two-part series on surgical infection prevention. Last month, we explored ways to improve core measure data. This month, we give strategies to reduce surgical infections.)
Increased public scrutiny of hospital performance on surgical infection prevention measures will continue, quality leaders predict. "From the point of view of quality managers, this is a wonderful thing," says Terry Hill, MD, medical director for quality improvement at San Francisco-based Lumetra.
"For all of us trying to improve care, we always struggle with not having enough resources and not being able to sustain leadership attention," he says. "Having publicly reported measures gives quality managers more traction."
As a result, surgical infection prevention now will get sustained attention from hospital administrators, Hill predicts. "Having publicly reported measures will get the attention of CEOs so the project stays on the front burner, which is one of the most important things for the quality manager. This is an area where the quality manager can have a very visible impact in a short period of time."
Use the following strategies to reduce surgical infections:
• Ensure patients get antibiotics in recommended time frames.
When researchers looked at 34,133 Medicare inpatients undergoing major surgery in 2001, they found that only 55.7% received antibiotics in the recommended time frame of one hour before incision, 92.6% received the correct antibiotic, and 40.7% of patients had antibiotics discontinued within 24 hours following surgery to limit resistance to antibiotics.1
"There is a great potential for improvement in the processes of care known to reduce surgical-site infections," says Dale W. Bratzler, DO, MPH, the study’s lead author and principal clinical coordinator for the Oklahoma Foundation for Medical Quality, based in Oklahoma City, and immediate past president of the American Health Quality Association. "Despite more than 40 years of research demonstrating the importance of providing antibiotics within a short window of time before an incision, our study demonstrated that many patients were not receiving antibiotics at the optimal time."
The Surgical Infection Prevention (SIP) project was jointly launched in August 2002 by the Centers for Medicare & Medicaid Services and the Centers for Disease Control and Prevention to improve the safety of surgical care through the reduction of postoperative complications.
Over the past three years, several hundred hospitals have worked with their local Medicare Quality Improvement Organizations to redesign procedures and protocols to cut the rate of surgical infections, such as ensuring surgical patients are given antibiotics within 60 minutes before incision.
The Surgical Care Improvement Project (SCIP) is scheduled for national rollout and implementation in January 2006, and will replace SIP. (For more information on SCIP, go to www.medqic.org/scip/.)
Quality professionals can use delivery of the antibiotic as a measure to monitor performance and assess how changes in systems of care affect performance on this measure, Bratzler says.
"There is a long list of activities that have been demonstrated to reduce the risk of a surgical-site infection. Although it is not possible to prevent all infections based on current science, many are preventable," he says, pointing to 1999 guidelines for prevention of surgical-site infections published by the Hospital Infection Control Practices Advisory Committee.
Proper selection and timing of antibiotic prophylaxis, use of sterile instruments, avoiding shaving of the surgical site, control of blood sugar, and avoiding operations on patients with infections remote to the surgical site are all proven ways of reducing infection rates, adds Bratzler.
• Obtain staff support and buy-in.
Explaining the rationale behind a desired change with supporting literature can have a dramatic impact on clinical staff compliance, says Jill Garrett, RN, CPHQ, perioperative care manager at Memorial Hospital in Colorado Springs, CO. The organization participated in CMS’ SIP project.
"At an educational inservice for perioperative staff, I presented a picture of a dramatic wound infection and the additional incurred costs," she says. "This really was the key, connecting the present surgery to potential outcomes."
Demonstrating the loss of quality of life to the surgical patient makes a bigger impact on health care providers than talking about hospital costs, Garrett adds. "Nurses want good outcomes for their patients. If a knee replacement implant becomes infected, there can be two or more additional surgeries. This is devastating to a patient’s life."
Clinical staff tend to focus on the here and now, not necessarily the long-term effects or outcomes, she explains. "I tried to convey the importance of their job and the effect it can play for many years to the patient. Relaying research studies and current literature in understandable means was critical. Once it makes sense, it is embraced and becomes practice."
The SIP measures have been integrated into the peer review process at Shreveport-based Louisiana State University Health Sciences Center, with identified cases sent to each practitioner for comments and to identify what steps will be taken to improve performance, and results reported to the governing board.
When a case is identified, such as the antibiotic not given within 60 minutes before incision, the chart is sent to the physician for comments as to why it was not administered. "It serves to remind the physician of the standard, and that the indicator and their performance is being monitored and reported," says Leisa Oglesby, assistant hospital administrator of quality.
• Use rapid-cycle change cycles.
Rapid-cycle change cycles are most effective, requiring consistent monitoring and real-time feedback, Garrett says. For example, in the transition from razors to clipper use for hair removal, a supply issue was identified. "During my daily chart monitoring, I discovered that razors were slipping back in. After further investigation, insufficient stocking of the clipper heads had occurred. Frequent checking with staff to assess this issue and changing the stocking process solved the problem."
When the rapid cycle begins, successful implementation demands full attention for a short time period. "It is full immersion with concentrated efforts to hardwire the changes," she adds. "My role as a quality manager was to facilitate the change, address the system failures, and liaison for best practice."
The staff’s personal commitment to hair removal by clippers was an essential factor in obtaining support from surgeons, although this measure was strongly resisted in the past, adds Garrett. To be proactive, staff initiated the use of clippers when the patient arrived in the OR.
Begin by testing one critical procedure that is high volume at your organization and see what results you get, recommends Karen Jones, manager of acute care services for Oak Brook-based Illinois Foundation for Quality Health Care.
"Once you get positive results, spread it to other areas of interest," she explains. "It might be difficult to get all different physicians and procedures on board to start with."
• Enlist the help of a physician champion.
One hospital in the collaborative selected an orthopedic surgeon to work with on discontinuation of antibiotic within 24 hours following surgery, and after achieving positive results, it got the attention and buy-in of other orthopedic physicians, Jones reports.
"Having a physician or surgeon as a champion is absolutely of the highest importance to make these things happen," she says. "They have a lot of influence over their peers. There are a lot of nonbelievers who don’t want to take part and have to be convinced, and who better to convince them than one of their peers?"
When the organization set out to ensure that prophylactic antibiotics were given within an hour of incision, the chief of anesthesia was the champion for this change, says Jones. "The appropriate antibiotic was being administered, but timing was inconsistent. Anesthesia agreed to own this process to decrease variability. Frequent feedback cemented the process."
The anesthesiologist now administers the antibiotic when the patient arrives in the OR suite. This ensures more consistent timing, as opposed to giving antibiotics in the holding area before the patient goes into the surgical suite, she adds. "Timing can vary then, since perhaps the suite they are going into isn’t available as soon as they think it is."
Reference
- Bratzler DW, et al. Use of antimicrobial prophylaxis for major surgery: Baseline results from the national surgical infection prevention project. Arch Surg 2005; 140:174-182.
[For more information, contact:
- Dale W. Bratzler, DO, MPH, Principal Clinical Coordinator, Oklahoma Foundation for Medical Quality, 14000 Quail Springs Parkway, Suite 400, Oklahoma City, OK 73134. Phone: (405) 840-2891, ext. 209. Fax: (405) 840-1343. E-mail: [email protected].
- Jill Garrett, RN, CPHQ, Perioperative Care Manager, Memorial Hospital, 1400 E. Boulder, Colorado Springs, CO 80909. Phone: (719) 365-2786. E-mail: [email protected].
- Terry Hill, MD, Medical Director for Quality Improvement, Lumetra, One Sansome St., Suite 600, San Francisco, CA 94104-4448. Phone: (415) 677-2000. Fax: (415) 677-2195. E-mail: [email protected].
- Karen Jones, Manager, Acute Care Services, Illinois Foundation for Quality Health Care, 2625 Butterfield Road, Suite 102E, Oak Brook, IL 60523-1234. Phone: (630) 928-5812. E-mail: [email protected].
- Leisa Oglesby, Assistant Hospital Administrator of Quality, Louisiana State University Health Sciences Center, 1541 Kings Highway, Shreveport, LA 71130. Phone: (318) 675-5030. Fax: (318) 675-4646. E-mail: [email protected].]
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