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Safety Plan Cuts Infections in Colon Surgery

Surgical site infections (SSIs) after colorectal surgery decreased by a third after implementation of a surgery- and unit-based safety program, investigators reported.

The incidence of SSIs declined from 27.3% in the 12 months prior to initiation of the safety program to 18.2% in the 12 months afterward, as reported online in the Journal of the American College of Surgeons.

Developed by a multidisciplinary team and reviewed monthly, the program emphasized standardization of procedures before, during, and after surgery to eliminate or minimize factors associated with SSIs.

“Based on our post-comprehensive unit-based safety program (CUSP) implementation SSI rate, we estimate that 28 infections were prevented in 2010 to 2011,” Elizabeth Wick, MD, of Johns Hopkins University and Hospital in Baltimore, and co-authors wrote.

The authors also calculated a significant reduction in costs with CUSP. “Assuming the average SSI costs $6,000 to $10,000, we estimate that the CUSP intervention resulted in $168,000 to $280,000 in cost savings at our institution in 1 year,” they wrote.

“In addition, assuming a nationwide incidence of 1.7 million SSIs per year, widespread application of the CUSP intervention can reduce the number of SSIs by 170,000 per year, saving $102 million to $170 million annually,” they said.

The authors pointed out that their study was not randomized so a causal relationship between program implementation and SSI reductions could not be established.

SSIs occur in 15% to 30% of patients who undergo colorectal surgery, making it the most common complication associated with the surgery. Treating SSIs after colorectal surgery costs an estimated $1 billion annually, according to the background information.

Increasingly, the Centers for Medicare and Medicaid Services (CMS) and other third-party payers have identified SSIs as a quality metric in surgical care.

Interest in the cost and quality implications of SSIs piqued after publication of four studies showed that compliance with the CMS-backed Surgical Care Improvement Project (SCIP) process measures explained much of the variation in surgical complications, the authors continued.

CUSP has evolved from the premise that front-line providers are best qualified to develop solutions for preventable problems in healthcare settings. Implementation of CUSP models has been credited with several reported improvements in complication rates, mortality, and associated costs. That favorable experience led Wick and colleagues to implement CUSP to reduce SSIs in a high-risk population.

The CUSP model has been described in detail previously (Crit Care Med 2010; 38:S292-S298). The 36-member CUSP team participated in an introductory session on safety education, and then submitted 95 concerns related to SSIs. The group prioritized and categorized the concerns, which resulted in three focus areas: skin preparation, maintenance of normothermia, and intraoperative sterile technique.

The team examined the issues in a 2-year pilot study of consecutive patients undergoing colorectal surgery, including open and laparoscopic procedures. The first 12 months provided the baseline information for SSIs, after which the CUSP was implemented, followed by an additional 12 months of evaluation

On the basis of data from the 12-month baseline period, the committee agreed on a core group of six interventions to reduce SSIs:

  • Standardization of skin preparation
  • Standardization of preoperative chlorhexidine wash cloths
  • Selective elimination of mechanical bowel preparation
  • Warming patients in the pre-anesthesia area
  • Enhanced sterile techniques
  • Addressing lapses in prophylactic antibiotics

The group met monthly to review progress and adjust the project to address new safety concerns.

The results showed that 278 patients underwent colorectal surgery during the baseline period and 324 during the post-intervention phase. The two groups did not differ with respect to baseline characteristics.

Overall, the rate of SSIs declined by 9.1% in absolute terms and 33% in relative terms (P<0.0001). The rate of superficial SSIs declined (16.9% to 13.6%) as did the rate of organ-space infections (9% to 4%). As anticipated with an SSI-focused intervention, the rate of deep-vein thrombosis did not differ between the two periods.

Adherence to SCIP process measures remained high throughout the intervention period. Rates of adherence were >95% for antibiotic measures (including timing, selection, and discontinuation), 100% for use of clippers for hair removal, and 98% for presence of a warming device during the procedure.

Primary source: Journal of the American College of Surgeons

Source reference: Wick EC, et al “Implementation of a surgical comprehensive unit-based safety program to reduce surgical site infections” J Am Coll Surg. 2012; DOI: 10.1016/j.jamcollsurg.2012.03.017.

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