A collaborative project of the American College of Surgeons (ACS) and the Joint Commission Center for Transforming Healthcare aimed at reducing colorectal surgical site infections (SSIs) saved seven participating health care institutions more than $3.7 million. A total of 135 SSIs were averted through the two-and-a-half year project. These and other results of the project were presented at a press conference late last year at The Joint Commission’s headquarters in Oakbrook Terrace, IL.
The collaboration used SSI outcomes data from the ACS National Surgical Quality Improvement Program (ACS NSQIP®) to guide the improvement effort. ACS NSQIP uses detailed medical information on the severity of illness and comorbidity to produce data on risk-adjusted outcomes for surgical procedures. SSI is one of the most prevalent negative outcomes reported by ACS NSQIP hospitals.
32 percent overall reduction
The participating hospitals were able to reduce superficial incisional SSIs, which affect skin and underlying tissue, by 45 percent and all types of colorectal SSIs by 32 percent. 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.
The seven health care organizations that volunteered to address colorectal SSIs as a critical patient safety problem include:
- Cedars-Sinai Medical Center, Los Angeles, CA
- Cleveland Clinic, Cleveland, OH
- Mayo Clinic–Rochester Methodist Hospital, Rochester, MN
- North Shore–Long Island Jewish Health System, Great Neck, NY
- Northwestern Memorial Hospital, Chicago, IL
- OSF Saint Francis Medical Center, Peoria, IL
- Stanford Hospital & Clinics, Palo Alto, CA
Colorectal procedures were selected as the focus of the project because SSIs are disproportionately higher among patients following these operations. Colorectal operations are commonly performed across different types of hospitals, may result in complications, present significant opportunities for improvement, and have high variability in performance across hospitals. The project addressed preadmission, preoperative, intraoperative, postoperative, and postdischarge 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 them.
Robust Process Improvement
The project addressed the problem of colorectal SSIs using Robust Process Improvement (RPI) methods. RPI is a fact-based, systematic, and data-driven problem-solving methodology that incorporates Lean Six Sigma and change management concepts. Using RPI, project participants measure the magnitude of the problem, pinpoint contributing causes, develop specific solutions that are targeted to each cause, and thoroughly test the solutions in real-life situations. The hospitals in the SSI project identified 34 unique correlating variables that increased the risk of colorectal SSIs, including patient characteristics; surgical procedure; antibiotic administration; preoperative, intraoperative, and postoperative processes; and measurement challenges.
Examples of some of the targeted solutions to reduce superficial incisional, colorectal SSIs include standardizing the preoperative instruction to patients and caregivers for applying the preoperative skin cleaning product and establishing specific criteria for the correct management of specific types of wounds, which 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 is consistently maintained at the recommended range for optimal wound healing and infection prevention and establishing solutions such as a weight-based antibiotic dosing protocol to address the inadequate administration of antibiotics.
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 regarding surgical techniques and protocols. Further work is being conducted by pilot organizations to validate measurement tools to identify significant correlating factors that can be improved upon to reduce these more severe types of SSIs.
“Reducing surgical site infections is a very real challenge, but one that must be addressed if we want to make health care more reliable in terms of patient safety,” Mark R. Chassin, MD, MPH, FACP, president of The Joint Commission, said during the press conference. “These seven organizations are leading the way in finding specific solutions to the complex problem of surgical site infections.”
“ACS NSQIP uses rigorous data to produce risk-adjusted outcomes. By collaborating with the Joint Commission Center for Transforming Healthcare on this surgical site infection project, we’ve made meaningful progress in learning how we can reduce the SSI rate in colorectal surgical patients and concomitantly produce a savings in costs. These results give the surgical community further impetus to continue working to solve this critical surgical care quality issue,” added Clifford Y. Ko, MD, MS, FACS, Director of ACS NSQIP and the ACS Division of Research and Optimal Patient Care. “The problem has been identified, and the targeted steps we’re taking are helping us to solve it. As increasingly more hospitals and individual providers get involved to study, learn, and improve upon their results, the benefits will be enormous for everyone but most importantly for our patients.”
“This vital project has rendered measurable results in reducing surgical site infections, a major source of preventable patient harm and greater health care costs,” said ACS Executive Director David B. Hoyt, MD, FACS. “Our partnership with the Joint Commission Center for Transforming Healthcare to reduce surgical site infections is helping participating hospitals save millions of dollars annually, and it is engaging surgical teams to become more effective in promoting a culture of surgical patient safety, which is our foremost priority.”
Solutions for colorectal SSIs will be added to the Targeted Solutions Tool (TST) this year after the solutions and improvement tools from this project are pilot tested in other health care organizations. The TST provides a step-by-step process to assist Joint Commission-accredited health care organizations in measuring performance, identifying barriers to excellent performance, and implementing the center’s proven solutions that are customized to address specific barriers. Targeted solutions are now available for improving hand hygiene, hand-off communications, and wrong site surgery. Accredited organizations can access the TST and solutions on their secure Joint Commission Connect extranet.
For detailed information regarding the contributing factors and targeted solutions identified in the SSI project, visit the Joint Commission Center for Transforming Healthcare project website.