Practice changes lower rates of transfusion, superficial SSI, and morbidity

Editor’s note: Hospitals that participate in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) use the program’s data and reports to improve performance and surgical outcomes. Sites are invited to share their experiences at the annual ACS Quality and Safety Conference (formerly the ACS NSQIP Conference) through abstract submissions for poster and panel presentations. Hospitals also are encouraged to share their quality improvement (QI) initiatives, so other institutions can learn from their experience and develop their own QI programs.

The “ACS NSQIP best practices case studies” column is an ongoing look at these experiences. These case studies, which have been edited to comply with Bulletin style, provide a description of the clinical problem being addressed, the context of the QI project, the planning and development process, a description of the activity, the resources needed, the results, and suggestions for developing other case studies.

Surgical site infections (SSIs) remain a substantial cause of morbidity, mortality, increased length of stay, and increased hospital costs. Blood transfusions also have been found to contribute to increased morbidity and mortality due to negative reactions to transfusion, over-transfusion, transfusion-related acute lung injury (TRALI), and transfusion-associated circulatory overload (TACO). Alloimmunization (immune response to foreign antigens after exposure to genetically different cells and tissues) and immunomodulation (any process in which an immune response is altered to a desired level) also are both possible reactions that can occur when receiving blood transfusions.

Why was the QI activity initiated?

Golisano Children’s Hospital (GCH), University of Rochester, NY, is a 124-bed facility that serves as the referral center for all seriously ill or injured children in the 17-county Finger Lakes region. With more than 200 pediatric specialists, GCH provides a spectrum of care that spans more than 40 specialty areas and serves more than 85,000 children and their families annually. Approximately 21,300 operations are performed each year, covering numerous subspecialties. Furthermore, GCH offers pediatric cardiac surgery and has the largest pediatric intensive care unit (ICU) in western and central New York, which averages 825 admissions annually.

According to the 2013 ACS NSQIP Pediatric Semiannual Report (SAR) released in July 2014, GCH had a high outlier status in the following categories: all morbidity (12.95 percent observed/8.86 percent expected), abdominal-neonate morbidity (41.43 percent observed/27.45 percent expected), and general morbidity (15.40 percent observed/10.95 percent expected). As a result of these findings, which indicated that GCH was above the NSQIP benchmark, GCH’s pediatric surgery QI group (PSQIG) began analyzing the morbidity data. Superficial SSIs and transfusions in the pediatric general and pediatric orthopaedic surgery patient populations were identified as two of the main contributors to the morbidity high outlier status. Pediatric general and pediatric orthopaedic superficial SSIs accounted for 12/18 (67 percent) of superficial SSIs with 25/28 (89 percent) of cases meeting excessive transfusion criteria (>25ml/kg).

How was the QI activity put in place?

The PSQIG began meeting in August 2013 and included representatives from infection prevention, pharmacy, pediatric quality, multiple pediatric surgery divisions (orthopaedic, general, urologic, and cardiac surgery), neonatal intensive care, and infectious disease. The group continues to grow, most recently adding representatives from the pediatric surgical suite which includes the nurses who work in that area.

One of the responsibilities of the PSQIG is to review the ACS NSQIP data and identify areas for quality improvement. After the release of the 2013 SAR in 2014, the PSQIG analyzed the following data published in that report:

  • Orthopaedic SSI bundle: At the time of the SAR’s release, the original orthopaedic bundle, a group of evidence-based practices that have shown to reduce the risk of SSIs, had already been launched and was in the process of being audited. The audit results were shared with members of the PSQIG on a monthly basis, and areas for improvement were identified. After reviewing the data, the PSQIG made the decision to split the orthopaedic SSI bundle into low- and high-risk bundles to provide the best possible care to each patient population.
  • Pediatric general surgery SSI bundle: In August 2014, the PSQIG began a bundle comparison to identify components of the orthopaedic bundle that could be used in the pediatric general surgery bundle. Once agreement was reached, the pediatric general surgery bundle was launched and auditing initiated.
  • Pediatric surgery transfusion protocols: ACS NSQIP blood transfusion data were presented at the September 2014 PSQIG meeting. ACS NSQIP criteria were discussed, and patients receiving >25ml/kg were identified. Discussion regarding development of blood transfusion protocols began at this time. Key stakeholders were identified and the first meeting to discuss pediatric transfusion protocols took place March 2015. Current protocols were identified, with discussions on using these protocols as templates for division-specific protocols.

What did the QI activity involve?

After the orthopaedic bundle and pediatric general surgery bundles were finalized and a launch date selected, the pediatric surgical quality assurance/performance improvement specialist provided in-services to the pediatric surgical suite, as well as to pediatric units where these patients would be admitted. An in-service in this context is an educational meeting to teach staff involved in the care of these patients what their involvement in the bundle compliance will be, such as performing chlorhexidine gluconate (CHG) bathing on inpatients prior to surgery.

The pediatric orthopaedic and pediatric general surgery bundles included many evidence-based practices, which follow:

  • Methicillin-resistant staphylococcus aureus (MRSA) screening: Performed on pediatric orthopaedic patients at their preoperative appointment with the orthopaedic nurse practitioner (NP) entering the order for preoperative vancomycin if indicated.
  • CHG wipes: Pediatric orthopaedic patients receive CHG baths the day before and the day after an operation. The CHG wipes for the day before bath are distributed to the family with instructions by the NP/resident at the preoperative appointment, and this transaction is documented in the patient’s medical record. For pediatric general surgery patients, the CHG wipes are used to clean the surgical site. This task is performed on all patients ages two months and older. All CHG bath information is documented in the patient’s medical record by the nurse in the preanesthesia unit.
  • Betadine nasal swabs:
    • Used to decolonize the nares of staphylococcus aureus preoperatively
    • Performed by anesthesia professionals on all pediatric orthopaedic patients in the operating room before the operation begins
  • Normothermia:
    • Preheat operating room to at least 78° Fahrenheit for infants up to six months old and at least 75° for all other pediatric patients
    • Maintain patient normothermia between 96.8° and 100.4° Fahrenheit
  • Standardized wound dressing:
    • Pediatric orthopaedics: Gauze and tape dressing, tegaderm used with any incision at risk for contamination, and prineo +/- gauze and nonadherent dressing for spine operations
    • Pediatric surgery: Standardized intraoperative application of wound dressing
  • Blood transfusion protocols: A pediatric surgery transfusion protocol was developed and shared with representatives of all pediatric surgery specialties. After the transfusion protocol was reviewed by all pediatric surgery specialties, it went to GCH’s quality council, which approved the standard for use with pediatric surgery patients. The next step will be to have the electronic health record builders integrate the protocol into the transfusion order set.

The initial orthopaedic bundle launched March 2014 with a split into high- and low-risk bundles in November 2014. The pediatric general surgery bundle launched February 2015.

What resources were needed?

The PSQIG reviewed the bundles as well as the transfusion protocols. Pediatric surgical suite, operating room, and anesthesia staff are key stakeholders in implementing bundle components and maintaining compliance.

No costs beyond normal hospital operations were necessary, although value analysis approval was needed for the purchase of CHG wipes and betadine nasal swabs; no additional funding was necessary.

What were the results?

A total of 569 pediatric general and pediatric orthopaedic cases were performed in 2013, and 566 were conducted in 2014. In comparison with 2013, the frequency of cases receiving transfusion significantly decreased in 2014 (17 percent versus 11 percent, p<0.01, see Figure 1) and fewer met criteria for excessive transfusion (25 versus 11, see Table 1). In comparison with 2013, superficial SSIs have been reduced from 12 (2 percent) to eight (1 percent) in 2014, and a continued decline has been noted for 2015 (see Table 2 and Figure 2). Observed cases for all morbidity, abdominal-neonate, and general morbidity categories have decreased from 107 to 65, 29 to 14, and 67 to 37, respectively, from 2013 to 2014. Each category had a decrease in decile from 10 to six, eight, and five, respectively, with concomitant improvement in odds ratios.

Figure 1. Transfusion before and after intervention

Figure 1. Transfusion before and after intervention

Table 1. Transfusion before and after intervention




Total cases




Excessive transfusion

25 (4%)

11 (2%)

18 (3%)

Table 2. SSIs before and after intervention




Total cases




Total superficial SSIs

12 (2%)

8 (1%)

4 (0.7%)

Figure 2. Superficial SSIs before and after intervention

Figure 2. Superficial SSIs before and after intervention

Setbacks were largely logistical, such as scheduling meetings with limited staff availability. No revisions were made in the original QI plan as a result of limitations encountered during the process; however, a revision was made in the orthopaedic SSI bundle after the original launch date due to an identified need to divide the bundle into high- and low-risk.

Recommendations for reducing morbidity and mortality due to transfusions and SSI complications

  • Obtain value analysis approval for additional supplies, which can sometimes be a challenge. Knowing who to contact to initiate, process, and complete additional supply requests in a timely manner may help the process run more smoothly.
  • Identify champions from each area of participation and include topics/projects that are important to everyone in the group.
  • Encourage all members of the group to participate in the PSQIG meetings and quality assurance and QI projects. Contributing to the process and sharing successes engages the group and encourages continued group participation to work toward improving patient care.
  • Identify a strong leader who is able to engage all participants throughout the process.


American College of Surgeons National Surgical Quality Improvement Program: Pediatric, 2014. ACS NSQIP Semiannual Report. Chicago, IL: American College of Surgeons. July 16, 2014.

Anderson DJ, Podgorny K, Berríos-Torres SI, et al. Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014;35(S2):S66-S88.

Centers for Disease Control and Prevention. Healthcare Infection Control Practices Advisory Committee. CDC 2014 draft guideline for the prevention of SSI. Available at: Accessed March 27, 2017.

Edmiston CE Jr, Okoli O, Graham MB, Sinski S, Seabrook GR. Evidence for using chlorhexidine gluconate preoperative cleansing to reduce the risk of surgical site infections. AORN. 2010;92(5):509-518.

Garey KW, Dao T, Chen H, et al. Timing of vancomycin prophylaxis for cardiac surgery patients and the risk of surgical site infections. J Antimicrob Chemother. 2006;58(3):645-50.

Hart SR, Bordes B, Hart J, Corsino D, Harmon D. Unintended perioperative hypothermia. Ochsner J. 2011;11(3):259-270.

Hogenmiller JR, Hamilton J, Clayman T. Preventing orthopedic total joint replacement surgical site infection through a comprehensive best practice bundle/checklist. Am J Infect Control. APIC Conference, June 2011 poster presentation. Available at: Accessed March 28, 2017.

Ingraham A, Shiloach M, Dellinger EP, Esnaola NF. ACS NSQIP Best Practices Guideline: Prevention of Surgical Site Infections. July 2009. Available at: Accessed April 17, 2017.

Lavoie J. Blood transfusion risks and alternative strategies in pediatric patients. Pediatr Anes. 2011;2(1):14-24.

Ryckman FC, Schoettker PJ, Hays KR, et al. Reducing surgical site infections at a pediatric academic medical center. Jt Comm J Qual Patient Saf. 2009;35(4):192-198.

Ying L, Glotzbecker M, Hedequist D. Surgical site infection after pediatric spinal deformity surgery. Curr Rev Musculoskelet Med. 2012; 5(2):111-119.

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