Impact of SSI reduction strategy after colorectal resection

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 ACS NSQIP Annual Conference through abstract submissions for poster and panel presentations. Hospitals also are encouraged to share their quality improvement initiatives, so other institutions can learn from their experience and develop their own quality improvement programs.

ACS NSQIP Best Practices Case Studies will be an ongoing series in the Bulletin starting with this issue. These case studies have been edited to comply with Bulletin style and provide a description of the clinical problem being addressed, the context of the quality improvement project, the planning and development process, a description of the activity, the resources needed, the results, and tips for other case studies.

This case study was conducted at Stony Brook Medicine, Long Island, NY, and focused on surgical site infection (SSI). SSI is a common complication of colorectal surgery, adding to increased morbidity, readmission rates, and overall costs.^1,2 In fact, SSIs are responsible for more than $3.5 billion in annual U.S. health care expenditures.^3,4 Colorectal surgery is consistently associated with SSI rates that are between 5 percent and 45 percent higher than other forms of surgery.

Stony Brook’s ACS NSQIP data from 2006 to 2009 indicated that colorectal surgery was a high outlier for SSI. With the first publication of decile ranks in 2009, our hospital ranked in the 10th (worst) tier. In response to the prevalence of SSIs in colorectal patients, our team designed a multidisciplinary approach to standardize the care and methods involved in managing colorectal patients to determine the impact on SSI rates following colorectal resection.

How was the quality improvement (QI) activity put in place?

Stony Brook Medicine is an academic medical center that encompasses Stony Brook University Hospital, Stony Brook Children’s Hospital, five health sciences schools (dental medicine, health care technology and management, medicine, nursing, and social welfare) and myriad centers, institutes, programs, and clinics. With 603 beds, the University Hospital serves as Suffolk County’s only tertiary care center and regional trauma center. With 106 beds, Stony Brook Children’s offers the most advanced pediatric specialty care in the region. We also are home to a Cancer Center, Heart Institute, and Neurosciences Institute. A Medical and Research Translation (MART) building, dedicated to imaging, neurosciences, and cancer care and research, and a new Hospital Pavilion and Children’s Hospital will open in 2017.

Stony Brook administrators have a vision for quality and patient safety and are working to achieve top decile in all clinical outcomes. Reducing SSI in colorectal surgery ties in with the institution’s goals of providing world-class health care to its patients.

In the development process, ACS NSQIP data from 2006 to 2014 were supplemented with an institutional review board-approved chart review. Patients were divided into three groups: a pre-SSI reduction strategy group (January 1, 2006–June 30, 2009), an SSI reduction strategy group (July 1, 2009–December 30, 2012), and a third group testing the durability of the implemented measures (January 1, 2012–September 30, 2014). The SSI reduction strategy was prospectively implemented in a single institution and compared with historical controls (pre-SSI strategy arm).

What strategies were used to reduce SSI?

The SSI reduction strategy included preoperative, intraoperative, and postoperative components (see Figure 1). Patients were given instructions and materials for preoperative procedures, including a chlorhexidine gluconate (CHG) shower. Mechanical bowel preparation without oral antibiotics was used before and after the SSI reduction strategy protocol.

Figure 1. SSI reduction strategies by phase of care

Prehospital Bowel preparation Over-the-counter enema two hours before leaving home for hospital Neck-down shower with chlorhexidine at completion of prep and after clear bowel movement (BM) Chlorhexidine antimicrobial scrub of abdomen morning of operation Preoperative Improved licensed independent practitioner (LIP) questions to determine patient readiness for OR Percent bowel prep consumed Color of last stool Enema two hours before leaving home Neck-down shower with chlorhexidine at completion of prep and after clear BM Chlorhexidine neck-down shower with additional antimicrobial scrub of abdomen morning of operation Blood glucose—preoperative holding area check (goal <200) Consider delay of case: ≥200 – 349 Consider cancellation of case: ≥350 Hair removal complete in preoperative holding area before going to OR Intraoperative Staff will wear surgical masks at all times in the OR Staff will minimize traffic and time OR door is left open Use of chlorhexidine skin prep unless contraindicated (stoma/allergy) Substitute Betadine when contraindicated: Allow to air dry Skin prep area extended from nipple line to knees: side to side Area inclusive of posterior axillary line Attending will be present in OR during skin prep to observe staff performing skin prep as per established guidelines Staff will be reeducated at point of care by attending if prep does not meet standard expected OR team operating within the sterile field will prepare for the case using chlorhexidine scrub brush for more than two minutes (this includes the scrub nurse) Chlorhexidine/alcohol-based preoperative hand antiseptics will not be considered an acceptable substitute for traditional brush hand scrubbing Clean scrubs must be worn at the start of every colorectal case (staff within the sterile field) Scrubs worn during a case will not be worn outside of the OR (surgeon) Surgeons will change into clean scrubs before entering or leaving OR Prophylactic antibiotic will be administered within 60 minutes of incision time for optimal results Place iodine-impregnated incision drape over abdomen Put Alexis wound retractor in place Before closing the abdominal wall, the OR team operating within the sterile field will: (1) Re-glove (2) Re-prep (3) Re-towel incision area (4) Use reserved clean instrument tray for closing Wound closure guidelines to be followed (see Figure 3) Normothermia (SCIP ≥36.0° C); discuss/address patient temperature at debriefing prior to surgeon leaving OR Sticker with dressing change instructions placed on dressed wound Postoperative Do not leave OR in scrubs except when directly walking to and from office to change to street clothes Discontinuation of antibiotic within 24 hours (SCIP) Foley catheter removal by POD #2 (SCIP) Glucose control (SCIP cardiac surgery measure) Appropriate hand hygiene/gloves on floor Dressing changes using sterile technique Prior to patient discharge; attending review of wound

Upon arrival at the hospital, the patient was taken to a preoperative holding area where a member of the colorectal team met the patient and completed a preoperative checklist to evaluate compliance (see Figure 2). Intraoperative procedures were standardized and included all members of the operative team. The surgical staff implemented wound closure guidelines with well-defined parameters for fascial and skin closure (see Figure 3) and delayed wound closure (see Figures 4A and 4B). Upon completion of the operation, a sticker was placed over the surgical dressings, stating that the surgical team was responsible for the initial dressing change, with contact information and instructions in the event that questions arose regarding the integrity or contamination of the dressing (see Figure 5).

Figure 2. Preoperative checklist

Figure 3. Wound closure guidelines

Wound closure guidelines
Delayed primary closure	Open/packed
Insulin-dependent diabetic Case >6 hours Malnutrition (pre-albumin <15 or albumin <2	All emergency cases (regardless of infection) All stoma closure sites Reoperation within the same hospital stay BMI ≥35
Wound closure standardization
Closing fascia	Closing skin
Single-strand PDS for laparoscopic port sites Single or double-strand PDS for laparatomy case	Titanium skin staples Interrupted monofilament suture when clinically necessary (example: risk of ascites)

Figure 4a and 4b. Delayed wound closure

Figure 5. Dressing sticker

ACS NSQIP data used in the study aided in standardizing our own patient data and the outcome against that of other institutions through their formatted evaluation system. This approach was beneficial in comparing the post-SSI strategy outcome with the pre-SSI value and aided in the study’s external validity because ACS NSQIP’s standardized definitions of evaluated variables allow for accurate comparison among institutions.

In selecting the processes that were anticipated to reduce the SSI rate, we used a combination of guiding principles, including best practice recommendations and evidence-based medicine. We began developing our strategy by first strengthening the SSI reducing protocols already in place while researching the literature for evidence-based practices that have proven beneficial in colorectal patients. In addition, we adapted and modified select practices that other surgical services had previously implemented in our institution and that had demonstrated beneficial results. In addition, we extrapolated possibilities for improvement by attempting to implement our own possible solutions to the known SSI risks inherent to colorectal resection.

What resources and skills were needed?

Before patients arrived at the hospital for their operation, they underwent a standard bowel preparation and took a prescribed enema two hours before leaving home. Patients were instructed to shower from the neck down with chlorhexidine after completion of the bowel prep and after noting clear bowel movements. An antimicrobial scrub brush and solution were provided for the patients’ use. On the morning of surgery, the patient underwent a chlorhexidine antimicrobial scrub of the abdomen. At preoperative admission on the day of surgery, the patient was asked a series of questions by trained nursing staff to determine readiness for transfer to the operating room (OR).

Blood glucose was closely monitored, with a preoperative goal of <200 mg/dl. A delay in the OR was considered if the patient had a preoperative glucose of 200–349 mg/dl, and cancellation of the operation was considered if the glucose level was >350 mg/dl. While the patient was in preoperative admission, hair removal by clipping was completed before presenting to the OR.

In the OR, staff was instructed to minimize traffic and the time the OR door was left open to minimize contamination risks. Chlorhexidine skin prep was used unless contraindicated (for example, because of stoma or known allergy). The skin preparation area extended from the patient’s nipple line down to the knees and between bilateral posterior axillary lines. The attending surgeon was present in the OR at this time to observe and confirm proper application of skin preparation. All staff working within the sterile field was required to wear clean scrubs at the start of every colorectal case, and all surgeons were to change into clean scrubs before entering or leaving OR. Hand washing was mandated; alternative hand sterilization methods were deemed an unacceptable substitute in colorectal abdominal surgery cases.

All patients were given a prophylactic antibiotic within 60 minutes of incision time to ensure optimal compliance with Joint Commission Surgical Care Improvement Project (SCIP) measures. An iodine-impregnated incision drape was placed on the patient’s abdomen, and the surgeon used an Alexis wound retractor to minimize infection risks.⁵ Before closing the abdominal wall, the team operating within the sterile field would re-glove, re-prepare the field, and place new sterile towels over the incision area. A new clean instrument tray was used for closing. The surgical team followed the specific wound closure guidelines outlined in Figure 4.

Surgeons worked with the anesthesia team to maintain normothermia (>36.0° C) per SCIP guidelines,⁶ which have shown to minimize SSI risk associated with mild hypothermia.⁷ After complete wound closure, an adhesive sterile dressing was placed over the site, with the overlying sticker identifying clear instructions for dressing changes. Delayed wound closure was used in patients meeting predetermined parameters. Delayed wound closure was reserved for insulin-dependent diabetic patients requiring more than six hours of surgery and patients with significant malnutrition. The decision to use delayed wound closure was undertaken prudently due to the associated discomfort and aesthetic impact on the patient.

Postoperatively, SCIP guidelines were followed with the discontinuation of prophylactic antibiotics within 24 hours of operation end time and removal of the urethral catheter by postoperative day two. Tight glucose control was maintained for further minimization of SSI. Appropriate hand hygiene and sterile gloves were used on the ward for sterile dressing changes. The attending surgeon evaluated the wound personally before the patient’s discharge.

Essential to the successful implementation of the SSI reduction strategy was the appropriate education and support of all staff involved in the patient’s care. Educational meetings were organized formally to train all OR and ward staff in the rationale and goals of these changes. Perioperative strategies for SSI reduction that were initially developed by the colorectal surgery department were then presented to physician and nursing leadership for review. Discussion and input from all levels were encouraged for the development of this strategy. Frequent multidisciplinary reviews evaluated and guided our strategy. Successful implementation of the goals rested not only on changing patient care, but also on changing the culture of all involved parties. Mandating certain standards of practice in the OR minimized the variability between the surgeons and resident physicians.

What were the results?

The strategy used in this study resulted in a 41 percent decrease in SSI rates following colorectal resection over a six-year period, and its durability was demonstrated by continuing improvement over an additional two years. Evaluation of follow-up data was correlated with independent review by the New York State Department of Health, which demonstrated parallel evidence of continual improvement.⁸

Although the most recent ACS NSQIP data have demonstrated increased SSI rates for colorectal surgery, they remain 50 percent lower than when the project began. A multidisciplinary team has been reinvigorated and meets biweekly. Work is being done to hardwire processes through the use of our electronic health record. The focus has turned to preoperative preparation of in-house surgical patients and comprehensive wound care instructions for patients and caregivers upon discharge.

Using the NSQIP return on investment calculator, Stony Brook has had an average of 22 fewer infections annually, saving the hospital $616,000 dollars per year or a total of $4,928,000 since the inception of our SSI reduction strategy.

Suggestions for other institutions

Some guidelines for other institutions considering the implementation of an SSI reduction system as described in this column include the following:

• Convene a monthly SSI committee
• Implement data tracking for process measures and bundle compliance, power plan use
• Institute a root-cause analysis tool with a brief case summary and bundle compliance
• Create a surgical service preoperative power plan and comprehensive wound care discharge order set
• Review real-time data whenever possible, including both Centers for Disease Control and Prevention National Healthcare Safety Network and ACS NSQIP events as discovered

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References

1. Tang R, Chen HH, Wang YL, et al. Risk factors for surgical site infection after elective resection of the colon and rectum: A single center prospective study of 2809 consecutive patients. Ann Surg. 2001;234(2):181-189.
2. Wick EC, Shore AD, Hirose K, et al. Readmission rates and cost following colorectal surgery. Dis Colon Rectum. 2011;54(12):1475-1479.
3. Mahmoud NN, Turpin RS, Yang G, Saunders WB. Impact of surgical site infections on length of stay and costs in selected colorectal procedures. Surg Infect (Larchmt). 2009;10(6):539-544.
4. Thompson KM, Oldenburg WA, Deschamps C, et al. Chasing zero: The drive to eliminate surgical site infections. Ann Surg. 2011;254(3):430-436.
5. Cheng KP, Roslani AC, Sehha N, et al. ALEXIS O-Ring wound retractor vs conventional wound protection for the prevention of surgical site infections in colorectal resections. Colorectal Dis. 2012;14(6):e346-351.
6. Bratzler DW, Hunt DR. The surgical infection prevention and surgical care improvement projects: National initiatives to improve outcomes for patients having surgery. Clin Infect Dis, 1. 2006;43(3):322-330.
7. Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. N Engl J Med. 1996;334:1209-1215.
8. New York State Department of Health. Hospital-Acquired Infections, New York State 2013. Available at: www.health.ny.gov/statistics/facilities/hospital/hospital_acquired_infections/. Accessed November 28, 2016.