Technology has continued to drive advances in surgery toward more minimally invasive, cost-conscious, patient-centric procedures. At the same time, the battle to prevent surgical complications has taken center stage as a means to improve patient outcomes and reduce overall health care costs for both patients and hospitals. Complications and their associated costs after surgical intervention vary widely in both complexity and cost. Wound infections alone can vary from estimated costs of $400 to $30,000 depending on complexity.* Major operations with significant complications, including those requiring reoperation, can drive up costs by five times, approximating an increase of $159,345 per case.†
Many guidelines have been developed to reduce surgical complications. Initiatives like Enhanced Recovery After Surgery (ERAS) have greatly reduced complications, reoperations, and readmissions, all while reducing costs and improving patient satisfaction.‡ Ideally, developing an overall plan that incorporates a multi-initiative approach to reduce complications and minimize returns to the operating room (OR) while decreasing length of stay (LOS) and improving patient satisfaction is key.
In 2017, Holston Valley Medical Center, Ballad Health, Kingsport, TN, launched an initiative to increase efficiency, quality of care, and safety within the OR. During a retrospective review of cases, concern arose regarding patient returns to the OR. These issues were brought to light when multiple returns labeled as “planned,” often consisting of acute care surgical patients left in discontinuity with wound vacuum-assisted closures, were identified as a cause for concern. For example, multiple surgeons returned one patient to the OR more than 30 times.
Whereas a reasonable number of returns to the OR is expected, we began our journey by reviewing all returns in an attempt to identify specific areas for improvement. Review of the nearly 11,000 cases performed yearly in the main OR at Holston Valley demonstrated that one in six patients experienced a return to the OR, most of which were unplanned. These returns led to decreased patient satisfaction and increased health care costs not only for the hospital, but, more importantly, for the patients. The return cases were clustered between acute care surgery and orthopaedic surgery, many of which were emergent/urgent in nature.
The goal of this quality improvement (QI) initiative was to focus on improving quality of care by working through a team effort to identify and reduce returns to the OR while improving overall outcomes. We identified that the cooperative involvement of our quality team, surgeons, and OR team combined with overall support of our hospital’s administrative team was critical to the success of this project. Of utmost importance was obtaining surgeon buy-in while maintaining a nonpunitive approach in both case review and communication.
Putting the QI activity in place
Holston Valley Medical Center is a not-for-profit, tertiary center. When this initiative began, Holston Valley served as one of two Level I trauma centers in our region. Since then, Holston Valley has merged into a larger system, Ballad Health. To minimize duplication and better serve our communities, Holston Valley became a Level III trauma center but remained a large tertiary care center in our region.
Since 2016, Holston Valley has participated in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) and is an active member of the Tennessee Surgical Quality Collaborative (TSQC). The hospital’s involvement in both programs dramatically increased from 2016 forward. As a result, our focus turned to improving areas demonstrated on our ACS NSQIP risk-adjusted score card. While focusing on overall improvements in surgical site infections, LOS, and moving forward with starting our ERAS program, reducing returns to the OR became a priority.
Once we learned that our return to the OR rate was 16.67 percent, we knew we needed to act swiftly. The process for improvement started by designating that all cases returned to the OR within 30 days of the original operation would be reviewed weekly, then presented to an overseeing body—the incident review committee (IRC). Additional review would be provided if necessary at monthly peer review or existing quality committee meetings. These committees report to the medical executive committee, which, in turn, report to the community board for Holston Valley.
To obtain buy-in from the surgeons, establishing their involvement early on was critical. The medical director of the OR, a surgeon, reviewed all return to the OR cases. Once presented to the IRC, the attending surgeon was sent a letter either stating that there were no concerns of care identified or asking for clarification. This letter serves to keep the surgeon in the loop regarding which cases are being reviewed and allows him or her to actively participate in the quality review process. With consensus reached among surgeons that reducing returns led to improved patient care, our project moved forward rapidly.
Having garnered the support of both surgeons and the administration, we began to outline a clear process that incorporated both the involvement of our quality team and our medical staff to facilitate change. The overall process was two-pronged. First, we established a process to review each return to the OR. Second, we focused on changes that can be made in the OR to reduce potential causes for unplanned returns.
With regard to the review process for returns to the OR, we developed the policy to review all returns to the OR on a case-by-case basis, regardless of whether the return was planned or unplanned. In addition, any case for which a concern is identified, regardless of whether it involves a return to the OR, can be reported through the incident report system by any staff member. This policy has allowed all staff members to feel empowered to report quality-of-care concerns in real time for evaluation.
The medical director of the OR reviews each return to the OR or reported concern. Once the case is reviewed, the medical director reports the details of the case along with a recommendation to either validate, invalidate, or request further review to the IRC. The IRC comprises the chief medical officer (CMO); medical staff executive committee, including the president, president-elect, past-president, and secretary/treasurer; quality physician chair; quality manager; risk management; chief nursing officer (CNO); and pharmacy director.
At this point, the reviewed case can be deemed invalid with no concerns, valid with concerns, or recommended to peer review for the respective specialty for further evaluation or to request an explanation from the attending surgeon. Peer review recommendations are sent to the quality committee, which forwards information to the medical executive committee. Validated concerns are placed on the surgeon’s ongoing professional practice evaluation scorecard for two years. The surgeon is contacted throughout the course of the review by letter for full transparency and is allowed to contribute to the dialogue throughout.
The second arm of our approach to QI focused on reducing potential risks contributing to returns to the OR. A considerable portion of the focus in the area used a team of infection prevention, quality, and OR managers who drove an effort to reeducate surgical care team members. Emphasis was placed on reinforcing sterilization techniques, hand hygiene, and patient care optimization as the patient moved through all phases of care. Traffic in and out of the individual operating suites was minimized. Vendors were monitored to ensure scrubs were changed, movement in and out of the operating suite was reduced, and reeducation performed to reiterate the importance of not violating sterile field.
In conjunction with the implementation of our return to the OR reduction initiative in late 2018, other initiatives contributed to a reduction in returns. In November 2016, a colorectal bundle aimed at reducing colon surgical site infections began, and ERAS protocols were implemented in April 2017. Both these initiatives reduced surgical complications in colorectal patients, thereby helping to reduce returns to the OR and improve quality of care.
The orthopaedists assisted during the initiative by helping to develop appropriate guidelines governing elective orthopaedic cases. These guidelines established body mass index (BMI) and glucose parameters that determine if a patient qualifies for elective orthopaedic procedures or if weight loss/improved glucose control is required before an operation can be scheduled. Appropriate antibiotic use also was closely monitored. To further contribute to the QI initiative, the orthopaedics peer review team requested the opportunity to review all joint infections on a monthly basis.
Resources used and skills needed
The staffing required for this QI project was filled with existing staff members. Those staff members included: perioperative and surgical nursing staff, OR manager, a quality nurse, and a risk manager. Leadership included the CMO, CNO, medical director of the OR, medical executive committee staff, and the quality chair. No additional staffing positions were created for this initiative. All surgeons actively participated on an as-needed basis depending on the cases under review.
No additional costs were created beyond existing costs, and funding in the form of an annual stipend from the TSQC was used to create the colorectal bundle and ERAS patient information and signs that contributed to this initiative.
When the percentage of returns to the OR were calculated for 2017 and 2018 prior to our initiative, the rates of return were 16.1 percent and 15 percent, respectively. The raw numbers showed 1,736 of 10,769 patients in 2017 experienced a return to the OR. In 2018, 1,611 of 10,763 patients experienced a return. Clearly, these numbers were unacceptable and demonstrate why this initiative became a priority.
TABLE 1. HOLSTON VALLEY MEDICAL CENTER RETURN TO THE OR, 2019
After the call to action was issued and a plan for a QI initiative focused on reducing unnecessary returns to the OR was set in motion, our data improved dramatically. We calculated our monthly returns to the OR for all cases, planned and unplanned, from January through August of 2019. It is important to note that starting in September 2019, Holston Valley Medical Center transitioned from a Level I to Level III trauma center. To preserve the integrity of the data, we stopped our data collection for this case study at that transition time. We continue to collect our return to the OR data, but beyond that time, it is not included in this analysis. The results demonstrated that Holston Valley saw a reduction in returns to the OR for all cases to 8.2 percent (see Table 1).
At times during the initiative, we did experience setbacks, mostly related to lack of communication or unwillingness to participate in reeducation opportunities. These experiences reiterated the need for continued open communication and use of our available resources to provide data in support of the initiative. For example, when resistance was met regarding guidelines for elective orthopaedic cases regarding BMI or appropriate antibiotic preoperatively, instead of demanding adoption of the recommendations, we relied on the orthopaedic service line meeting to discuss among themselves, provide the most recent guidelines/recommendations, and vote them into acceptance. Using experts in their respective specialty facilitates buy-in and lends credibility to the initiative.
The overall magnitude of cost savings realized by our initiative is difficult to calculate. As cited earlier, complications range in severity, and therefore, their additional health care costs also vary widely, from as low as $400 to as much as $159,345.*† Assuming the case volume held stable for 2019 at 10,770 cases, 8.2 percent returns to the OR translates to approximately 883 fewer cases of varying complexity. The cost savings from this decrease in returns is demonstrated by multiple factors, including fewer incurred OR costs, decreased complications necessitating a return, and reduced LOS.
Tips for others
Fortunately, this initiative and many others that have a significant impact do not require considerable funding. Identifying those individuals in key roles who have access to the data and collect it appropriately is critical. Once the plan for data collection is solidified, the data often can be gathered relatively quickly. When the goal of the initiative and the plan for data collection are established, early involvement from critical participants (surgeons, managers, and staff) is crucial. These individuals should be motivated and supportive of the task at hand.
Once the pathway for data collection, monitoring, and implementation for change has been established, routine meetings must be scheduled to allow for constant data analysis and near real-time implementation of change. It is far too easy to allow backward slipping into old habits and the progress made is lost.
Sharing of outcomes data can be a strong motivator, especially to outliers or late adaptors. It is important to always remain supportive and not malevolent in all interactions with data sharing. Individuals take data very personally and often will self-motivate once the data are available.
*Urban JS. Cost analysis of surgical site infection. In: Surgical Infections. Mary Ann Liebert, Inc; New Rochelle, NY: 2006: s19-s22.
†Vonlanthen R, Slankamenac K, Breitenstein S, et al. The impact of complications on costs of major surgical procedures: A cost analysis of 1,200 patients. Ann Surg. 2011;254(6):907-913.
‡Ljungqvist O, Scott M, Fearon KC. Enhanced recovery after surgery: A review. JAMA Surg. 2017;152(3):292-298.