#41
PROJECT NAME: Long term sustainability of a quality
improvement project to decrease colorectal surgery
infections using a multidisciplinary approach.
Institution: South Texas Veterans Health Care System
Primary Author: Jose A Cadena, MD
Secondary Author: Robin SantaMaria, RN
Project Category: Sustainability in IC
Choose most appropriate category: 1) Emergency Department, 2) General Efficiency,
3) General Quality Improvement, 4) ICU, 5) Infectious Disease, 6) Information Technology or
Systems, 6) Lab, 7) Medical Homes/Reform, 8) Surgery
Team members: Mary Jane Cornell, RN, William Perry, MD, Michelle Savu,
MD, Mark Wong, Pharm D, Brad Hall, MD, Maria Burgos, RN, Daniel RodriguezHowell, RN, MSN, Diane LaGesse, RN, Enelda Romo, RN, Vanessa Lewis, RN
Purpose/Aim:
To decrease the rate of colorectal surgical site infections by 30% over a 3 month
period, by reviewing the patient care process and implementing evidence based
practices during the perioperative care of the patients, and sustain the improvement
over time.
Tools and Measurement:
This was a quality improvement project to decrease the rate of colorectal surgery
infections at the South Texas Veterans Health Care System in San Antonio, a
quaternary level facility affiliated with the UTHSCSA. It provides healthcare
services to approximately 93,000 veterans.
During the first quarter of FY 2010, the infection control office noticed a high rate of
infections among patients undergoing colorectal surgeries. Rates of infection were
30% during the first quarter, as compared to 20% for FY 09.
A group of physicians (surgeons, infectious diseases), nurses (OR nurses, QM
nurses, Infection Prevention nurse, nurse anesthetists), and pharmacists was
assembled to review the perioperative care of the patients and institute evidence
based interventions to decrease rates of infections. This quality improvement
group was supported by the chief of staff, and hospital leadership. This project
was on line with the VA Mission: Honor America’s veterans by providing
exceptional health care that improves their health and well-being.
This quality improvement project was initially presented a the CS&E course in
2012. At that time, we had data available (post intervention) from April 2010 to
June 2012. Since then, we have maintained the interventions, with feedback
provided to surgeons, nurses and staff at the OR meetings, and frequent tracking
of the intervention (see updated data).
Fishbone diagram- Cause Effect Diagram:
Process Flow chart-Pre intervention:
Process Flow Chart- Post intervention
Intervention and Improvement:
We measured the rate of colorectal surgery infection per month. In addition, we
monitored the implementation of evidence based measures, such as appropriate
use of prophylactic antibiotics (selection, dose, duration, re dosing intervals),
perioperative normothermia, glucose control, preoperative bath and skin
preparation with chlorhexidine (CHG). We used quality improvement tools to
present the process to the hospital leadership, staff and service chiefs involved in
the process.
Means, and proportions, odds ratios, and 95% confidence intervals will be
determined. To compare differences between groups, Chi square or Fisher’s exact
tests were used.
Interventions and timeline:
Timeline of interventions
Infectious diseases, pharmacy and surgery reviewed the literature and suggested
improving the preoperative antibiotic prophylaxis, based on recommendations from
the IDSA, ASHP and SCIP. A retrospective review revealed that the compliance with
the guidelines was 50%. During the first phase of the working group the focus was to
improve antibiotic administration. This was corrected by updating the antibiotic
prophylactic cards used by residents and staff. In addition, an electronic medical
record template was created to facilitate perioperative antibiotic administration.
Timing of antibiotic administration was standardized, to be administered within one
hour of incision, even among those patients receiving antibiotics for other reasons.
Interventions and Rational
Antibiotic protocols were updated and template with appropriate antibics became available on
electronic medical records. Antibiotic quick cards were provided to residents and staff (SCIP/ ASHP
and IDSA concordant regimens).*
-
Appropriate antibiotic selection, timing and dosing
Skin preparation changed to chlorhexidine skin preparation**
New system to ensure normothermia was successfully implemented ***
Training of surgery residents on hand hygiene was performed monthly when they started surgery
rotation, as well as education on antibiotic prophylaxis during surgery. Residents received a quick
card that explained the preferred regimens.
Operating room remodeling:
OR back doors were deactivated to maintain positive air pressure in the OR. An alarm was
installed to alert providers if doors were left open. Improved control of temperature and humidity
in the OR . Humidity and temperature correction.
Glucose levels were monitored closely in all patients to evaluate if hyperglycemia was a
contributing factor. However, it was ruled out by chart review
*Am J Health Syst Pharm. 2013 Feb 1;70(3):195-283. (no major changes from prior guideline, except more use of ertapemen,
concordant with our practice).
**N Engl J Med 2010;362:18-26, British Journal of Surgery 2010; 97: 1614–1620).
***&N Engl J Med 1996;334:1209-15).
****J Gastrointest Surg (2009) 13:508–515
The timeline of the implementation of change varied over time, and was modified in
accordance with the Plan-Do-Study- Act process improvement approach.
Reports on the progress of the QI group continue to be reported at the infection
control committee and the Clinical Executive board.
Intervention Results:
Intervention
Pre intervention
Post Intervention
Prophylactic antibiotics:
June 2009, proper antibiotic
choice was observed on 73 %,
timing in 81%.
March 2010, proper antibiotic
choice 88% ( 7/8).
December 2010, proper antibiotic
choice in 56% (5/9), timing in 67%,
(6/9).
June 2010, proper antibiotic
choice: 100%, (9/9), Timing 9/9
(100%), dose 7/9 (78%).
July 2012, proper antibiotic
choice: 100%( 12/12), Timing
100%, choice 100%.
January 2013, proper antibiotic
choice: 94% (15/16), timing 15/16
(94%), dose 16/16 (100%).
Normothermia:
June 09 11 surgeries were
reviewed, 4 correct
May 10: 80% (8/10) maintained
normothermia
Jul 11: 100% (12/12) maintained
normothermia.
January 2013: 100% (16/16)
maintained normothermia.
CHG bath before
surgery:
NA
(Implemented May
2011)
Aug 11: 100% 9/9 preoperative
bath with CHG impregnated
cloths.
Sept 11: 80% (8/10) preoperative
bath with CHG impregnated
cloths
Jan 2013: 88% ( 14/16)
preoperative bath with CHG
impregnated cloths
CHG skin prep:
Pre intervention:
Oct/Nov 2010: CHG use for skin
preparation before surgery: 73%.
11/15.
July 2011: CHG use for skin
preparation before surgery: 50%
(6/12). At this time we enforced
CHG skin prep.
Aug 2011 CHG use for skin
preparation before surgery:
100% (9/9)
Sept 2011 CHG use for skin
preparation before surgery: 70%
(7/10)
Feb 2012 CHG use for skin
preparation before surgery: 62%,
(8/13)
January 2013 CHG use for skin
preparation before surgery: 75%
(12/16)
There was no association between use of hand ports during surgery and infection on
analysis so we did not continue to track this measurement.
The rate of surgical site infection among patients undergoing clean or clean
contaminated colorectal surgeries decreased from 23% (24/104) during the preintervention period to 14% ( 48/343) during the post intervention period (OR: 0,5,
95% CI: 0.3-095, p:0.03)
Process Control Charts
Per month, Pre and Post Intervention:
Per Quarter: Pre and Post intervention:
.
Revenue Enhancement /Cost Avoidance / Generalizability:
At the ALMVA we perform an average of 90 clean/ clean contaminated colorectal surgeries a
year. If we decrease the rate of infection from 23% to 14%, we would be able to avoid about 7
surgical site infections per year. Our QI project has already been running over 3.5 years, so it
may have led to avoiding about 25 surgical site infections.
The cost of a general surgery infection in the US is estimated to be $10,497 dollars (Surgery
2011; 150:934-42). This allows us to calculate a possible cost avoidance of $262,425 dollars
during the intervention period. We did not use additional staff or resources to implement our
interventions; beyond those already planned by the institution (i.e. remodeling of the ORs was an
ongoing process, we only standardized clinical care processes).
We have shared our experience with the UT infection control collaborative, at the CS&E
course in 2010 and the Texas Medical Association meeting in 2013.