PROJECT NAME: Decreasing Colorectal Surgery
Infection Rate Using a Multidisciplinary Approach
Institution: South Texas Veterans Health Care System and University of
Texas Health Science Center at San Antonio.
Primary Author: Jose A Cadena Zuluaga MD
Secondary Author: Robin Santamaria, RN
Project Category: Patient Safety
Overview:
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.
Aim Statement (max points 150):
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.
Measures of Success:
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 chlorexidine (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.
Use of Quality Tools (max points 250):
Fishbone diagram- Cause Effect Diagram:
Process Flow chart-Pre intervention:
Process Flow Chart- Post intervention:
Bair hugger
temperature
management
system
Patients goes to
preprocedure appointment
Colorectal surgery
starts
Normothermia
NO
YES
Foley catheter
placed
Consent signed/
education
Anesthesia adjusts
temperature Bair
hugger
Redose antibiotics if
needed during surgery
Skin Prep with
chlorexidine
YES
Proper Preoperative
Antibibiotics at Clinic Using
CPRS template and quick cards
YES
NO
NO
Door monitor System.
Doors opening during
surgery?
Surgeon/ OR Check
antibiotics
NO
Hair clipping
Alarms alert OR
staff to close door
OR Humidity and
Temperature
YES
YES
Wound
dressing
Silver coated
dressing
Patient transferred
to OR
NO
Patient comes to \
hospital/ check in
Alarms Alert
Engineering for
correction
Surgeon reviews
Chlorexidine bath
Wound class
confirmed
YES
IV placed and MRSA
screening done
Proper preoperative
antibiotics
administered
NO
Patient transferred to
SICU
Process Control Charts:
Per month, Pre and Post Intervention:
Per Quarter: Pre and Post intervention:
Interventions (max points 150 includes points for innovation):
The QI improvement team plan was to review all the evidence based measures to decrease
colorectal surgery infections, and implement those interventions consecutively, while
tracking the implementation rate. All team members contributed to select the interventions
based on their knowledge.
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.
Skin preparation was changed from a surgeon specific protocol based on preferences to
chlorexidine skin preparation (N Engl J Med 2010;362:18-26, British Journal of Surgery
2010; 97: 1614–1620).
Perioperative normothermia was closely monitored and encouraged. A new system to
ensure 100% normothermia was successfully implemented by anesthesia (N Engl J Med
1996;334:1209-15).
Glucose levels were monitored closely in all patients to evaluate if hyperglycemia was a
contributing factor. However, it was ruled out by chart review (J Gastrointest Surg (2009)
13:508–515).
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.
Nurses from the OR observed that the doors in the OR had automatic sensors that would
open the doors during procedures. These doors were deactivated to ensure maintenance of
positive air pressure in the OR. Also, an alarm was installed to alert providers if doors
were left open. Improved control of temperature and humidity in the OR was achieved.
The alarm systems were also more easily monitored by engineering. When temperature or
humidity deviated from the standard, they were quickly corrected.
The timeline of the implementation of change varied over time, and was modified in
accordance with the Plan-Do-Study- Act process improvement approach. Initially there was
a focus on data analysis followed by improvement in administration of perioperative
antibiotic prophylaxis, hair removal, and normothermia adjustments (February to
September 2010). After this, rates of infection decreased. The QI improvement team
thought that they had achieved their main goal. However, rates started to increase and the
team met again and started evaluating and implementing additional interventions on April
2011 (CHG skin preparation and use of CHG impregnated wipes prior to surgery at
preoperative area), CHG skin preparation was associated with additional decrease in the
rates of infection, and sustained infection rate change.
During review there were some discordances regarding wound classification. This was
standardized after an in- service was provided to the OR staff. Also, reference cards for
wound classification were disseminated. Surgeons were asked to verify wound class to
facilitate surveillance requirements.
Information regarding the progress of the QI group was presented at the infection control
committee, and at the Clinical Executive Board meetings every other month, during the
preparation and implementation period of the project.
Results (max points 250):
Prophylactic antibiotics:
Preoperative antibiotic use was evaluated before intervention:
-
June 2009, proper antibiotic choice was observed on 73 %, timing in 81%.
-
December 2010, proper antibiotic choice in 56% (5/9), timing in 67%, (6/9).
Post intervention:
-
March 2010, proper antibiotic choice 88% ( 7/8).
-
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%.
Normothermia:
Pre intervention:
-
June 09 11 surg reviewed 4 correct
-
Post intervention:
-
May 10: 80% (8/10) maintained normothermia
-
Jul 11: 100% (12/12) maintained normothermia.
CHG bath before surgery:
(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
Glucose control:
-
Feb 11 No hyperglycemia within 48 hours of surgery: 82% (9/11).
-
July 11 No hyperglycemia within 48 hours of surgery: 83% (10/12).
The team, led by a Pham D, reviewed and found no significant correlation between
infection and hyperglycemia.
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.
Post intervention:
-
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)
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 pre-intervention period to
16% ( 37/226) during the post intervention period (OR: 0.65, 95% CI: 0.4- 1.2, p:0.15)
Revenue Enhancement /Cost Avoidance / Generalizability (max
points 200):
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 16%, we would be able to
avoid about 7 surgical site infections per year. Our QI project has already been running
over 2.5 years, so it may have led to avoiding about 18 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
$188,946 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 are planning to share our experience with the UT affiliated hospitals participating on
the UT infection prevention collaborative so they can implement their own processes to
decrease colorectal SSIs.
Conclusions and Next Steps:
Colorectal surgical site infection rates can be decreased when implementing a bundle of
evidence based practices including proper perioperative antibiotic dosing, skin preparation
with CHG, increased education on hand hygiene, sustained perioperative normothermia
and avoidance of frequent unintended opening of operating room doors. This goes in line
with the organizational goals to provide the best possible care to our veterans. We plan to
continue monitoring the application of these evidence base interventions and make them
part of our patient safety culture.
We will continue to monitor our rates of infection and share our experience with other
hospitals involved in the UT infection prevention collaborative, in order to provide them
with information about the implementation process of best practices.