UNDERSTANDING IMPLEMENTATION OF SURGICAL QUALITY IMPROVEMENT: AUDITING TOOL
FOR SURGICAL SITE INFECTION PREVENTION PRACTICES
Elizabeth Hechenbleikner, Deb Hobson, Jennifer Bennett, Renee Demski, Bashar Safar, Susan Gearhart,
Sandy Fang, Jonathan Efron, Elizabeth Wick
The Johns Hopkins Hospital, Department of Surgery, Baltimore, MD, United States
Purpose: Surgical site infections (SSI) are a largely avoidable cause of patient harm. Evidence-based
process measures are effective for SSI reduction but for many hospitals implementation has failed to
translate to improved outcomes. Implementation science is an emerging field of study focused on improving
the process of translating research evidence to everyday practice. We developed a tool to evaluate and
address defects in implementation of SSI process measures among colorectal surgery patients.
Methods: We identified best practices, beyond SCIP, for SSI reduction using the comprehensive unit
based safety program (CUSP) and developed a tool to assess compliance with practices. All colectomy
patients (FY13) with identified SSIs in our ACS-NSQIP database were reviewed in the electronic medical
record using the tool and non-compliance with process measures were surfaced and addressed by a
multidisciplinary group of frontline providers (CUSP team).
Results: Our baseline SSI rate (FY12) was 20% (84/397patients). After use of the tool, our rate decreased
to 12% (35/275patients); p<0.05. The tool surfaced many defects with process measure implementation
(Table 1). The CUSP team analyzed defects and, with executive support, developed system fixes to
improve compliance. Improvement was seen with use of pre-op forced air warming devices [electronic flag
placed on OR schedule to identify patients for warming], incision temperature >36 degrees Celsius,
cefotetan redosing [education of CRNAs], use of chlorhexidine washcloths [electronic patient education]
and mechanical bowel preparation with oral antibiotics before surgery [electronic patient education and
bowel preparation materials provided to patient by clinic when surgery scheduled].
Conclusions: Understanding implementation science is essential to improving care. The SSI investigation
tool combined with learning from surfaced defects approach is a practical strategy to improve integration of
new processes and optimize clinical outcomes. This is an iterative process which requires patient, frontline
provider and executive engagement.
Table 1. Compliance with Process Measures in Patients with Identified Infections at Baseline and Final
Quarter of Auditing Tool Implementation
--
2nd Quarter 2012
(Baseline)
1st Quarter 2013
(Final)
--
No. of Patients with Infections (SSI)
19
18
--
Process Measures
% patients compliant
% patients compliant
pvalue
Team
--
--
--
Member of Anesthesia Team in Operating Room
(OR)
45% (5/11)
40% (6/15)
1.0
Member of GI Nursing Team in OR
73% (8/11)
87% (13/15)
0.62
Antibiotics
--
--
--
Gentamicin Dosing (5mg/kg) in Penicillin Allergic
Patients
100% (2/2)
100% (4/4)
1.0
Cefotetan Redosing Q6 hours
0% (0/4)
64% (7/11)
0.08
Temperature Management
--
--
--
Use of a Forced Air Warming Device in Pre-op
Area
27% (3/11)
87% (13/15)
0.004
Temperature at Incision >36.0° Celsius (C)
27% (3/11)
53% (8/15)
0.25
Temperature Immediately Post-Op >36.0° C
91% (10/11)
87% (13/15)
1.0
Skin Preparation
--
--
--
Chlorhexidine Washcloth Use Pre-op
9% (1/11)
67% (10/15)
0.005
Chloraprep Skin Prep by Trained RN or Attending
Surgeon
72% (8/11)
67% (10/15)
1.0
Bowel Preparation
--
--
--
Mechanical Bowel Prep with Oral Antibiotics
45% (5/11)
90% (9/10)
0.06
Denominator based on the number of patients who were evaluated and/or eligible for measure (i.e.,
patients with pre-op bowel obstructions were not considered in the denominator for bowel preparation)