Safer Surgery - Standardized Practice Improves Patient Outcomes

Two North Carolina hospitals are continuing to make strides in their quality-of-care initiatives to standardize practice to prevent surgical site infections (SSIs) and improve surgical care safety.

Moses Cone Health System in Greensboro, N.C., and CaroMont Health in Gastonia, N.C., are focusing on evidence-based practices outlined by the Institute for Healthcare Improvement (IHI) to get a better handle on normothermia, antibiotic administration, glucose control, hair removal, and more, which target areas where the incidence and cost of complications of SSIs are high. This focus comes as the pressure mounts for hospitals to reveal their rates of hospital-acquired infections and other preventable errors.

In 2003, the Centers for Medicare & Medicaid Services and the CDC initiated the Surgical Care Improvement Project (SCIP), a national quality partnership of organizations committed to improving the safety of surgical care through the reduction of postoperative complications.

SCIP was initiated because of the high toll SSIs take on patients and finances. SSIs account for 14% to 16% of all hospital-acquired infections and are among the most common complications of care. SSIs occur in 2% to 5% of patients after clean extra-abdominal operations and in about 20% of patients who undergo intra-abdominal procedures. Hospitals that participate in SCIP could see savings of about $3,152 per patient and a reduction in length of stay by seven days for patients who develop SSIs, according to the Sept. 14, 2004, article “Making Surgery Safer Project Overview.”

After implementing components of the collaborative to reduce SSIs – part of the IHI’s 100k Lives Campaign - Moses Cone Health System reduced its SSI rates.

The cornerstone of the collaborative is to infuse the appropriate preventative antibiotic within 60 minutes prior to incision. When nurse anesthetists began running antibiotics while preparing patients for the OR, it improved Moses Cone’s compliance within a one-hour time frame from 50% to more than 80%, according to Marion Martin, RN, MSN, MBA, patient safety officer at Moses Cone Health System.

Moses Cone staff has also implemented maintenance of normothermia preoperatively, intraoperatively, and postoperatively as well as skin prep with an electric clipper instead of a razor.

“Doing away with razors, thought to be the hardest to accomplish, has turned out to be the simplest. Over 95% of patients receive appropriate hair removal,” Martin says. “Removing the razors from unit supply carts made all the difference.”

Maintaining patient normothermia intraoperatively proved to be one of the biggest challenges. Pre and post-operative normothermia was maintained at well over 80%. Intraoperatively, the rates fell to less than 50%, despite use of warmed blankets and fluids. “Implementation of the Bair Hugger system eliminated the intraop temperature drops,” Martin says.

The goal of the initiative was to double the number of days between infections or double the number of cases between SSIs. While seeing a drop in reported surgical site infections, Moses Cone Health System, like all other hospitals, continues to strive to improve on its methods to collect SSI cases, Martin says.

CaroMont Health is reporting success with SCIP – a program with a goal to reduce surgical complications by 25% by 2010.

For its patients undergoing coronary artery bypass graft, the hospital is almost 100% compliant in administering on-time antibiotics, selecting appropriate prophylactic antibiotics, and discontinuing antibiotics within 24 hours after surgery. The staff has initiated standardized programs for SSIs and other medical issues. They have achieved near 100% compliance for glucose control in cardiac patients and patients with diabetes undergoing noncardiac surgery; proper hair removal; temperature control in patients; perioperative beta blockers for adverse cardiac events; DVT-pulmonary embolism prophylaxis; and ventilator-associated pneumonia, according to Jan Mathews, RN, MPHA/ MBA, CPHQ, CNAA, director of clinical performance improvement at CaroMont Health’s Gaston Memorial Hospital.

The CaroMont team has since spread the SCIP initiative to all surgical patients, Mathews says, and normothermia and antibiotic administration were among the easy implementations because SCIP recommendations were already in place. The biggest challenge has been implementing the suggested DVT prophylaxis.

“Not every patient gets pharmacological and nonpharmacological prophylaxis, so, basically, you had to change your practice,” Mathews says. “We implemented an order set that goes on every surgical patient’s chart so that the physicians can address what they’d like to have as far as DVT prophylaxis.” Having the cooperation of a multidisciplinary team of physicians and clinicians, hospital-wide, has been key, Mathews says. Since the hospital started collecting data in July, Gaston Memorial patients have had no SSIs during hospitalization. Mathews says the next step is to look at rates 30 days after hospitalization; they now are determining how to collect that data. Implementing changes designed to eliminate SSIs takes constant monitoring and flexibility, Mathews says. “We call it ‘hard wiring,’ or making changes a part of our everyday care of patients. It takes constant monitoring and change to improve the process".

Excerpts above by Lisette Hilton