Surgical site infections (SSIs) are the most common complication facing colorectal surgery patients, occurring in 15% to 30% of cases. SSIs prolong hospitalization, increase readmissions, require subsequent treatment, affect quality of life, and increase healthcare costs to the tune of $1 billion annually. Research has not shown an association between adherence to well-known infection control process measures and substantial SSI reduction. While the occurrence of SSIs can never be fully eliminated in any feasible scheme, many can be prevented.
Addressing SSIs as a Team
In a study published in the August 2012 Journal of the American College of Surgeons, my colleagues and I found that physicians and nurses often feel as though they know what needs to be done to improve safety for colorectal surgery patients, but they feel disempowered. Using these perceptions as the basis for our study, we tested the implementation of a surgery-based comprehensive unit-based safety program (CUSP) designed to address SSIs. Participants in CUSP met monthly for as little as 1 hour in small groups of surgeons, nurses, operating room technicians, and anesthesiologists, along with a senior hospital executive who ensured access to necessary resources.
CUSP team members identified six key interventions that were believed to help reduce SSIs:
1. Standardization of skin preparation.
2. Prescription of preoperative chlorhexidine showers.
3. Restricted use of by-mouth bowel cleansing solution before procedures.
4. Warming of patients in the pre-anesthesia area.
5. Adoption of enhanced sterile techniques for bowel and skin portions of the case.
6. Addressing lapses in prophylactic antibiotics.
With a focus on these areas, simple safety checklists were created, and caregivers were urged to speak up if they witnessed any potentially unsafe practices. After 12 months, the rate of SSIs following colorectal operations dropped by one-third—from 27.3% to 18.2%—when compared with the 12 months prior to implementation of CUSP. An estimated 28 infections were prevented in 2010-2011 at our center, saving about $168,000 to $280,000. Applying the CUSP program to all surgical procedures in the United States could potentially reduce the total number of SSIs by 170,000 per year, saving an estimated $102 million to $170 million annually.
“With a minimal time commitment and the support of hospital executives, it’s highly feasible that frontline providers can make major changes to improve healthcare quality.”
Key Implications of SSI Interventions
With a minimal time commitment and the support of hospital executives, it’s highly feasible that frontline providers can make major changes to improve healthcare quality. Although we continue to expand our knowledge, the coordination of clinical services has been a forgotten task, representing an important barrier to the delivery of high-quality healthcare. It’s encouraging to see that a program like CUSP can bridge the gap between frontline workers and hospital executives.
Based on its success, CUSP is now being applied on a generalized, national scale. As these programs are being introduced nationwide, hospital executives are more frequently walking the surgical floors and listening to how frontline providers feel they can decrease SSIs and improve patient safety. There has been tremendous enthusiasm among physicians to start CUSP-like teams. This momentum will hopefully gain greater support in years to come.
Readings & Resources (click to view)
Wick E, Hobson D, Bennet J, et al. Implementation of a surgical comprehensive unit-based safety program to reduce surgical site infections. J Am Coll Surg. 2012;215:193-200. Available at www.journalacs.org/article/S1072-7515%2812%2900264-5/abstract.
Wick E, Hirose K, Shore A, et al. Surgical site infections and cost in obese patients undergoing colorectal surgery. Arch Surg 2011;146:1068-1072.
Darouiche R, Wall M, Itani K, et al. Chlorhexidine-alcohol versus povidone-iodine for surgical-site antisepsis. N Engl J Med. 2010;362:18-26.
Wick E, Shore A, Hirose K, et al. Readmission rates and cost following colorectal surgery. Dis Colon Rectum. 2011;54:1475-1479.
Hawn M, Vick C, Richman J, et al. Surgical site infection prevention: time to move beyond the surgical care improvement program. Ann Surg. 2011;254:494-499.
Edmiston C, Spencer M, Lewis B, et al. Reducing the risk of surgical site infections: did we really think SCIP was going to lead us to the promised land? Surg Infect (Larchmt). 2011;12:169-177.
Lipitz-Snyderman A, Steinwachs D, Needham D, et al. Impact of a statewide intensive care unit quality improvement initiative on hospital mortality and length of stay: retrospective comparative analysis. BMJ. 2011;342:d219.