Preventing Surgical Infections Using Teamwork and “Local Wisdom”

From 15 to 30% of people who have colorectal surgery will get an surgical-site infection—and those surgical infections (just among colorectal patients) cost an estimated $1 billion a year. The surgical infections cause longer hospital stays; are the most common cause of hospital readmission within 30 days; and require more doctor visits, wound-care supplies, and home care. Not to mention the added difficulties for patients and their families.

A two-year study at Johns Hopkins Hospital, just published in the August 2012 Journal of the American College of Surgeons, describes how a team of front-line providers used their “local wisdom” plus an evidence-based safety system to cut their infection rate in colorectal surgery patients by 33.3 percent in one year.

Reducing surgical infections improves patient care and saves dollars–a national priority shared by Medicare and other insurers, medical staff, and patients alike. A national Surgical Care Improvement Project (SCIP) using standardized checklists and measures was launched six years ago, but four recent studies show little connection between compliance and overall patient outcomes.

Leaders at Johns Hopkins Hospital decided to add an element seen in other successful quality-improvement programs—intentionally bridging the typical divide between front-line staff and the experts who bring in a standardized improvement system.

They formed a team of surgery, anesthesia, nursing, and infection control leaders, plus a team coach (to facilitate meetings and manage improvement projects), and a hospital executive who could help front-line staff overcome institutional barriers. The leadership team also invited other interested front-line nurses, nurse anesthetists, scrub technicians, and anesthesiologists to join what became a 36-member team. They launched a CUSP (Comprehensive Unit-based Safety Program) that used the national SCIP checklist, but also added their own interventions to the checklist:

  • Only surgical nurses, rather than a variety of staff, did the pre-op skin preparation on each patient ;
  • All patients were given antibiotic-treated wash cloths to use the evening before surgery;
  • After studying literature, the team added oral antibiotics to routine pre-surgical mechanical bowel preparation;
  • Because a separate hospital study showed that many patients were hypothermic both before and after surgery, they began warming patients in the pre-anesthesia area;
  • When scrub technicians pointed out that instruments used for intestinal suturing were also frequently used for skin closure, the team designed a system to replace all instruments and change the entire teams’ surgical gloves after completing the bowel work and again before beginning wound closure; and
  • The team found and fixed lapses in giving antibiotics after surgery.

This last action showed why “local wisdom” might improve standardized checklists.

Previous compliance was 99 percent with the national SCIP measure of “appropriate antibiotic selection.” But frank talk on the team revealed that staff didn’t think all patients were actually getting the correct medications. In fact, before the team was formed, only 33% of penicillin-allergic patients were getting recommended doses of the gentamicin/clindamycin recommended by the infection control staff. (Patients were either under-dosed or not receiving gentamicin because of concerns about side-effects.) After team intervention, 92% of patients received the correct antibiotics.

Based on average costs of $6,000 to $10,000 per surgical-site infection, the study authors estimated that by decreasing their infection rate by 33%, their hospital saved from $168,000 to $280,000 in one year alone— just among its 278 colorectal surgery patients.

The authors described study limitations—it was not randomized; it was only at one hospital; and all improvement measures were introduced simultaneously and not analyzed separately for effectiveness. They called for further, multi-institutional studies.

But their overall conclusion: “Formation of small groups of front-line providers to address patient harm using local wisdom and existing evidence can improve patient safety. “

SOURCE: August 2012 Journal of the American College of Surgeons     



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