The four key changes below are recommended by SCIP and are part of the 5 Million Lives Campaign intervention to reduce surgical complications:

* surgical site infection prevention

* beta-blockers for patients on beta-blockers prior to admission

* venous thromboembolism prophylaxis

* ventilator-associated pneumonia prevention.

Strategies that have been successful in reducing surgical complications include the following:

Surgical site infection prevention

The SCIP and IHI recommendations for reducing surgical site infection include four components of care: appropriate use of antibiotics; appropriate hair removal; postoperative glucose control for major cardiac surgery patients; and immediate postoperative normothermia for colorectal surgery patients.

The reliable application of infection prevention interventions can result in reductions in infection rates and costs, and can improve throughput by releasing inpatient beds and avoiding additional hospital days. Additionally, reliable application of other surgical complication-prevention strategies may result in significant cost avoidance and increased inpatient bed availability.

Based on our experience at the BMC, we can identify a few key success factors in reducing surgical complications. The importance of the work to reduce surgical complications needs to be acknowledged by hospital personnel at all levels. Changes may be labor- and resource-intensive at the start until they become embedded into the culture. Ongoing, clear, concise, and open communication is crucial to success. Physicians should be encouraged and supported to have ownership of the improvement initiative and in their team building efforts. A well-regarded practicing physician champion is key to moving the adoption process forward, as he or she can provide realistic practical feedback on tests or changes. The implementation timeline needs to be realistic and mapped out based on the readiness to adopt and spread. Team member selection is extremely important, and efforts to recruit interested personnel at the point of service who model desired behaviors and lead the changes are very desirable.

Critical to implementation success is developing and providing broad-based education tailored to the needs of the staff regardless of their level of knowledge. Identification of a flexible timeline to help guide the education rollout, as well as the process redesign and reporting, has helped to keep the work at the BMC on track. Involving staff in the review of surgical complications helps to emphasize the message that misses or failures impact the individual patient. In fact, this may help reinforce with staff members that if every intervention was applied as indicated, then those misses and failures may not have resulted in patients developing surgical complications.

On rare occasions, late adopters or resistant clinicians may be encountered. At the BMC, timely information is directly communicated to these potential "barriers" by peer-level SCIP team members, who are very helpful in gaining acceptance and buy in. Additionally, the trend in increased public reporting in healthcare will help engage clinicians to support the development and use of care processes to prevent or avoid complications from occurring in all patients who undergo surgical procedures.

Zero tolerance

Healthcare providers must adopt a zero tolerance for all healthcare-related adverse events. Pressure on healthcare for adoption of defect-free care is being applied as public reporting of compliance with evidence-based interventions expands. Mandatory public reporting of SCIP metrics has accelerated the implementation of SCIP measures in many American hospitals. Currently, only SCIP process measures are reported; outcome measures are soon to follow. Additionally, more than 45% of states have either passed laws or are considering passing laws to publicly report hospital infections and complications.

The Centers for Medicare & Medicaid Services (CMS) and the federal government have made a strong statement that they'll no longer pay costs related to certain hospital-acquired complications starting in October 2008. This transparency and openness of quality care ensures continued focus and support not only from staff members that care for surgical patients, but also from hospital senior leaders. Additionally, national projects that have been put in place to drive healthcare quality, such as the Agency for Healthcare Research and Quality Patient Safety Indicator Program, Hospital Quality Alliance, and the CMS/Premier Hospital Quality Incentive Demonstration project, have helped to maintain energy and focus, and have increased awareness that improving quality is the responsibility of the entire care team, and not just one clinician or specialty.

REFERENCES

Account for 14% to 16 % of all hospital-acquired infections

Second most common hospital adverse event

2% to 5% of operative patients will develop an SI (0.8 to 2 million infections per year)

Third most common infection type after urinary and bloodstream infections

SI increase length of stay (average 7.5 additional days)

60% more likely to spend time in an ICU

Five times as likely to be readmitted

Have a mortality rate twice that of noninfected patients

40% to 60% of infections are preventable by reliable application of prevention strategies

Adverse cardiac events

Rates range from 2% to 34%, depending on patient population (1 million events per year)

If complication is a myocardial infarction (MI), mortality can be as high as 40% to 70%

Leading cause of death after surgery

Thought to be a result of sympathetic response results in postoperative ischemia

Ischemia associated with 20 times increase in in-hospital MI

May increase risk of infarction for months, or years, later by destabilizing coronary plaques

Are preventable if patients are assessed and optimized prior to surgery

Venous thromboembolic events (pulmonary embolism [PE] and DVT)

Most common preventable cause of hospital death (10% of all hospital deaths-150,000 to 200,000 deaths per year)

In 70% to 80% of deaths due to PE, diagnosis not considered prior to death

Incidence increases after major procedure without prophylaxis: DVT = 20% of major procedures; 50% of major orthopedic procedures

PE = 7% to 30%

Incidence increases with age

100 times greater in people who've been hospitalized

Besides risk of sudden death: 30% survivors develop recurrent venous thromboembolic events within 10 years 28% survivors develop venous stasis syndrome within 20 years

Prophylaxis is often underused or misused: 50% reduction in fatal PE with appropriate prophylaxis

Postoperative respiratory events

High-fatality rates: 30% to 46%

Occurs in 9% of patients, 15% of patients receiving mechanical ventilation

Responds to medical interventions > preventable

Conservative estimate of savings of reduced hospitalizations = $22,000 to $52,466 per patient

Ventilator-associated pneumonia is caused by a number of factors, including aspiration of gastric secretions.

Risk factors: Tracheostomy, multiple central line insertions, reintubation, and the use of antacids

REFERENCES

2. Kirkland KB, Briggs JP, Trivette SL, et al. The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs. Inf Con Hosp Epi. 1999;20(11):725-730.

3. Dimick JB. Hospital costs associated with surgical complications: a report for the private sector: National Surgical Quality Improvement Program. J Am Coll Surg. 2004;199:531-537.

Section Description

The Institute for Healthcare Improvement challenges clinicians and administrators to raise care quality through its 5 Million Lives Campaign, a sequel to the 100,000 Lives Campaign. Here, learn how one facility decreased surgical complications by implementing various changes to prevent infections.