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More than 45 million inpatient, operative procedures are performed in the United States each year. Approximately 40% of these procedures incur some type of complication, the most common being surgical infections (SIs), postoperative venous thromboembolic events, postoperative cardiac events, and respiratory failure.1 (See "Postoperative complications: Etiology, impact, and scope.") These perioperative adverse events affect more than 1 million people and are associated with increased costs of approximately $25 billion.1-3 Based on the results of various research efforts, a collaborative project sponsored by several national organizations known as the Surgical Infection Prevention (SIP) Project was developed in 2002. Baystate Medical Center (BMC), Springfield, Mass., joined the initial project in 2002 as the Massachusetts representative hospital.4,5 Since then, changes in the CMS Inpatient Perspective Payment System now require every hospital in the United States to report selected SIP/Surgical Care Improvement Project (SCIP) process measures as part of the reimbursement model. This recent change has helped increase not only the adoption of interventions, but the speed of which they're translated into clinical care.
The SIP project demonstrated a 27% reduction in infections after the first 15 months.5 The program's success was the major impetus to expand the project scope to include surgical complications in 2005-this became known as SCIP.6 SCIP is a partnership of national organizations, including the Institute for Healthcare Improvement (IHI), which is supporting SCIP and the adoption of four key changes to reduce surgical complications through the 5 Million Lives Campaign.7 (See "Changes recommended to reduce surgical complications.")
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.
Additional considerations that IHI recommends are teamwork and organizational culture.
According to data tabulated in 2003, postoperative complications accounted for 22% of preventable deaths among hospitalized patients. 2,3 Moreover, an additional 2.4 million days and 9.3 billion in hospital charges as a result of complications were identified.2,3 These facts are compelling and drive the case for the broad-based adoption of interventions to reduce surgical complications. Widely applying the recommended SCIP interventions based on the incidence noted above could prevent 13,000 deaths and 270,000 surgical complications each year, based on Medicare patients alone.2,3
Nationally, the IHI has led the charge in using reliability theory to ensure optimal appropriate care is provided to avoid harm as a result of the healthcare system.8 Using reliability principles to design care delivery models was a foundational block of the 100,000 Lives Campaign, and has gained an even greater foothold in the 5 Million Lives Campaign launched in December 2006. Successful change is linked to senior leadership providing a clear direction and encouraging culture change to adopt an improvement framework, such as the Model for Improvement, to guide and accelerate improvement efforts.9 (See "Model for Improvement.")
Strategies that have been successful in reducing surgical complications include the following:
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 process for ordering the prophylactic antibiotic works best when standardized, such as through an automatic protocol or preprinted order set. Selection of appropriate prophylactic antibiotics should be based on Centers for Disease Control and Prevention guidelines, as well as on a review of the medical literature.10-13 These recommendations should be adopted at the facility by the Pharmacy and Therapeutics Committee and the Department of Surgery, and result in standardized recommendations for antibiotic choice based on surgical procedure. The recommendations should also be converted to an "opt-out" process for ease of use-this refers to a process whereby the clinician has to actively choose not to use the standard process and specify the reason for doing so. Typically, opting out is more time consuming or difficult than allowing the agreed-upon process to occur as part of the flow of work. Using the opt-out method promotes the desired action to be applied more consistently to a greater number of eligible patients.
The preoperative prophylactic dose of antibiotic must be administered within 0 to 60 minutes before incision, thus it's generally best to administer in the preoperative area, or operating room (OR) suite, rather than on the nursing unit prior to the patient being sent to the OR. Case delays and long patient preparation time can result in the majority of preoperative antibiotic doses not being administered on http://time.The intraoperative process should require staff members to verify that the preoperative dose of antibiotic has been administered as part of the surgical "time out" to identify and mitigate any potential misses. This process also supports intraoperative redosing when appropriate.
Evidence suggests that continuing prophylactic antibiotics after the incision is closed doesn't reduce the rate of postoperative infections.14 It does, however, support the increasing number of resistant organisms that have developed in the last 5 to 10 years. This increase is the major rationale for promoting prophylactic antibiotic duration less than 24 hours after the surgery's end time (except in cardiothoracic surgery where 48 hours is appropriate). Process changes to support discontinuation can include changing physician order sets to give any postoperative doses immediately on admission to the postanesthesia care unit and then every 8 hours times two doses, thereby ensuring antibiotics will be discontinued within 24 hours. Education for the nursing staff should be provided and reinforced to ensure that antibiotics are stopped within 24 hours of the surgery end time-even if a dose was missed-and to chart the time the dose was actually given instead of letting the electronic medical record default to the time charted.
Other infection prevention interventions include removing razors so that hair removal is done using clippers or isn't done at all.15 Although the bulk of research demonstrating the effects of normothermia has been done in colorectal patients, maintaining normothermia by prewarming or applying forced warm air as soon as possible in the OR suite keeps all patients comfortable and helps to decrease the rate of postoperative infection, bleeding, and the pain threshold. Monitoring is best done after identification of a standard tool used at a standard time. Tympanic thermometers are sometimes referred to as "random number generators," and, in particular cases, aren't recommended.16 Glycemic control starting in the first 48 hours postoperatively in cardiac surgery patients has demonstrated a significant reduction in SIs.17-18 This intervention requires a well-coordinated team approach to customize each hospital's methodology. Continuous monitoring of compliance with each component of care is important, with results tracked and shared with clinicians and overlaid with infection rates to merge process measure compliance with outcome measures.
To reduce perioperative cardiovascular events, beta-blockers should be continued in patients who are currently on them and considered for patients at high risk who are undergoing major noncardiac surgery. Key to this is ensuring that patients who are receiving beta-blockers prior to surgery have them continued during and after surgery.19-20 This is essentially medication reconciliation, a recommended intervention in the 5 Million Lives Campaign and a Joint Commission National Patient Safety Goal.
Deep vein thrombosis (DVT) prophylaxis in surgical patients should be based on recommendations for mechanical and pharmaceutical prophylaxis in the American College of Chest Physician Guidelines.21 All patients undergoing surgery should be screened for DVT risk prior to admission and recommended prophylaxis prescribed based on that risk. Best-practice hospitals have included this assessment and ordering as part of the surgical procedure booking process and, in many cases, therapy is started preoperatively. Electronic or manual reminders can support appropriate hospital-wide use. Mechanical prophylaxis can easily be adopted for the majority of patients and applied as part of the parallel processing that occurs in the OR preoperatively. Postoperative monitoring can be incorporated into the daily review of each patient's plan of care and verified during rounds.
Continuous feedback regarding compliance and intervention implementation that can impact outcomes should be shared with the clinical staff members. Cases identified as not passing a measure should be acted upon within the hospital's existing review process for omissions in care. Data collection and presentation should be done on a routine predetermined basis so that even small rate changes will be identified sooner rather than later. Current performance data should be reviewed on a quarterly basis at various leadership meetings to keep senior leadership aware and engaged to get "Boards on Board," another intervention in the 5 Million Lives Campaign.22 In addition to the process measures, outcome measures are shared with senior leaders and the clinical care team to show the impact of reliable application of these of evidence-based interventions.
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.
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.
1. Medicare Quality Improvement Community. Surgical Care Improvement Project. Available at: http://medqic.org. Accessed September 24, 2007. [Context Link]
2. Kirkland KB, Briggs JP, Trivette SL, et al. The impact of surgical site infections in the 1990s: attributable morality, excess length of hospitalization, and extra costs. Inf Con Hosp Epi. 1999;20(11):725-730. [Context Link]
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. [Context Link]
4. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Institute of Medicine; November 1, 1999. [Context Link]
5. Medicare Quality Improvement Community. From SIP to SCIP. Available at: http://www.medqic.org/dcs/ContentServer?cid=1136495755695&pagename=Medqic%2FOthe. Accessed August 10, 2007. [Context Link]
6. Bratzler DW, Houck PM. Antimicrobial prophylaxis for surgery: an advisory statement from the national surgical infection prevention project. Clin Infect Dis. 2004;38(12):1706-1715. [Context Link]
7. Institute for Healthcare Improvement. 5 Million Lives Campaign. Getting started kit: reduce surgical complications. Available at: http://www.ihi.org/nr/rdonlyres/ac9aaeed-7516-4371-8810-8bf45b8ce9c2/0/sciphowto. Accessed September 24, 2007. [Context Link]
8. Nolan T, Resar R, Haraden C, Griffin FA. Improving the Reliability of Health Care. Boston, Mass: Institute for Healthcare Improvement; 2004. Available at: http://www.ihi.org/IHI/Results/WhitePapers/ImprovingtheReliabilityofHealthCare.h. Accessed September 24, 2007. [Context Link]
9. Langley G, Nolan K, Nolan T, Norman C, Provost L. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. Chapter 6. San Francisco, Calif: Jossey-Bass Publishers; 1996. Available at: http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/HowToImprove/. Accessed September 24, 2007. [Context Link]
10. Mangram AJ, Horan TC, Pearson ML, et al. Prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol. 1999;20:250-278. [Context Link]
11. ASHP: Therapeutic guidelines on antimicrobial prophylaxis in surgery. American Society of Health-System Pharmacists. Am J Health Syst Pharm. 1999;56:1839-1888. [Context Link]
12. Page CP, Bohnen JM, Fletcher JR, et al. Antimicrobial prophylaxis for surgical wounds: guidelines for clinical care. Arch Surg. 1993;128:79-88. [Context Link]
13. Treatment guidelines for antimicrobial prophylaxis in surgery. Treat Guidel Med Lett. 2004;43:98. [Context Link]
14. DiPiro JT, Cheung RP, Bowden TA Jr, Mansberger JA. Single dose systemic antibiotic prophylaxis of surgical wound infections. Am J Surg. 1986;152(5):552-559. [Context Link]
15. Kjonniksen I, Andersen BM, Sondenaa VG, Segadal L. Preoperative hair removal: a systematic literature review. AORN J. 2002;75(5):928-938, 940. [Context Link]
16. Inarmura M, Matsukawa T, Sessler DI. The accuracy and precision of four infrared aural canal thermometers during cardiac surgery.Acta Anaesthesiol Scand. 1998;42(10):1222-1226. [Context Link]
17. Furnary AP, Zer KJ, Grunkemier GL. Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infections in diabetic patients after cardiac surgical procedures. Ann Thorac Surg. 1999;67:353-362. [Context Link]
18. Van de Berghe G, Wouters P, Weekers F. Intensive insulin therapy in the critically ill patients. New Eng J Med. 2001;345: 1359-1367. [Context Link]
19. Grayburn PA, Hillis LD. Cardiac events in patients undergoing noncardiac surgery: shifting the paradigm from noninvasive risk stratification to therapy. Ann Intern Med. 2003;138(6):506-511. [Context Link]
20. Auerbach AD, Goldman L. Beta-blockers and reduction of cardiac events in noncardiac surgery: clinical applications. JAMA. 2002;287(11):1445-1447. [Context Link]
21. Geerts WH, Heit JA, Clagett GP. Prevention of venous thromboembolism. The seventh ACCP conference on antithrombotic and thrombolytic therapy. Chest. 2004;126: 338-400S. [Context Link]
22. Institute for Healthcare Improvement. 5 Million Lives Campaign. Getting started kit: governance leadership. Available at: http://www.ihi.org/nr/rdonlyres/95eadb8f-3ad6-4e09-8734-fb7149cfdf14/0/boardhowt. Accessed September 24, 2007. [Context Link]
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)
Excess costs: adds $1,398 to $26,019 per patient; $130 to $845 million per year1
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
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
Excess costs: adds $7789 to $26,019 per patient; $20 billion per year1
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
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
Complication impact: Second most common cause of excess LOS; third most common cause of excess mortality Excess hospital charges: $18,310 to $27,089 per patient1
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
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
1. Surgical Care Improvement Project. Available at: http://www.medqic.org. Accessed September 24, 2007. [Context Link]
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.
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.
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