Preventing SSIs after Colorectal Surgery: Lessons learned from

Northwestern Memorial Hospital

Amanda Hayman, MD, MPHDepartment of Surgery

ACS NSQIP National Conference21 July 2012

Northwestern Memorial HospitalChicago, Illinois

• 894-bed Academic Medical Center Hospital– 49,777 Inpatient Admissions

– 12,211 Deliveries – Largest Birthing Center in Illinois

• Primary Teaching Affiliate of Northwestern University Feinberg School of Medicine

• Nationally Recognized for Clinical Excellence

– “Top Hospital” for 2011 by Thomson Reuters

– Ranked #1 hospital in the Chicago Metro area by “America’s Best Hospitals” and Consumer Choice Awards

• Magnet Recognition for Nursing Excellence since 2006

• Honored with the National Quality Health Care Award

• One of five Healthcare Institutions in the U.S. with a AA+ Bond Rating

• Affiliated with Northwestern Lake Forest Hospital in February 2010

Feinberg and Galter pavilions

Prentice Women’s Hospital

Background•Northwestern Memorial Hospital joined NSQIP in 2005

•Track all our post-surgical SSIs–Started 100% capture of colorectal cases 3/11

•For 2009, our SSI rate after colorectal surgery was 17.72%–Our expected rate was: 13.09%*

–O/E ratio: 1.35*

•This spurned the initiation of a quality improvement project to decrease our SSI rate after colorectal surgery

*using standard NSQIP algorithm

Project Goals•Goals

1. Reduce overall colorectal SSI rate by 25%

2. Reduce O/E SSI ratio to 1.0

•Target populationAll colorectal surgery patients from pre-operative preparation through 30-day discharge

•InterventionsImplemented multipronged process improvement project as part of multi-institutional collaborative

Improvement Project timeline• March 2011

– Implemented “OR closing bundle” protocol

– Compliance documented via survey by circulating nurse

Improvement Project timeline• March 2011

– Implemented “OR closing bundle” protocol

• June 2011– Internal data analysis of patient and surgeon factors associated with

colorectal SSIs

Internal Data Analysis• Source population

– All colorectal procedures in NSQIP from 1/1/09 – 3/31/11 for top 3 volume colorectal surgeons

• Rate of SSIs– 22/216 cases (10.2%): superficial 54%, deep 14%, organ space 32%

• Univariate analysis– Factors not associated with SSIs (p<0.1):

– Patient factors: smoking, sepsis, ASA, lab values (Cr, Hct, Plt), Bmi, DM,

HTN, MI, Age

– Technical factors: lap/open, rectal/colon, emergent case, concurrent

procedure, surgeon

Factors associated with SSI (multivariate logistic regression)

Variable Odds ratio (95% CI) p-valueIBD 3.15 (1.25 – 7.93) 0.015

Wound class 3+ 2.75 (1.10 – 6.90) 0.031

Op time >180 2.45 (1.0 – 6.01) 0.051

Albumin < 3.5 2.40 (0.94 – 6.16) 0.069

Internal Data Analysis

• Conclusions:– IBD was the strongest risk factor for SSI

– IBD patients accounted for 1/3 of all SSIs but only 16% of total cases

Improvement Project timeline• March 2011

– Implemented “OR closing bundle” protocol

• June 2011– Internal data analysis of patient and surgeon factors associated with

colorectal SSIs

Improvement Project timeline• March 2011

– Implemented “OR closing bundle” protocol

• June 2011– Internal data analysis of patient and surgeon factors associated with

colorectal SSIs

• January 2012 – Infection Control begins root cause analyses (RCA) for all colorectal SSI

1. Colorectal SSI is reported to Infection Control

2. Infection Control completes RCA form

3. RCA form sent to surgeon for review and input

4. Conclusions from each RCA shared with SSI project team

Root Cause Analysis Form

Summary questions from RCA• Sent to surgeons for completion:

– Were any events or breaks in sterile technique reported that may have contributed this infection?

– What are some potential factors that could have contributed to this infection?

– Did we do everything we could to prevent this SSI?

– Any action/follow-up items to prevent future occurrence?

RCA Summary: 1/12 – 7/12

Overall Results

• Goal performance1. Reduce colorectal SSIs by 25%

– 2011 Target: 10.8% – 2011 Performance: 11.8% (represents 18% reduction from 2009)

2. Reduce our O/E from 1.38 to 1.0– 2009: 1.09*– 2011: 0.87

*used as baseline for collaborative via alternative NSQIP algorithm

Year TotalCases

Total SSIs Superficial Deep Organ Space

2009 202 29 (14.4%)

20 (9.9%)

3 (1.5%)

11 (5.4%)

2011 306 36 (11.8%)

17 (5.6%)

8 (2.6%)

12 (3.9%)

Lessons learned• Made good progress towards project goals

– Successfully decreased our O:E to <1– Nearly accomplished 25% decrease in SSI rate (18%)

• Despite high compliance with new OR closing bundle, no association found between protocol compliance and SSIs

• Despite SCIP-compliance, RCAs revealed aberrations in peri-op antibiotic and normothermia protocols– Preventable factors implicated in 15 of 19 (79%) SSIs– Start RCAs at beginning of project?

• Collaboration with other institutions extremely beneficial– Increased clinician buy-in– Sharing of quality improvement tools

Next Steps

• Continue 100% capture of colorectal cases for NSQIP

• Ongoing improvements to antibiotic use and administration protocols– Stopped window pick up– Pre-op weights on OR schedule

• Still reporting out our colorectal SSI O/Es to collaborative– Will revisit committee if outliers detected

Project Team

Process Improvement Leaders• Jennifer Van Dyke• Stephen Reinhart

Surgeon Leaders• Amy Halverson, MD, FACS

Division of Colon & Rectal Surgery• Amanda Hayman, MD, MPH

Chief Resident, General Surgery

NSQIP Nurse Abstracters• Kara Nelis, RN• Margarita Salinas-Watts, RN

OR Leadership• Ella Eschavez, RN• Karen Anderson, RN

Director of Surgical Services• Elizabeth Brill, MD

Medical Director of Surgical Services• Medy Manual, RN

ORSC, GI/Endocrine Surgery

Infection Control• Christina Silkaitis, ICP• Kristen Metzger, MPH, CIC• Janet Franck, MBA, RN, CIC• Katie Eggerstedt