Developing Targeted Strategies to Reduce Surgical Site Infections

In November, The Joint Commission released data from a surgical site infection project led by its Center for Transforming Healthcare in collaboration with the American College of Surgeons. The project began in August 2010 and focused on reducing colorectal SSIs. The seven hospitals that participated in the two-and-a-half year study collectively reduced all colorectal SSIs by 32 percent, resulting in an estimated savings of more than $3.7 million.

One of the keys to the project's success was each hospital's use of robust process improvement methods to identify causes of infections and develop solutions targeted to these causes rather than taking a cover-all approach.

In a news conference Nov. 28, leaders of the project shared how data-driven, targeted solutions can reduce infections and save costs.

Robust process improvement
The participant hospitals include Cedars-Sinai Medical Center in Los Angeles; Cleveland Clinic; Mayo Clinic-Rochester (Minn.) Methodist Hospital; North Shore-Long Island Jewish Health System in Great Neck, N.Y.; Northwestern Memorial Hospital in Chicago; OSF Saint Francis Medical Center in Peoria, Ill.; and Stanford Hospital & Clinics in Palo Alto, Calif.

The hospitals adopted RPI methods to address colorectal SSIs. RPI incorporates Lean, Six Sigma and change management strategies to achieve improvements. Under RPI, hospitals measured the magnitude of colorectal SSIs at their facility, pinpointed specific causes and developed solutions tailored to each cause. Finally, the hospitals tested their solutions and made adjustments when necessary. "The same set of targeted interventions won't work the same way in all hospitals," said Mark R. Chassin, MD, FACP, MPP, MPH, president of The Joint Commission.

By the numbers:

7 Hospitals participated
2 ½-year project
34 unique correlating variables that increased the risk of colorectal SSIs
135 SSIs avoided
$3.7 million saved
45% decrease in superficial incisional SSIs
32% decrease in all colorectal SSIs
2 day decrease in average length of stay for patients with any type of colorectal SSI
Together, the hospitals identified 34 unique factors that were associated with increased risk of colorectal SSIs. While some risk factors were true for all seven hospitals, such as a body mass index below 20 or higher than 30, not every hospital shared all 34 factors. Each hospital's patient population, location, culture and other characteristics made each facility unique. For example, patients younger than 44 or older than 60 were at increased risk for colorectal SSIs at only two hospitals.

To identify a facility's specific risk factors, hospitals need "to be introspective — to look at oneself, one's facility, to see what we're doing well and what we're doing not so well," said Clifford Y. Ko, MD, MS, MSHS, FACS, director of the American College of Surgeons' National Surgical Quality Improvement Program and the ACS Division of Research and Optimal Patient Care.

Targeted solutions
To improve colorectal SSI rates, each hospital developed specialized solutions to address each contributing factor. Examples of a targeted solution to reduce superficial incisional colorectal SSIs are standardizing the preoperative instruction to patients and caregivers for applying the preoperative skin cleaning product and establishing specific criteria for the correct management of specific types of wounds, according to a report by the Center for Transforming Healthcare.

At Mayo Clinic, a big risk factor was patients' BMI, so many interventions were focused on addressing that risk. For example, Mayo Clinic developed an electronic trigger tool that alerts providers whenever a colorectal surgery patient has a BMI over 30, according to Jenna Lovely, PharmD, BCPS, surgical pharmacotherapy manager at Mayo Clinic. "We embedded consensus-based items in the system and environment whenever possible," she said.

Universal solutions
While there is a need to target strategies for each facility, there are some solutions that are successful in nearly all healthcare facilities. The hospitals in the colorectal SSI project had the following common characteristics, according to Center for Transforming Healthcare:

• Emphasis on the use of data to guide and drive improvement decisions and implementations

• Sharing real-time data with all staff who care for colorectal surgical patients

• A committed colorectal surgeon champion who led the project

• A dedicated core team that included front-line staff from each process area and subject
matter experts

• Continuous engagement of the core team throughout the project

• Leadership ensured that surgeons and other staff who worked on the project received
needed support, including dedicating a certain amount of time to the project

• Engagement of staff and patient/caregivers, giving a voice to both internal and external

• An organizational culture that held everyone accountable for preventing the occurrence of SSIs

More Articles on Surgical Site Infections:

Colorectal Surgical Site Infection Project Saves More Than $3.7M
6 Practices Cedars-Sinai Used to Reduce Colorectal SSIs by More Than 60%

Survey: Majority of CEOs Believe Their Influence Can Reduce CIED Infections, Costs

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