Association for Academic SurgerySurgical care improvement project and surgical site infections: can integration in the surgical safety checklist improve quality performance and clinical outcomes?1
Introduction
Surgical site infections (SSI) complicate up to 5% of all operations in the US and are the most frequent nosocomial infection among surgical patients [1]. With over 15 million surgical procedures performed in the US annually, an estimated 750,000 SSI will occur, resulting in additional direct and indirect cost to both the patient and the healthcare systems [1], [2], [3], [4]. It has been reported that SSI can increase the postoperative length of stay by 7 to 10 dand hospital costs by 300% [5], [6]. Furthermore, mortality rates can exceed 10% with certain infections [7]. Although effective prevention strategies exist, compliance is poor and outcomes are difficult to track [8], [9]. Therefore, national programs for surgical quality performance and perioperative outcomes have been introduced as strategies to improve patient care and reduce complications [10], [11], [12].
The Surgical Care Improvement Project (SCIP) was developed by the Centers for Medicare and Medicaid Services to reduce SSI rates by 10% [10], [12]. SCIP measures for SSI prevention (SCIP Inf) involve a multi-disciplinary approach including the proper timing of antibiotic infusion (SCIP Inf1), antibiotic selection (SCIP Inf2), appropriate discontinuation of prophylactic antibiotics (SCIP Inf3), appropriate hair removal method (SCIP Inf6), and maintenance of perioperative normothermia (SCIP Inf10), and euglycemia (SCIP Inf4). Compliance with SCIP quality performance measures is publicly reported and is tied to hospital reimbursement. [11], [13] The National Surgical Quality Improvement Program (NSQIP) is a validated program used for improving surgical care through outcome measurement and direct provider feedback. Participation in NSQIP has shown to improve surgical outcomes in both low and high performing hospitals [14], and has been used to track outcomes of quality performance measures including SCIP [14], [15], [16], [17]. While adherence to SCIP measures has controversial effects on patient outcomes [15], [16], [18], [19], [20], [21], [22], there is a growing incentive for compliance through pay-for-performance and pay-for value initiatives [11], [13], [23].
Multi-disciplinary checklists including the World Health Organization (WHO) Surgical Safety Checklist (SSC) have been shown to decrease SSI, complications and mortality rates [24], [25]. These improved patient outcomes are achieved, in part, through standardized steps during the checklist process that achieve error reduction and improve compliance with process-of-care measures. Haynes and colleagues showed that implementing a 19-item checklist in the perioperative period increased appropriate timing of antibiotic infusion from 56% to 83% with a significant reduction in SSI from 6.2% to 3.4% [24]. However, this study did not report other core SCIP Inf performance measures targeting SSI reduction. The purpose of this study was to determine if implementation of a standardized SSC (1) improved surgical team perceptions of SCIP Inf SSI reduction strategies, and (2) how implementation affected SCIP Inf quality performance measures and patient outcomes.
Section snippets
Methods
Scott and White Memorial Hospital is a 636 bed tertiary care hospital that actively participates in SCIP and NSQIP data bases and quality performance reporting. On September 1, 2010, we implemented a SSC with integration of SCIP Inf quality performance metrics in effort to improve patient safety and reduce complications, including SSI. The implementation process included a multidisciplinary team for development, validation through focused and limited SSC trial, surgical team training and
Surgical team perceptions
Survey invitations were sent to a total of 824 surgical team members (469 baseline and 355 follow-up groups). Although the survey was related to all aspects of the SSC, the results reported in this study represent the surgical teams' perceptions related to SCIP Inf performance measures only. The overall response rate was 53% with a total of 210 responses in the baseline group and 227 responses in the follow-up group. There were three questions specific to SCIP Inf performance measures, and
Discussion
The main findings of our study is that a SSC with integrated SCIP Inf quality performance measures improves surgical team perceptions and compliance with these process-of-care measures on an institutional level. Improved perceptions of surgical team communication and intervention for hypothermia resulted in a decrease in number of patients with hypothermia upon arrival to the PACU. These findings did not result in overall improved SSI rates; however, a significant reduction in SSI was seen in
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Presented at the Academic Surgical Congress, Outcomes Plenary Session, New Orleans, LA, February 5–7, 2013.