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34 Ways to Stop Colorectal Surgery Infections

 |  By cclark@healthleadersmedia.com  
   December 03, 2012

When a seven-hospital collaboration tackled colorectal surgical site infections—the second most common type of SSI—the rates dropped 32%, from 15.8% of patients to 10.7%, and the average length of stay for an infected patient fell from 15 to 13 days.

These hospitals discovered 34 factors that increased the risk of failure and then devised solutions, saving the seven hospitals approximately $3.7 million in care, medication, and other avoided costs. A non-infected colorectal surgical patient usually stays in the hospital about eight days.

"These improvements represent victories for patients, caregivers, and healthcare as a whole, and are an example of how preventing complications like surgical site infections can save money," says Mark Chassin, MD, president of the Joint Commission, which partnered with the American College of Surgeons to create the Center for Transforming Healthcare’s Surgical Site Infection Project.

"In the period before the interventions took effect, there were 420 surgical site infections among sampled patients at all seven hospitals," Chassin says. With the 32% reduction, the seven participating hospitals were able to avoid 135 surgical site infections after all the solutions were implemented. The project began in March, 2009, and ended in September, 2012.

During a news briefing to announce the results, Chassin said that during the two-and-a-half year effort, the test hospitals found that there was no one-size-fits-all solution, because solutions need to be customized for the type of patients.

"At any one hospital, only a small number of these [34] factors will explain the majority of failures, and those key causes differ from one hospital to another, so the same set of targeted interventions won't work the same way in all hospitals," Chassin says. "Each contributing factor requires a different intervention to get rid of it, which means you have to target interventions to your most important factors."

At one hospital, for instance, patient might benefit from nutritional counseling, infection screening, and built-in electronic alerts to identify high-risk patients, whereas at another hospital, the key tactics were weight-based antibiotic dosing protocols and ensuring that a patient's temperature is maintained for optimal wound healing.

The hospitals participating in the project were: Cedars-Sinai Medical Center in Los Angeles, Cleveland Clinic, Mayo Clinic—Rochester (MN) Methodist Hospital, North Shore—Long Island Jewish Health System, Northwestern Memorial Hospital in Chicago, OSF Saint Francis Medical Center in Peoria, IL, and Stanford Hospital & Clinics in Palo Alto, CA.

Effective solutions not only varied from hospital to hospital, but sometimes from surgeon to surgeon, says Shirin Towfigh, MD, an attending surgeon and surgeon champion at Cedars-Sinai. At her hospital, which has 46 affected surgeons, major points of implementation were summarized in a simple pamphlet that broke tactics down into three categories, before, during, and after surgery.

Her team found four methods were the most effective:

  1. The night or day of the patient's surgery, the patient was asked to take a shower with a chlorhexadine-based antibacterial soap provided by the hospital.
  2. Antibiotic administration doses and frequency were standardized "so there was no confusion."
  3. If an operation goes beyond four hours, make sure that the same antibiotic was redosed. This step was found to be even more important than initial antibiotic infusion.
  4. During surgery, before closure of skin, all members of the surgical team must do a complete change to new gowns, gloves, suction devices, cautery pens, and closure instruments.

Towfigh says that prior to the interventions, Cedars-Sinai’s SSI rate for colorectal surgeries was 15.5%, "slightly above that for the nation." The test protocols brought that rate down to 5.5%.

Clifford Ko, MD, director, American College of Surgeons National Surgical Quality Improvement Program, and a colorectal surgeon at UCLA's Jonsson Comprehensive Cancer Center, says that skin preparation and providing patients with antibacterial wipes to take home were solutions most of the hospitals benefited from.

"But even more than that, probably, was the changing of the gloves and instruments at surgical site closure. That was something that across the board, from the seven hospitals, everyone agreed on," he says.

Chassin and Ko say that any Joint Commission—accredited hospital that wants to use the tools to implement the center's changes may do so without charge, and should contact the Joint Commission for more information.

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