An analysis of factors that can lead to surgical site infections has led to significant changes in standards and information integration.
This article appears in the September 2015 issue of HealthLeaders magazine.
As the Centers for Medicare & Medicaid Services begins tying surgical site infections to value-based purchasing and other programs, healthcare organizations could experience an impact on reimbursements. But surgeons tasked with lowering SSI rates say monetary penalties are the least of their concerns.
"Honestly, as surgeons, we don't care about an institutional number we're trying to hit. We're the ones seeing the patient with the wound infection, and when they are in front of us, it's 100% a problem," says Mark Lane Welton, MD, MHCM, chief of staff and chief of colorectal surgery at Stanford Hospital, a 613-licensed-bed facility with 49 operating rooms based in California.
Mark Lane Welton, MD, MHCM |
SSIs, which occur in 2%–5% of patients undergoing inpatient surgery, can lead to prolonged stays, additional surgeries, additional courses of IV antibiotics, disability among patients, and even mortality. SSIs also create tremendous cost, up to $10 billion annually, according to the Centers for Disease Control and Prevention.
For the past five years, Welton and his team have been focused on reducing the risk for SSIs in general colorectal surgeries. Stanford participated in the Joint Commission Center for Transforming Healthcare's SSI Project, along with six other hospitals. The project's mission from 2010 to 2012 was to track colorectal surgeries, which are notoriously at high risk for infection, and identify variables that significantly influence the occurrence of colorectal SSIs. The project identified 34 correlating variables and, across the participating hospitals, reduced superficial incisional colorectal SSIs by 45% and all types of colorectal SSIs by 32%.
More than those specific numbers, what the hospitals discovered about the procedures at the time and continue to monitor is the real game changer, according to Welton. As part of the SSI Project, Stanford assembled a task force comprising surgeons, nurses, anesthesiologists, and others involved in surgeries to analyze processes and procedures. They immediately found that contamination was a serious issue.
"When I was in surgical training, the nurses were strict about contamination and we relied on them to help maintain sterile technique in the field," Welton says. "[The task force observed] nurses setting staplers that had been used during surgery on top of sterile instruments needed for wound closing, causing contamination." Also, they noticed that surgeons weren't changing their gloves and gowns before closing wounds.
Stanford instituted significant changes in the wake of the SSI project, including empowering nurses to speak to surgeons about correct procedures, educating covering nurses about the opportunities for contamination in colorectal surgeries, and introducing a separate closing tray, with sterile instruments, just before wound closure.
The hospital also established standards such as primarily using chlorhexidine as a skin cleanser, allowing for consistency and a reduction in inventory of multiple skin cleansers.
Instituting these improvements "drove our wound infections down," Welton says.
Assessing risk
OSF Saint Francis Medical Center in Peoria, Illinois—a 609-licensed-bed facility that is part of OSF HealthCare, a system with $7 billion in gross patient service revenue—also participated in The Joint Commission's SSI Project and crystalized some best practices across the care continuum for colorectal surgeries that are still in place today.
For instance, OSF's registered nurses in the surgical preadmission chart office contact patients a week before surgery to review the patient's history and medications, explain the risks, and educate patients on the procedure. Additional assessment and education are given by its surgical advanced practice nurse at the surgery education and testing program clinic.
"The advanced practice nurse will alert physicians to any issues the patients mention that might negatively impact the surgery," says Terry Malone, RN, MSN, CNOR, director of surgery and allied services at OSF Saint Francis. Physicians also are tied into preoperative screening results such as elevated glucose, use of steroids, or elevated BMI. "We also inspect the patient's body for potential infection elsewhere," she adds.
All of this information is fed into the American College of Surgeons' National Surgical Quality Improvement Program database. ACS' Surgical Risk Calculator draws from NSQIP data to estimate the chance of an unfavorable outcome, such as complications.
As part of its newly minted best practices, some physicians at OSF Saint Francis share the Surgical Risk Calculator's assessment with patients. If the patient and/or physician are uncomfortable with the risk, the surgery can be delayed until certain health factors improve.
Like Stanford, OSF Saint Francis adopted operating room improvements such as the closing tray and mandatory gown and glove changes before wound closure. The hospital also heightened restrictions on dress code and the amount of traffic allowed in and out of the operating room.
In addition to the SSI Project, OSF Saint Francis participates in the Surgical Care Improvement Project used by CMS to inform reimbursements. SCIP measures such factors as prophylactic antibiotic selection and anti-thrombosis medication and measures, to name a few.
When OSF Saint Francis intensified focus on SCIP compliance in 2010, it had scores in the 70% range. As of 2015, the hospital is fully compliant, according to Malone. "Everyone involved in SSI prevention understands the cost of infection and devastation to the patient. No surgeon wants a high infection rate," she says.
Reimbursements, while not a primary concern, do come into play as the hospital doesn't get reimbursed for preventable infections. "SSI prevention is beneficial in financial ways, but it's most important to have a patient who is free of complications, with a great surgical outcome," she says.
Building a better engine
At the University of Iowa Hospitals and Clinics—an Iowa City–based system that includes a 730-licensed-bed hospital—leaders have had an interest in SSIs that predates the government's financial incentives.
John Cromwell, MD |
In 2009, John Cromwell, MD, director of surgical quality and safety, and director of gastrointestinal surgery, decided to combine data from NSQIP, various registries, and other databases into a single data warehouse. Analysis from the warehouse showed SSI as the leading hospital-acquired infection, and Cromwell decided to make general GI surgery—his specialty—the pilot project.
The key, according to Cromwell, was having good definitions for the various types of SSIs (he used the CDC definitions) and narrowing down the patient population to be studied.
Using a set of IT-provided servers behind a firewall, otherwise known as a sandbox, Cromwell analyzed data from 2009, shortly after a new electronic medical records system was installed, to 2011. While a lot of factors that impacted outcomes weren't surprising—weight, smoking history, the presence of comorbidities—some were, including the patient's ZIP code.
"The ZIP code is a surrogate marker for socioeconomic status, health literacy, and distance from providers," he says, adding that the variable had never been used before.
By identifying high-risk patients, the hospital was able to take precautions such as applying negative pressure to the wound. Typically a costly procedure that tethers patients to the hospital, Cromwell developed a scoring system that would ensure the procedure was optimally used.
Cromwell also made sure that patients were followed for 30 days so that the hospital could gather the most accurate postoperative data.
In the first two years of using the data, the hospital saw a 58% reduction in SSIs in general GI surgeries. Now, that reduction has grown to 70%, according to Cromwell. The program has been so effective that the hospital wants to use it across more disciplines, which has led Cromwell to adopt a commercial-grade analytics engine, Dell Statistica. "From the system we put together with bubble gum and string, this is an upgrade. It was smart to start on a small scale, though, and show the ROI based on a well-defined group," he says.
Further examination
While many hospitals have targeted their SSI programs at colorectal and gastrointestinal surgeries, some, including the UMass Memorial Medical Center in Worcester, Massachusetts, are looking at other vulnerable areas such as cardiac surgery and joint replacement surgery.
In 2008, UMass Memorial Medical Center—which has 779 beds and an active medical staff of 1,338—created a task force to figure out how to decrease surgical site infections in orthopedic surgery. The chair of the orthopedics department, a surgical quality officer, and others convened regularly to review best practices.
They first looked at what could be done preoperatively, including screening for staph infections and ensuring diabetics had blood sugars under control. They also standardized sanitization of the surface of the skin and dispensing of antibiotics. Then they examined the operating room environment and found that airflow needed to be addressed.
"When you do a knee replacement or a hip replacement, you have to make large incisions which expose more of the inside of the body to the outside air," says Richard Ellison III, MD, hospital epidemiologist. "The air not only needs to be clean but it also has to have a low turbulent flow so that bacteria is not stirred up."
The task force consulted with the facilities team to ensure proper humidity and that overall air quality is monitored, as well. An additional concern related to alterations in airflow was the number of healthcare workers walking in and out of the operating room during procedures, and personnel policies were put in place to limit this "traffic" during hip and knee replacements.
Quantifying the results of these changes can be difficult, especially as infections decrease below 1 in 100. In addition to lowering infection rates and standardizing patient surgical care, Ellison says a benefit of the program has been the development of a repeatable analysis process to share with other departments.
Analysis paralysis
Elie Berbari, MD, a consultant for infectious diseases, hospital epidemiologist, and head of the Infection Control Research Committee at the Mayo Clinic in Rochester, Minnesota, says many hospitals today are hamstrung in their analysis by the variations in data.
The Mayo Clinic—which treats more than 1.3 million patients a year and has nearly 60,000 employees—participates in the SCIP and NSQIP databases, as well as the CDC's National Healthcare Safety Network, a healthcare-associated infection tracking system. But Berbari points out that the stratifying scheme used by these reporting engines aren't always on target.
"While current stratification schemestake into account certain factors, they don't always address the complexityof the practice in each hospital," Berbari says. "Therefore, they still aren't fully predictive about what the expected number of infections are."
For instance, if a hospital does a lot of colon surgeries for patients with immunosuppressed systems due to Crohn's disease or ulcerative colitis, the SSI complexity will be greater than a hospital dealing primarily with patients with diverticulitis and normal immune systems. "The SSI prediction schemes do not take this into account, so they wind up penalizing practices that take on high-risk patients," Berbari says.
When the public sees published SSI rates, details about risk stratification are often not taken into account. "Referral rates and prestige could be impacted over poor prediction schemes," he says. And with value-based payments picking up steam, these skewed results could even affect reimbursements.
"We need more robust systems that engage the patient more and standardize the approach to stratification and follow-up of surgical cases. Otherwise we won't be able to adequately predict, detect, and report on surgical site infections," Berbari says.
Sandra Gittlen is a contributing writer for HealthLeaders Media.
Reprint HLR0915-6