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Mull HJ, Rosen AK, Charns MP, Itani KM, Rivard PE. Identifying Risks and Opportunities in Outpatient Surgical Patient Safety: A Qualitative Analysis of Veterans Health Administration Staff Perceptions. J Patient Saf 2021; 17:e177-e185. [PMID: 29112029 PMCID: PMC8445239 DOI: 10.1097/pts.0000000000000311] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Little is known about patient safety risks in outpatient surgery. Inpatient surgical adverse events (AEs) risk factors include patient- (e.g., advanced age), process- (e.g., inadequate preoperative assessment), or structure-related characteristics (e.g., low surgical volume); however, these factors may differ from outpatient care where surgeries are often elective and in younger/healthier patients. We undertook an exploratory qualitative research project to identify risk factors for AEs in outpatient surgery. METHODS We developed a conceptual framework of patient, process, and structure factors associated with surgical AEs on the basis of a literature review. This framework informed our semistructured interview guide with (1) open-ended questions about a specific outpatient AE that the participant experienced and (2) outpatient surgical patient safety risk factors in general. We interviewed nationwide Veterans Health Administration surgical staff. Results were coded on the basis of categories in the conceptual framework, and additional themes were identified using content analysis. RESULTS Fourteen providers representing diverse surgical roles participated. Ten reported witnessing an AE, and everyone provided input on risk factors in our conceptual framework. We did not find evidence that patient race/age, surgical technique, or surgical volume affected patient safety. Emerging factors included patient compliance, postoperative patient assessments/instruction, operating room equipment needs, and safety culture. CONCLUSIONS Surgical staff are familiar with AEs and patient safety problems in outpatient surgery. Our results show that processes of care undertaken by surgical providers, as opposed to immutable patient characteristics, may affect the occurrence of AEs. The factors we identified may facilitate more targeted research on outpatient surgical AEs.
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Affiliation(s)
- Hillary J. Mull
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA
- Department of Surgery, Boston University School of Medicine, Boston, MA
| | - Amy K. Rosen
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA
- Department of Surgery, Boston University School of Medicine, Boston, MA
| | - Martin P. Charns
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA
| | - Kamal M.F. Itani
- Department of Surgery, Boston University School of Medicine, Boston, MA
- Department of Surgery, VA Boston Healthcare System, West Roxbury, MA
- Harvard Medical School, Boston, MA
| | - Peter E. Rivard
- Healthcare Administration, Sawyer Business School Suffolk University, Boston, MA
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Ahmad H, Nordin AB, Halleran DR, Kenney B, Jaggi P, Gasior A, Weaver L, Sanchez AV, Wood RJ, Levitt MA. Decreasing surgical site infections in pediatric stoma closures. J Pediatr Surg 2020; 55:90-95. [PMID: 31704044 DOI: 10.1016/j.jpedsurg.2019.09.058] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 09/29/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Gastrointestinal (GI) operations represent a significant proportion of the surgical site infection (SSI) burden in pediatric patients, resulting in significant morbidity. We have previously demonstrated that a GI bundle decreases SSI rates, length of stay (LOS), and hospital charges. Following this success, we hypothesized that by targeting the preoperative antibiotics for stoma closures based on organisms found in infected wounds, we could further decrease SSI rates. METHODS As part of a broad quality improvement effort to reduce SSI rates, we reviewed the responsible pathogens and their sensitivities as well as the preoperative antibiotic used, and found that 15% of wound infections were caused by enterococcus. Based on this information, starting in April 2017, we changed the prior preoperative antibiotic cefoxitin to ampicillin-sulbactam, which more accurately targeted the prevalent pathogens from April 2017 to October 2018. RESULTS The baseline SSI rate for all stoma takedown patients was 21.4% (25 of 119). After bundle implementation, this decreased to 7.9% (17 of 221; p = 0.03) over a period of 2.5 years. Then, after changing the preoperative antibiotics, our rate of SSI decreased further to 2.2% (1 of 44; p = 0.039) over a period of 1.5 years. CONCLUSION Significant reduction of SSI in GI surgery can be accomplished with several prevention strategies (our GI bundle). Then a change of the preoperative antibiotic choice, chosen based on causative wound infection organisms, may further decrease SSI rates. We recommend an institution specific analysis of wound infections and modification of preoperative antibiotics if the responsible organisms are resistant to the original antibiotic choice. TYPE OF STUDY Retrospective cohort study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Hira Ahmad
- Center of Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, OH.
| | - Andrew B Nordin
- State University of New York University at Buffalo, Department of General Surgery, Buffalo, NY
| | - Devin R Halleran
- Center of Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, OH
| | - Brian Kenney
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH
| | - Preeti Jaggi
- Children's Healthcare of Atlanta, Emory University, Atlanta, GA
| | - Alessandra Gasior
- Center of Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, OH; Department of Colorectal Surgery, The Ohio State University, Columbus, OH
| | - Laura Weaver
- Center of Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, OH
| | | | - Richard J Wood
- Center of Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, OH; Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH
| | - Marc A Levitt
- Center of Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, OH; Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH
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Artificial Intelligence Methods for Surgical Site Infection: Impacts on Detection, Monitoring, and Decision Making. Surg Infect (Larchmt) 2019; 20:546-554. [DOI: 10.1089/sur.2019.150] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Wæhle HV, Harthug S, Søfteland E, Sevdalis N, Smith I, Wiig S, Aase K, Haugen AS. Investigation of perioperative work processes in provision of antibiotic prophylaxis: a prospective descriptive qualitative study across surgical specialties in Norway. BMJ Open 2019; 9:e029671. [PMID: 31230033 PMCID: PMC6596935 DOI: 10.1136/bmjopen-2019-029671] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 04/05/2019] [Accepted: 05/17/2019] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE Surgical site infections are known postoperative complications, yet the most preventable of healthcare-associated infections. Correct provision of surgical antibiotic prophylaxis (SAP) is crucial. Use of the WHO Safe Surgical Checklist (SSC) has been reported to improve provision of SAP, and reduce infections postoperatively. To understand possible mechanisms and interactions generating such effects, we explored the underlying work processes of SAP provision and SSC performance at the intersection of perioperative procedures and actual team working. DESIGN An ethnographic study including observations and in-depth interviews. A combination of deductive and inductive content analysis of the data was conducted. SETTING Operating theatres with different surgical specialities, in three Norwegian hospitals. PARTICIPANTS Observations of perioperative team working (40 hours) and in-depth interviews of 19 experienced perioperative team members were conducted. Interview participants followed a maximum variation purposive sampling strategy. RESULTS Analysis identified provision of SAP as a process of linked activities; sequenced, yet disconnected in time and space throughout the perioperative phase. Provision of SAP was handled in relation to several interactive factors: preparation and administration, prescription accuracy, diversity of prescription order systems, patient-specific conditions and changes in operating theatre schedules. However, prescription checks were performed either as formal SSC reviews of SAP items or as informal checks of relevant documents. In addition, use of cognitive reminders and clinical experiences were identified as mechanisms used to enable administration of SAP within the 60 min timeframe described in the SSC. CONCLUSION Provision of SAP was identified as a complex process. Yet, a key element in provision of SAP was the given 60 min. timeframe of administration before incision, provided in the SSC. Thus, the SSC seems beneficial in supporting timely SAP administration practice by either being a cognitive tool and/or as a cognitive intervention.
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Affiliation(s)
- Hilde Valen Wæhle
- Department of Research and Development, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Stig Harthug
- Department of Research and Development, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Eirik Søfteland
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Nick Sevdalis
- Centre for Implementation Science, Health Service & Population Research Department, King's College, London, UK
| | - Ingrid Smith
- Department of Essential Medicines and Health Products, World Health Organization, Geneve, Switzerland
| | - Siri Wiig
- Centre for Resilience in Healthcare (SHARE), Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Karina Aase
- Centre for Resilience in Healthcare (SHARE), Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Arvid Steinar Haugen
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
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Parikh PP, Rubio GA, Patel K, Gupta K, Jones K, Rey J, Robinson H. Transverse versus Longitudinal Incisions for Femoral Artery Exposure in Treating Patients with Peripheral Vascular Disease. Ann Vasc Surg 2018; 47:143-148. [DOI: 10.1016/j.avsg.2017.08.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 07/30/2017] [Accepted: 08/03/2017] [Indexed: 12/01/2022]
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Nordin AB, Sales SP, Besner GE, Levitt MA, Wood RJ, Kenney BD. Effective methods to decrease surgical site infections in pediatric gastrointestinal surgery. J Pediatr Surg 2017; 53:S0022-3468(17)30640-1. [PMID: 29108847 DOI: 10.1016/j.jpedsurg.2017.10.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 10/05/2017] [Indexed: 01/22/2023]
Abstract
BACKGROUND Gastrointestinal (GI) surgeries represent a significant proportion of the surgical site infection (SSI) burden in pediatric patients, resulting in significant morbidity. Previous studies have shown that perioperative bundles reduce SSIs, but few have focused on pediatric GI operations. We hypothesized that a GI bundle would decrease SSI rates, length of stay (LOS), and hospital charges. METHODS After establishing baseline SSI rates, a GI bundle was created and implemented in November 2014. We prospectively collected data including demographics, procedure type, LOS, inpatient charges, bundle compliance, and SSI development. We analyzed SSI rates, LOS, and charges using process control charts. RESULTS The baseline SSI rate for all GI operations was 3.4%, which increased to 7.1%, then decreased to 4.7%. Midgut/hindgut and stoma closure SSI rates decreased from 11.3% to 8.0% (p<0.05) and 21.4% to 7.9%, respectively (p<0.05). Although overall LOS and charges were unchanged, average LOS for midgut/hindgut surgeries and stoma closures decreased from 20.3 to 13.6days (p=0.015) and 12.6 to 7.9days (p=0.04), respectively. Stoma closure charges decreased from $94,262 to $50,088 (p=0.01). CONCLUSIONS Our perioperative GI bundle decreased SSI rates, primarily among midgut/hindgut operations. Bundle usage decreased LOS and charges most effectively in stoma closures. TYPE OF STUDY Prognosis Study. LEVEL OF EVIDENCE Level 2.
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Affiliation(s)
- Andrew B Nordin
- Nationwide Children's Hospital, Department of Pediatric Surgery, Columbus, OH; State University of New York University at Buffalo, Department of General Surgery, Buffalo, NY
| | - Stephen P Sales
- Nationwide Children's Hospital, Department of Pediatric Surgery, Columbus, OH
| | - Gail E Besner
- Nationwide Children's Hospital, Department of Pediatric Surgery, Columbus, OH; The Ohio State University College of Medicine, Columbus, OH
| | - Marc A Levitt
- Nationwide Children's Hospital, Department of Pediatric Surgery, Columbus, OH; The Ohio State University College of Medicine, Columbus, OH; Nationwide Children's Hospital, Center for Colorectal and Pelvic Reconstruction, Columbus, OH
| | - Richard J Wood
- Nationwide Children's Hospital, Department of Pediatric Surgery, Columbus, OH; The Ohio State University College of Medicine, Columbus, OH; Nationwide Children's Hospital, Center for Colorectal and Pelvic Reconstruction, Columbus, OH
| | - Brian D Kenney
- Nationwide Children's Hospital, Department of Pediatric Surgery, Columbus, OH; The Ohio State University College of Medicine, Columbus, OH.
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Musmar SMJ, Ba'ba H, Owais A. Adherence to guidelines of antibiotic prophylactic use in surgery: a prospective cohort study in North West Bank, Palestine. BMC Surg 2014; 14:69. [PMID: 25204205 PMCID: PMC4168988 DOI: 10.1186/1471-2482-14-69] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Accepted: 08/13/2014] [Indexed: 11/10/2022] Open
Abstract
Background Surgical site infection is a major contributor to increased mortality and health care costs globally which can be reduced by appropriate antibiotic prophylactic use. In Palestine, there is no published data about preoperative antibiotic use. This study aims to find the pattern of antimicrobial prophylaxis use by evaluating time of the first dose, antibiotic selection and duration after surgery in three governmental hospitals in North West Bank/ Palestine during 2011. Methods After approval of Institutional Review Board, a prospective cohort study included a total of 400 abdominal, orthopedic, and gynecological operations which were performed during study period. Trained clinical pharmacists observed selected 301 operations and followed the patient’s files for the three intended study parameters. Compliance of prophylactic antibiotic administration was evaluated according to published guidelines of the American Society for Hospital Pharmacist. Data were analyzed using SPSS version 16 applying descriptive methods. Relationship between guideline compliance and selected operation factors such as type of surgery, patient care unit, and hospital shift, in addition to provider’s age, gender, experience, and specialization were examined applying chi square test. The statistically significant factors with p < 0.01 were further analyzed using logistic regression model. Results Overall compliance for the studied parameters was very low (2%); only 59.8% received their first dose in appropriate time, 18.5% had appropriate antibiotic selection, and 31.8% of patients received antibiotic in appropriate duration. The OBGYN department had much better compliance regarding timing and duration of antibiotic use (P < 0.001), however the proper antibiotic selection was best adhered to for the abdominal surgeries (OR = 3.64, P = 0.002). Male providers were statistically significantly much less adherent to the timing of antibiotic dose (OR = 0.28, p < 0.001), but better adherent in antibiotic selection (OR = 0.191, p = 0.028). Anesthetic technicians showed higher compliance than nurses in timing and duration of antibiotic use. Conclusions Lack of guidelines explains the low adherence to appropriate surgical antibiotic prophylaxis in Palestine, with high rate of broad spectrum antibiotic use, long duration and inappropriate time of first dose .We recommend adopting guidelines for prophylaxis and training all health care providers accordingly.
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Affiliation(s)
- Samar M J Musmar
- Department of Community and Family Medicine, Faculty of Medicine and Health Sciences, An-Najah National University, P,O Box 7, 707, Nablus, Palestine.
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Patient Safety: A Perspective from the Developing World. Patient Saf Surg 2014. [DOI: 10.1007/978-1-4471-4369-7_30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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9
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The Ability of Databases and Guidelines to Drive Quality Improvement. CURRENT OTORHINOLARYNGOLOGY REPORTS 2013. [DOI: 10.1007/s40136-013-0032-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Katlic MR, Facktor MA, Berry SA, McKinley KE, Bothe A, Steele GD. ProvenCare lung cancer: a multi-institutional improvement collaborative. CA Cancer J Clin 2011; 61:382-96. [PMID: 21748730 DOI: 10.3322/caac.20119] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Geisinger's ProvenCare™ Program (for elective coronary artery bypass surgery, total hip replacement, and others) has shown that the principles of reliability science, facilitated by a robust electronic health record and institutional commitment, allow the re-engineering of complicated clinical processes. This eliminates unwarranted variation and promotes the completion of evidence-based elements of care. It has not been established that ProvenCare can be generalized to other institutions. Now, under the auspices of the American College of Surgeons Commission on Cancer, ProvenCare has been adapted to a multi-institutional collaborative for the care of the patient with resectable lung cancer.
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Affiliation(s)
- Mark R Katlic
- Department of Thoracic Surgery, Geisinger Wyoming Valley Medical Center, Wilkes-Barre, PA, USA.
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Hawn MT, Vick CC, Richman J, Holman W, Deierhoi RJ, Graham LA, Henderson WG, Itani KM. Surgical Site Infection Prevention. Ann Surg 2011; 254:494-9; discussion 499-501. [PMID: 21817889 DOI: 10.1097/sla.0b013e31822c6929] [Citation(s) in RCA: 211] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Ho VP, Barie PS, Stein SL, Trencheva K, Milsom JW, Lee SW, Sonoda T. Antibiotic Regimen and the Timing of Prophylaxis Are Important for Reducing Surgical Site Infection after Elective Abdominal Colorectal Surgery. Surg Infect (Larchmt) 2011; 12:255-60. [DOI: 10.1089/sur.2010.073] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Vanessa P. Ho
- Department of Surgery, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
| | - Philip S. Barie
- Department of Surgery, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
- Department of Public Health, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
| | - Sharon L. Stein
- Department of Surgery, University Hospital Case Western Medical Center, Cleveland, Ohio
| | - Koiana Trencheva
- Department of Surgery, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
| | - Jeffrey W. Milsom
- Department of Surgery, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
| | - Sang W. Lee
- Department of Surgery, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
| | - Toyooki Sonoda
- Department of Surgery, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
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Larochelle M, Hyman N, Gruppi L, Osler T. Diminishing surgical site infections after colorectal surgery with surgical care improvement project: is it time to move on? Dis Colon Rectum 2011; 54:394-400. [PMID: 21383558 DOI: 10.1007/dcr.0b013e318206165b] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Surgical site infections are a major source of expense and morbidity after colon resection. OBJECTIVE This study aimed to assess the effect of a targeted intervention to improve compliance with Surgical Care Improvement Project measures on the incidence of surgical site infection. STUDY DESIGN A cohort of patients was prospectively monitored. SETTING The investigation was conducted at a university teaching hospital. PATIENTS Consecutive patients underwent open colon resection with anastomosis. INTERVENTION A multidisciplinary committee consisting of a surgeon, anesthesiologist, nurses, and quality specialists was convened in late 2004 and a series of initiatives were designed, implemented, and tracked to improve performance on the 4 infection-related components of the Surgical Care Improvement Project program. MAIN OUTCOME MEASURES Compliance with the 4 Surgical Care Improvement Project process measures and the rate of surgical site infection were documented. RESULTS There was no improvement in the use of appropriate antibiotics (P = .66), administration within 1 hour of incision (P = .11), cessation within 24 hours (P = .36), or achievement of normothermia (P = .46). Similarly, there was no effect whatsoever on the incidence of surgical site infection over the study period (P = .84). LIMITATIONS The single-institution nature of the study limited its usefulness. CONCLUSIONS A 5-year multidisciplinary program of targeted initiatives and interventions failed to improve compliance with Surgical Care Improvement Project measures or to decrease surgical site infection at our institution where colon resections are performed almost exclusively by high-volume specialists. These efforts consumed considerable resources and expenditures, but were of little or no value in our setting.
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Affiliation(s)
- Michael Larochelle
- Department of Surgery, University of Vermont College of Medicine, Burlington, Vermont, USA
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Potenza B, Deligencia M, Estigoy B, Faraday E, Snyder A, Angle N, Schwartz A, Chang L, Hackett J, Minokadeh A, Madani M, MacAulay K, Ramamoorthy S, Blaner L, James C, Bansal V, Torriani F, Coimbra R. Lessons learned from the institution of the Surgical Care Improvement Project at a teaching medical center. Am J Surg 2009; 198:881-8. [DOI: 10.1016/j.amjsurg.2009.08.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2009] [Revised: 08/17/2009] [Accepted: 08/17/2009] [Indexed: 11/28/2022]
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Itani KM. Fifteen years of the National Surgical Quality Improvement Program in review. Am J Surg 2009; 198:S9-S18. [DOI: 10.1016/j.amjsurg.2009.08.003] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2009] [Accepted: 08/04/2009] [Indexed: 12/22/2022]
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Cartmill C, Lingard L, Regehr G, Espin S, Bohnen J, Baker R, Rotstein L. Timing of surgical antibiotic prophylaxis administration: complexities of analysis. BMC Med Res Methodol 2009; 9:43. [PMID: 19549329 PMCID: PMC2711115 DOI: 10.1186/1471-2288-9-43] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2008] [Accepted: 06/23/2009] [Indexed: 11/17/2022] Open
Abstract
Background The timing of prophylactic antibiotic administration is a patient safety outcome that is recurrently tracked and reported. The interpretation of these data has important implications for patient safety practices. However, diverse data collection methods and approaches to analysis impede knowledge building in this field. This paper makes explicit several challenges to quantifying the timing of prophylactic antibiotics that we encountered during a recent study and offers a suggested protocol for resolving these challenges. Challenges Two clear challenges manifested during the data extraction process: the actual classification of antibiotic timing, and the additional complication of multiple antibiotic regimens with different timing classifications in a single case. A formalized protocol was developed for dealing with incomplete, ambiguous and unclear documentation. A hierarchical coding system was implemented for managing cases with multiple antibiotic regimens. Interpretation Researchers who are tracking prophylactic antibiotic timing as an outcome measure should be aware that documentation of antibiotic timing in the patient chart is frequently incomplete and unclear, and these inconsistencies should be accounted for in analyses. We have developed a systematic method for dealing with specific problematic patterns encountered in the data. We propose that the general adoption of a systematic approach to analysis of this type of data will allow for cross-study comparisons and ensure that interpretation of results is on the basis of timing practices rather than documentation practices.
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Pharmacokinetics of topical and intravenous cefazolin in patients with clean surgical wounds. Plast Reconstr Surg 2009; 122:1773-1779. [PMID: 19050530 DOI: 10.1097/prs.0b013e31818d5899] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Surgical-site infection is a common postoperative nosocomial infection. Surgeons frequently treat operative patients with protective antibiotics and often choose cefazolin as the drug. Treatment schemes include both preoperative intravenous dosing and intraoperative dosing by irrigation. This study was designed to measure cefazolin concentrations both in serum and in wound drain fluid after intravenous dosing and after irrigation. METHODS The authors conducted an institutional review board-approved study involving randomized allocation of breast reduction patients to group 1 (preoperative intravenous dosing) or group 2 (intraoperative dosing by irrigation). Each patient had serum and wound drainage specimens measured over time for cefazolin concentrations. Cefazolin dosing was based on preparations commonly used in the authors' hospital. Results from 24 patients are reported. RESULTS Patients treated by conventional preoperative intravenous dosing displayed the expected serum degradation curve. These patients also demonstrated wound drainage concentrations (peak, 22.49 microg/ml) for approximately 4 to 5 hours. Measured concentrations were above the minimum therapeutic concentration (8 microg/ml) for Staphylococcus aureus. Patients treated by wound irrigation also demonstrated serum concentrations above minimum therapeutic concentration. In addition, these patients' wound drain fluid demonstrated very high cefazolin concentrations (peak, 4185.93 microg/ml), which remained high for 24 hours. CONCLUSIONS Protective cefazolin concentrations in the wound can be achieved by both intravenous and irrigation delivery. Wound irrigation produces higher concentrations for longer periods of time.
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Trussell J, Gerkin R, Coates B, Brandenberger J, Tibi P, Keuth J, Montefour K, Salisbury H, Ferrara J. Impact of a patient care pathway protocol on surgical site infection rates in cardiothoracic surgery patients. Am J Surg 2008; 196:883-9; discussion 889. [DOI: 10.1016/j.amjsurg.2008.07.024] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2008] [Revised: 06/05/2008] [Accepted: 07/03/2008] [Indexed: 10/21/2022]
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Multivalvular Bacterial Endocarditis After Suction Curettage Abortion. Obstet Gynecol 2008; 112:1179; author reply 1180-1. [DOI: 10.1097/aog.0b013e31818cb8bf] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Nguyen N, Yegiyants S, Kaloostian C, Abbas MA, Difronzo LA. The Surgical Care Improvement Project (SCIP) Initiative to Reduce Infection in Elective Colorectal Surgery: Which Performance Measures Affect Outcome? Am Surg 2008; 74:1012-6. [DOI: 10.1177/000313480807401028] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
One component of the Surgical Care Improvement Project (SCIP) is the prevention of surgical site infections (SSIs) by: 1) timing the administration of prophylactic antibiotics (PAs) within 1 hour of incision; 2) using approved PA regimens; and 3) discontinuing PA within 24 hours. We sought to evaluate institutional compliance with SCIP recommendations in patients undergoing elective colorectal surgery and determine whether they affected the incidence of SSI. One hundred four elective colorectal cases were reviewed. In 58 patients (56%), PAs were administered within 1 hour of incision. In 71 cases (68%), the PA choice was considered compliant. There were a total of 12 SSIs (11.5%) overall. The incidence of SSI was significantly higher in cases in which PAs were not administered within 1 hour of incision (10 of 46 or 22% vs two of 58 or 3.5%, P = 0.005). There was no significant difference in the incidence of SSI in patients who received compliant versus noncompliant PA (12.7% vs 9.1%, P = 0.75). Timely PA administration significantly reduces the incidence of SSI in patients undergoing elective colorectal surgery. Efforts should focus on ensuring that PAs are given in a timely manner to reduce SSI in colorectal surgery.
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Affiliation(s)
- Nhien Nguyen
- From Kaiser Permanente Los Angeles Medical Center, Department of Surgery, Los Angeles, California
| | - Sara Yegiyants
- From Kaiser Permanente Los Angeles Medical Center, Department of Surgery, Los Angeles, California
| | - Carolyn Kaloostian
- From Kaiser Permanente Los Angeles Medical Center, Department of Surgery, Los Angeles, California
| | - Maher A. Abbas
- From Kaiser Permanente Los Angeles Medical Center, Department of Surgery, Los Angeles, California
| | - L. Andrew Difronzo
- From Kaiser Permanente Los Angeles Medical Center, Department of Surgery, Los Angeles, California
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Hawn MT, Itani KM, Gray SH, Vick CC, Henderson W, Houston TK. Association of Timely Administration of Prophylactic Antibiotics for Major Surgical Procedures and Surgical Site Infection. J Am Coll Surg 2008; 206:814-9; discussion 819-21. [DOI: 10.1016/j.jamcollsurg.2007.12.013] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2007] [Accepted: 12/01/2007] [Indexed: 11/29/2022]
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Hope WW, Newcomb WL, Schmelzer TM, Pope SD, Lincourt AE, Heniford BT, Sing RF. Antibiotic prophylaxis in colon surgery. J Am Coll Surg 2007; 205:189-90. [PMID: 17617351 DOI: 10.1016/j.jamcollsurg.2007.02.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2007] [Accepted: 02/20/2007] [Indexed: 11/24/2022]
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Altpeter T, Luckhardt K, Lewis JN, Harken AH, Polk HC. Expanded Surgical Time Out: A Key to Real-Time Data Collection and Quality Improvement. J Am Coll Surg 2007; 204:527-32. [PMID: 17382210 DOI: 10.1016/j.jamcollsurg.2007.01.009] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2006] [Accepted: 01/03/2007] [Indexed: 11/25/2022]
Abstract
UNLABELLED Some of the concepts contained here have been discussed and incorporated in another publication, but the data are entirely unique to this manuscript. (See: Transforming the Surgical "Time-Out" Into a Comprehensive "Preparatory Pause." Backster A, Teo A, Swift M, MD, Polk HC Jr, MD, FACS, Harken AH, MD, FACS. J Cardiac Surg, in press.) BACKGROUND The increasing push for quality improvement coincides with the slowly growing use of surgical time out (STO) to lessen the likelihood of wrong-site operation. We believe that the use of STO as a reflective pause or a preoperative briefing has broader value. The purpose of this article is to describe one institution's experience with this technique and to validate its potential use by others. STUDY DESIGN An enhanced use of STO was conducted in a 400-bed teaching hospital in calendar year 2006. Before and after conducts and constructs were rated. RESULTS The institution found the technique to be of value, and substantially clarified and improved its performances with respect to prophylactic antibiotic choice and timing; appropriate maintenance of intraoperative temperature and glycemia; and institution of secondary issues, such as maintenance of beta-blockade and appropriate venous thromboembolism prophylaxis. Surgeon leadership and real-time data collection became essential and helpful components. CONCLUSIONS Prompt feedback to surgeons is vital; identification of future targets for performance improvement is feasible, although useless measures are eliminated. Because surgeons grapple with pay-for-performance, STO is a useful safety, data, and quality improvement tool.
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Affiliation(s)
- Terry Altpeter
- University of Louisville Hospital, Department of Surgery, University of Louisville School of Medicine and Quality, Louisville, KY 40292, USA
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