The return of investment of hospital-based surgical quality improvement programs in reducing surgical site infection at a Canadian tertiary-care hospital

A systematic review of cost and well-being in hip and knee replacements surgical site infections

This systematic review examined peer-reviewed literature published from 2010 to 2020 to investigate the health care system costs, hidden out-of-pocket expenses and quality of life impact of surgical site infections (SSIs) and to develop an overall summary of the burden they place on patients. SSI can significantly impact patients' treatment experience and quality of life. Understanding patients' SSI-related burden may assist in developing more effective strategies aimed at lessening the effects of SSI in financial and well-being consequences. Peer-reviewed articles on adult populations (over 18 years old) in orthopaedic elective hip and knee surgeries published from 2010 to 2020 were considered. Only publications in English and studies conducted in high-income countries were eligible for inclusion. A search strategy based on the MESH term and the CINAHL terms classification was developed. Five databases (Scopus, EMBASE, CINAHL, Medline, Web of Science) were searched for relevant sources. Reviewers categorised and uploaded identified citations to Covidence and EndNoteX9. Reviewers will assess article titles, abstracts and the full text for compliance with the inclusion criteria. Ongoing discussions between reviewers resolved disagreements at each selection process stage. The final scoping review reported the citation inclusion process and presented search results in a PRISMA flow diagram. Four main themes were extracted from a thematic analysis of included studies (N = 30): Hospital costing (n = 21); Societal perspective of health system costing (n = 2); Patients and societal well-being (n = 6) and Epidemiological database and surveillance (n = 22). This systematic review has synthesised a range of themes associated with the overall incidence and impact of SSI that can inform decision making for policymakers. Further analysis is required to understand the burden on SSI patients.

A mobile application for wound and symptom surveillance after colorectal surgery: a feasibility randomized controlled trial protocol

Background

Surgical site infections (SSIs) are the most common nosocomial infection and occur in 16.3% of patients undergoing colorectal surgery at our institution (The Ottawa Hospital), the majority of which are identified after discharge from hospital. Patients who suspect having an SSI generally present to the emergency department or surgery clinic. Both options for in-person interaction are costly to the health care system and patients. A mobile app, how2trak, has proven to be beneficial for patients with complex wounds at our institution by facilitating at-home monitoring and virtual consultations.

Objective

This study aims to assess the feasibility of a randomized controlled trial to assess if how2trak can improve patients’ experience and increase detection of SSIs after colorectal surgery while reducing patients’ risk of COVID-19 exposure.

Methods

In this single-center prospective feasibility trial, eligible patients undergoing colorectal surgery will be randomized to either standard care or how2trak postoperative monitoring of their incision, symptoms, and ostomy function. Patient self-assessments will be monitored by a nurse specialized in wound and ostomy care who will follow-up with patients with a suspected SSI. The primary outcome is feasibility as measured by enrollment, randomization, app usability, data extraction, and resource capacity.

Results

This study was approved by our institution’s ethics board on February 26, 2021, and received support from The Ottawa Hospital Innovation and Care Funding on November 12, 2021. Recruitment started June 3, 2021, and 29 were patients enrolled as of September 2021. We expect to publish results in spring 2022.

Conclusions

This study will determine the feasibility of using a mobile app to monitor patients’ wounds and detect SSIs after colorectal surgery. If feasible, we plan to assess if this mobile app facilitates SSI detection, enhances patient experience, and optimizes their care.

Trial Registration

ClinicalTrials.gov NCT04869774; https://clinicaltrials.gov/ct2/show/NCT04869774

International Registered Report Identifier (IRRID)

DERR1-10.2196/26717

What work is required to implement and sustain the National Surgical Quality Improvement Program (NSQIP)? A qualitative study of NSQIP implementation in Alberta, Canada

OBJECTIVES

Hospitals introducing the National Surgical Quality Improvement Program (NSQIP) face implementation challenges. To understand the work of embedding NSQIP into routine practice, we explored interactions between contextual factors and the work among implementation teams at the individual, team and organisational level to illuminate how to support and sustain NSQIP implementation.

DESIGN

Qualitative interpretative study using thematic analysis.

SETTING

Five contextually diverse hospital sites in Alberta, Canada, for in-depth interviewing and four additional hospitals for observation of NSQIP meetings.

PARTICIPANTS

9 Surgeon and Anaesthesiologist Champions; 6 Surgical Clinical Reviewers; 4 Directors and 1 Surgical Site Manager; 3 Operating Room Managers; 3 Quality Improvement Consultants; 1 Surgeon and 1 Provincial NSQIP Lead.

METHODS

To capture context, process and the dynamic interplay between the two, we integrated the Consolidated Framework for Implementation Research (CFIR) and Normalisation Process Theory (NPT) to guide data collection and analysis. 28 individual semi-structured interviews with key informants and observations with field notes of 10 NSQIP meetings were conducted. Data were coded deductively and inductively and analysed thematically.

RESULTS

Key findings informed by CFIR describe the impact of Provincial Collaboratives, leadership support and resources to support NSQIP work. Key findings illuminated by NPT highlight how teams overcame mistrust in NSQIP through relationship building, creating formative spaces to inform collective understandings of NSQIP and inviting feedback from professional groups to cocreate quality improvement solutions. This approach led to increased engagement with NSQIP data and encouraged shifts in conversations within and between nursing and physician groups from problems to solutions based.

CONCLUSIONS

The work the teams did to implement and sustain NSQIP highlights the need for time and resources to develop shared understandings of work processes, reorganise themselves to work together and understand how to help others in the surgical community interpret and value using NSQIP to improve care.

Committed to Better Outcomes: Reducing Infection after Surgery Across the Ontario Surgical Quality Improvement Network

BACKGROUND

In 2015, the Ontario Surgical Quality Improvement Network was established to create a community of practice for Ontario hospitals to improve surgical quality. A provincial campaign to decrease postsurgical infections was launched in 2017.

STUDY DESIGN

Thirty hospitals implemented activities related to the campaign from April 2018 to March 2019. The community of practice was used to disseminate suggested change ideas in each area. Self-reported data from participating hospitals and collaborative-wide aggregate risk-adjusted data from the American College of Surgeons NSQIP were reviewed to determine the impact of the campaign on the rates of postoperative surgical site infections (SSIs), urinary tract infections (UTIs), and pneumonia.

RESULTS

A total of 24, 8, and 2 hospitals selected SSIs, UTIs, and pneumonia, respectively, as their targets for improvement. Three hospitals selected both SSIs and UTIs, 1 hospital selected SSIs and pneumonia, and 1 hospital selected all 3 indicators as targets. Self-reported data demonstrated that the rates of SSIs and UTIs decreased significantly post campaign from 4.87% to 3.99% (p < 0.0001) and from 3.65% to 1.25% (p = 0.007), respectively. Pneumonia rates also decreased from 1.27% to 1.05%. Overall rates of SSIs, UTIs, and pneumonia across all Ontario Surgical Quality Improvement Network hospitals were reduced from 3.4%, 1.29%, and 0.88% to 3.37%, 1.14%, and 0.84%, respectively.

CONCLUSIONS

The 1-year campaign resulted in a clinically significant reduction in the rates of SSIs and UTIs, as well as a trend for decrease in pneumonia incidence among participating hospitals. Using a flexible approach with priority setting and leveraging the community of practice for dissemination of change ideas is an effective way of sustaining quality improvement activities.

Collaborative Antimicrobial Stewardship: Working with Hospital and Health System Administration

Successful antimicrobial stewardship programs rely on engagement with hospital administrators. Antimicrobial stewards should understand the unique pressures and demands of hospital and health system administration and be familiar with key terminology and regulatory requirements. This article provides guidance on strategies for engaging hospital and health system administration to support antimicrobial stewardship, including recommendations for designing a successful antimicrobial stewardship program structure, pitching resource requests, setting meaningful and measurable goals, achieving and communicating results, and fostering ongoing relationships with hospital and health system administration.