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Tran G, Kelly B, Hammersley M, Norman J, Okely A. The utility of website-based quality improvement tools for health professionals: a systematic review. Int J Qual Health Care 2024; 36:mzae068. [PMID: 38985665 PMCID: PMC11277856 DOI: 10.1093/intqhc/mzae068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 06/03/2024] [Accepted: 07/09/2024] [Indexed: 07/12/2024] Open
Abstract
As technology continues to advance, it is important to understand how website-based tools can support quality improvement. Website-based tools refer to resources such as toolkits that users can access and use autonomously through a dedicated website. This review examined how website-based tools can support healthcare professionals with quality improvement, including the optimal processes used to develop tools and the elements of an effective tool. A systematic search of seven databases was conducted to include articles published between January 2012 and January 2024. Articles were included if they were peer reviewed, written in English, based in health settings, and reported the development or evaluation of a quality improvement website-based tool for professionals. A narrative synthesis was conducted using NVivo. Risk of bias was assessed using the Mixed Methods Appraisal Tool. All papers were independently screened and coded by two authors using a six-phase conceptual framework by Braun and Clarke. Eighteen studies met the inclusion criteria. Themes identified were tool development processes, quality improvement mechanisms and barriers and facilitators to tool usage. Digitalizing existing quality improvement processes (n = 7), identifying gaps in practice (n = 6), and contributing to professional development (n = 3) were common quality improvement aims. Tools were associated with the reported enhancement of accuracy and efficiency in clinical tasks, improvement in adherence to guidelines, facilitation of reflective practice, and provision of tailored feedback for continuous quality improvement. Common features were educational resources (n = 7) and assisting the user to assess current practices against standards/recommendations (n = 6), which supported professionals in achieving better clinical outcomes, increased professional satisfaction and streamlined workflow in various settings. Studies reported facilitators to tool usage including relevance to practice, accessibility, and facilitating multidisciplinary action, making these tools practical and time-efficient for healthcare. However, barriers such as being time consuming, irrelevant to practice, difficult to use, and lack of organizational engagement were reported. Almost all tools were co-developed with stakeholders. The co-design approaches varied, reflecting different levels of stakeholder engagement and adoption of co-design methodologies. It is noted that the quality of included studies was low. These findings offer valuable insights for future development of quality improvement website-based tools in healthcare. Recommendations include ensuring tools are co-developed with healthcare professionals, focusing on practical usability and addressing common barriers to enhance engagement and effectiveness in improving healthcare quality. Randomized controlled trials are warranted to provide objective evidence of tool efficacy.
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Affiliation(s)
- Georgie Tran
- Early Start, Faculty of the Arts, Social Sciences and Humanities, University of Wollongong, Wollongong, NSW 2522, Australia
| | - Bridget Kelly
- Early Start, Faculty of the Arts, Social Sciences and Humanities, University of Wollongong, Wollongong, NSW 2522, Australia
| | - Megan Hammersley
- Early Start, Faculty of the Arts, Social Sciences and Humanities, University of Wollongong, Wollongong, NSW 2522, Australia
| | - Jennifer Norman
- Health Promotion Service, Illawarra Shoalhaven Local Health District, Warrawong, NSW 2502, Australia
| | - Anthony Okely
- Early Start, Faculty of the Arts, Social Sciences and Humanities, University of Wollongong, Wollongong, NSW 2522, Australia
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Rarani SA, Kramer A. Three steps to reduction surgical site infection: presentation of a comprehensive model. GMS HYGIENE AND INFECTION CONTROL 2023; 18:Doc17. [PMID: 37693849 PMCID: PMC10486815 DOI: 10.3205/dgkh000443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
To prevent surgical site infections (SSIs), a three-step model is proposed, which integrates perioperative measures, multidisciplinary collaboration, and continuous quality improvement (CQI) initiatives.
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Affiliation(s)
- Saeid Amini Rarani
- Department of Operating Room, Nursing and Midwifery Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Axel Kramer
- Institute of Hygiene and Environmental Medicine, University Medicine Greifswald, Greifswald, Germany
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Antonacci AC, Antonacci CL, Dechario SP, Husk G, Schilling ME, Cifu-Tursellino K, Armellino D, Coppa G, Jarrett M. Reducing surgical site infections after colectomy: bundle item compliance, process, and outlier identification. Surg Endosc 2022; 36:6049-6058. [PMID: 35511342 DOI: 10.1007/s00464-022-09234-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 04/02/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND The purpose of this study was to implement a checklist monitoring system and identify critical surgical checklist items associated with post-colectomy surgical site infections (SSI). The relationship between checklist compliance, infection rates, and identification of non-compliant surgeons was explored. MATERIALS AND METHODS National Health Safety Network (NHSN) data were imported annually to establish baseline incidence of post-colectomy SSI from 2016 to 2019. A colectomy checklist was used to monitor compliance for 1694 random colectomies (1274 elective; 420 emergency). Reports were generated monthly to profile system, hospital, surgeon-specific infection, and checklist compliance rates. RESULTS Checklist compliance improved in elective and emergent colectomies to > 90% for all items except oral antibiotic and mechanical bowel prep in elective cases. Annualized total SSI and organ space infection rates in elective cases decreased by 33% and 45%, respectively. Elective and emergency SSI's were reduced for Superficial Incisional Primary (SIP), Deep Incisional Primary (DIP), and Intra-Abdominal Abscess (IAB) by 66%, 60.4%, and 78.3%, respectively. Checklist compliance between low (< 3%) and high (> 3%) infection rate surgeons demonstrated significantly lower utilization of oral antibiotic prep (p < 0.03) and mechanical bowel prep (p < 0.02) in high infection rate surgeons. CONCLUSION Surgeons compliant with colectomy checklists decreased elective and emergency colectomy infection rates. Ceiling compliance rates > 95% for bundle items are suggested to achieve optimal reductions in SSIs and efforts should be focused on surgeons with NHSN infection rates > 3%. Oral antibiotic prep and mechanical bowel prep compliance rates in elective colectomy appeared to differentiate high infection rate surgeons from low infection rate surgeons.
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Affiliation(s)
- Anthony C Antonacci
- Northwell Health, 2000 Marcus Avenue, Manhasset, NY, 11030, USA.
- , New York, USA.
| | | | - Samuel P Dechario
- Institute for Spine & Scoliosis (ISS), 3100 Princeton Pike, Bldg. 1-D, Lawrenceville, NJ, 08648, USA
| | - Gregg Husk
- Northwell Health, 2000 Marcus Avenue, Manhasset, NY, 11030, USA
| | | | | | - Donna Armellino
- Northwell Health, 2000 Marcus Avenue, Manhasset, NY, 11030, USA
| | - Gene Coppa
- Northwell Health, 2000 Marcus Avenue, Manhasset, NY, 11030, USA
| | - Mark Jarrett
- Northwell Health, 2000 Marcus Avenue, Manhasset, NY, 11030, USA
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Falconer R, Ramsay G, Hudson J, Watson A. Reducing surgical site infection rates in colorectal surgery - a quality improvement approach to implementing a comprehensive bundle. Colorectal Dis 2021; 23:2999-3007. [PMID: 34396654 PMCID: PMC9293099 DOI: 10.1111/codi.15875] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 06/07/2021] [Accepted: 08/05/2021] [Indexed: 12/24/2022]
Abstract
AIM Surgical site infections (SSIs) are a preventable cause of morbidity following surgical procedures. Strategies to reduce rates of SSI must address pre-, peri- and postoperative factors and multiple interventions can be combined into 'bundles'. Adoption of these measures can reduce SSIs, but this is dependent on high levels of compliance. The aim of this work is to assess the change in rates of SSI in elective colorectal surgery after implementing a colorectal SSI bundle. METHOD This is a single-centre prospective cohort study. All elective colorectal procedures from 2011 until 2018 (inclusive) were included. The primary outcome was inpatient SSI. A multimodal bundle was implemented using quality improvement methodology. The bundle was altered during the timeframe of the study to optimize outcomes. Data were analysed by interrupted time series analysis assessing points at which the bundle was altered. RESULTS In the study period, 1075 elective colorectal procedures were performed. Prior to the introduction of the colorectal SSI bundle, the SSI rate was 16.4%. During the implementation period (2013-2015), the overall rate of SSI fell from 15.9% to 9.4%, with the most significant reduction being in superficial SSI, from 8.6% to 4.7%. In the postimplementation period from 2015-2018, there was a further reduction in the overall rate of SSI (5.1%). In 2018, there were 87 consecutive cases without infection. CONCLUSION A successful reduction in the rate of SSI following elective colorectal surgery can be achieved by adopting a comprehensive perioperative bundle. This is complemented by a process of continuous measurement and evaluation. The current bundle has achieved a significant reduction in superficial SSI.
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Affiliation(s)
| | - George Ramsay
- Department of General SurgeryAberdeen Royal Infirmary, Aberdeen and Rowett Institute for Nutrition and Health, ForesterhillUniversity of AberdeenAberdeenUK
| | - Jemma Hudson
- Health Services Research UnitUniversity of AberdeenAberdeenUK
| | - Angus Watson
- Department of General SurgeryRaigmore HospitalInvernessUK
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Kerezoudis P, Kelley PC, Watts CR, Heiderscheit CJ, Roskos MC. Using a Data-Driven Improvement Methodology to Decrease Surgical Site Infections in a Community Neurosurgery Practice: Optimizing Preoperative Screening and Perioperative Antibiotics. World Neurosurg 2021; 149:e989-e1000. [PMID: 33515799 DOI: 10.1016/j.wneu.2021.01.060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 01/13/2021] [Accepted: 01/15/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE We used a data-driven methodology to decrease the departmental surgical site infection rate to a goal of 1%. METHODS A prospective interventional study with historical controls comparing preimplementation/intervention (unknown methicillin-sensitive Staphylococcus aureus [MSSA]/methicillin-resistant Staphylococcus aureus [MRSA] status and standard weight and drug allergy-based preoperative antibiotics) with postimplementation/intervention (optimized preoperative chlorhexidine showers, MSSA/MRSA screening, MSSA/MRSA decolonization, and optimized preoperative antibiotic order set implementation). The American College of Surgeons National Surgical Quality Improvement Program was used for case surveillance. The primary outcome was the presence of a surgical site infection with a secondary outcome of cost(s) of implementation. RESULTS A total of 317 National Surgical Quality Improvement Program abstracted neurosurgical cases were analyzed, 163 cases before implementation and 154 cases after implementation. There were no significant differences between the preimplementation and postimplementation cohorts regarding patient demographics and baseline comorbidities, with the exceptions of inpatient and functional status (P < 0.001). The most common procedures were lumbar decompression (31%), lumbar discectomy (27%), and anterior cervical discectomy and fusion (10.4%). After implementation, 30 patients were MSSA positive (20%) and 4 MRSA positive (2.6%). Thirty patients received preoperative intranasal mupirocin decolonization (88%), and 4 patients received adjusted preoperative antibiotics (12%). After protocol implementation, the surgical site infection rate decreased from 6.7% (odds ratio, 2.82) to 0.96% (odds ratio, 0.91). The cost of implementation was $27,179, or $58 per patient. CONCLUSIONS The findings highlight the importance of systematically investigating areas of gap in existing clinical practice and quality improvement projects to increase patient safety and enhance the value of care delivered to neurosurgical patients.
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Affiliation(s)
| | - Parker C Kelley
- Department of Neurosurgery, Mayo Clinic Health System, La Crosse, Wisconsin, USA
| | - Charles R Watts
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Department of Neurosurgery, Mayo Clinic Health System, La Crosse, Wisconsin, USA.
| | - Chris J Heiderscheit
- Department of Clinical Quality Management, Mayo Clinic Health System, La Crosse, Wisconsin, USA
| | - Michael C Roskos
- Department of Surgery, Mayo Clinic Health System, La Crosse, Wisconsin, USA
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Park CM, Ha TS, Lee WY, Chung DR, Park YA, Choi JR, Jeong NY. Implementing a multidisciplinary care bundle to reduce colon surgical site infections. Ann Surg Treat Res 2020; 99:285-293. [PMID: 33163458 PMCID: PMC7606129 DOI: 10.4174/astr.2020.99.5.285] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 07/10/2020] [Accepted: 07/29/2020] [Indexed: 12/03/2022] Open
Abstract
Purpose The aim of this study was to investigate how rates of surgical site infections (SSI) were changed over 2 years after applying colon SSI bundle in patients who underwent colon surgery. Methods The multidisciplinary working group developed a care bundle consisting of 8 components, including several recommendations of Surgical Care Improvement Project and monitoring of medical/surgical hand washing. We implemented the care bundle for each patient who underwent colon surgery from April 2013 to December 2014. Results Overall bundle compliance was 87.9% before implementation, 88.2% in 2013, and 90.5% in 2014. In particular, compliance of the following 3 components was substantial improved during the project period; discontinuation of prophylactic antimicrobial agent within 24 hours of surgery (from 88.3% to 100%), surgical hand washing (from 50.0% to 78.9%), and medical hand washing (from 74.7% to 82.8%). The rate of SSI was 8.0% (12/150) during 3 months before implementation, 3.3% (16/480) from April to December in 2013, and 2.3% (14/607) in 2014. Conclusion After implementation of multidisciplinary care bundle, the compliance of each component was increased and rates of SSIs were significantly decreased compared to those before the quality improvement project.
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Affiliation(s)
- Chi-Min Park
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Tae Sun Ha
- Department of Surgery, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Woo Yong Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Doo Ryeon Chung
- Department of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yoon Ah Park
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong Rim Choi
- Infection Control Office, Samsung Medical Center, Seoul, Korea
| | - Na Yeon Jeong
- Infection Control Office, Samsung Medical Center, Seoul, Korea
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Grass F, Storlie CB, Mathis KL, Bergquist JR, Asai S, Boughey JC, Habermann EB, Etzioni DA, Cima RR. Challenges of Modeling Outcomes for Surgical Infections: A Word of Caution. Surg Infect (Larchmt) 2020; 22:523-531. [PMID: 33085571 DOI: 10.1089/sur.2020.208] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Background: We developed a novel analytic tool for colorectal deep organ/space surgical site infections (C-OSI) prediction utilizing both institutional and extra-institutional American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) data. Methods: Elective colorectal resections (2006-2014) were included. The primary end point was C-OSI rate. A Bayesian-Probit regression model with multiple imputation (BPMI) via Dirichlet process handled missing data. The baseline model for comparison was a multivariable logistic regression model (generalized linear model; GLM) with indicator parameters for missing data and stepwise variable selection. Out-of-sample performance was evaluated with receiver operating characteristic (ROC) analysis of 10-fold cross-validated samples. Results: Among 2,376 resections, C-OSI rate was 4.6% (n = 108). The BPMI model identified (n = 57; 56% sensitivity) of these patients, when set at a threshold leading to 80% specificity (approximately a 20% false alarm rate). The BPMI model produced an area under the curve (AUC) = 0.78 via 10-fold cross- validation demonstrating high predictive accuracy. In contrast, the traditional GLM approach produced an AUC = 0.71 and a corresponding sensitivity of 0.47 at 80% specificity, both of which were statstically significant differences. In addition, when the model was built utilizing extra-institutional data via inclusion of all (non-Mayo Clinic) patients in ACS-NSQIP, C-OSI prediction was less accurate with AUC = 0.74 and sensitivity of 0.47 (i.e., a 19% relative performance decrease) when applied to patients at our institution. Conclusions: Although the statistical methodology associated with the BPMI model provides advantages over conventional handling of missing data, the tool should be built with data specific to the individual institution to optimize performance.
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Affiliation(s)
- Fabian Grass
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - John R Bergquist
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA.,Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Shusaku Asai
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Judy C Boughey
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - David A Etzioni
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Scottsdale, Arizona, USA
| | - Robert R Cima
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Tomsic I, Heinze NR, Chaberny IF, Krauth C, Schock B, von Lengerke T. Implementation interventions in preventing surgical site infections in abdominal surgery: a systematic review. BMC Health Serv Res 2020; 20:236. [PMID: 32192505 PMCID: PMC7083020 DOI: 10.1186/s12913-020-4995-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 02/14/2020] [Indexed: 02/07/2023] Open
Abstract
Background Surgical site infections (SSIs) are highly prevalent in abdominal surgery despite evidence-based prevention measures. Since guidelines are not self-implementing and SSI-preventive compliance is often insufficient, implementation interventions have been developed to promote compliance. This systematic review aims to identify implementation interventions used in abdominal surgery to prevent SSIs and determine associations with SSI reductions. Methods Literature was searched in April 2018 (Medline/PubMed and Web of Science Core Collection). Implementation interventions were classified using the implementation subcategories of the EPOC Taxonomy (Cochrane Review Group Effective Practice and Organisation of Care, EPOC). Additionally, an effectiveness analysis was conducted on the association between the number of implementation interventions, specific compositions thereof, and absolute and relative SSI risk reductions. Results Forty studies were included. Implementation interventions used most frequently (“top five”) were audit and feedback (80% of studies), organizational culture (70%), monitoring the performance of healthcare delivery (65%), reminders (53%), and educational meetings (45%). Twenty-nine studies (72.5%) used a multimodal strategy (≥3 interventions). An effectiveness analysis revealed significant absolute and relative SSI risk reductions. E.g., numerically, the largest absolute risk reduction of 10.8% pertained to thirteen studies using 3–5 interventions (p < .001); however, this was from a higher baseline rate than those with fewer or more interventions. The largest relative risk reduction was 52.4% for studies employing the top five interventions, compared to 43.1% for those not including these. Furthermore, neither the differences in risk reduction between studies with different numbers of implementation interventions (bundle size) nor between studies including the top five interventions (vs. not) were significant. Conclusion In SSI prevention in abdominal surgery, mostly standard bundles of implementation interventions are applied. While an effectiveness analysis of differences in SSI risk reduction by number and type of interventions did not render conclusive results, use of standard interventions such as audit and feedback, organizational culture, monitoring, reminders, and education at least does not seem to represent preventive malpractice. Further research should determine implementation interventions, or bundles thereof, which are most effective in promoting compliance with SSI-preventive measures in abdominal surgery.
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Affiliation(s)
- Ivonne Tomsic
- Hannover Medical School, Centre for Public Health and Healthcare, Department of Medical Psychology, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - Nicole R Heinze
- Hannover Medical School, Centre for Public Health and Healthcare, Institute of Epidemiology, Social Medicine and Health Systems Research, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Iris F Chaberny
- Leipzig University Hospital, Centre for Infection Medicine (ZINF), Institute of Hygiene, Hospital Epidemiology and Environmental Medicine, Liebigstr. 22, 04103, Leipzig, Germany
| | - Christian Krauth
- Hannover Medical School, Centre for Public Health and Healthcare, Institute of Epidemiology, Social Medicine and Health Systems Research, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Bettina Schock
- Leipzig University Hospital, Centre for Infection Medicine (ZINF), Institute of Hygiene, Hospital Epidemiology and Environmental Medicine, Liebigstr. 22, 04103, Leipzig, Germany
| | - Thomas von Lengerke
- Hannover Medical School, Centre for Public Health and Healthcare, Department of Medical Psychology, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
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Zheng X, Huang J, Lin J, Yang D, Xu T, Chen D, Zan X, Wu A. 3D bioprinting in orthopedics translational research. JOURNAL OF BIOMATERIALS SCIENCE-POLYMER EDITION 2019; 30:1172-1187. [PMID: 31124402 DOI: 10.1080/09205063.2019.1623989] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- XuanQi Zheng
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou, China
| | - JinFeng Huang
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou, China
| | - JiaLiang Lin
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou, China
| | - DeJun Yang
- Wenzhou Institute of Biomaterials and Engineering, CNITECH, Chinese Academy of Sciences, Wenzhou, China
| | - TianZhen Xu
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou, China
| | - Dong Chen
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou, China
| | - Xingjie Zan
- Wenzhou Institute of Biomaterials and Engineering, CNITECH, Chinese Academy of Sciences, Wenzhou, China
| | - AiMin Wu
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou, China
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Abstract
Surgical site infection (SSI) following colorectal surgery is associated with worse postoperative outcomes, longer length of stay, and higher rates of readmission. SSI rates have been established as a surrogate metric for the overall quality of surgical care and are intricately tied to financial incentives and the public reputation of an institution. While risk factors and prevention mechanisms for SSI are well established, the rates of SSI remain high. This article discusses the clinical and economic impact of SSI and strategies for mitigating the risk of SSI through bundled prevention practices.
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Affiliation(s)
- Megan C Turner
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - John Migaly
- Division of Advanced GI and Oncologic Surgery, Duke University Medical Center, Durham, North Carolina
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Implementation strategies to reduce surgical site infections: A systematic review. Infect Control Hosp Epidemiol 2019; 40:287-300. [PMID: 30786946 DOI: 10.1017/ice.2018.355] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Surgical site infections (SSIs) portend high patient morbidity and mortality. Although evidence-based clinical interventions can reduce SSIs, they are not reliably delivered in practice, and data are limited on the best approach to improve adherence. OBJECTIVE To summarize implementation strategies aimed at improving adherence to evidence-based interventions that reduce SSIs. DESIGN Systematic reviewMethods:We searched PubMed, Embase, CINAHL, the Cochrane Library, the WHO Regional databases, AFROLIB, and Africa-Wide for studies published between January 1990 and December 2015. The Effective Practice and Organization Care (EPOC) criteria were used to identify an acceptable-quality study design. We used structured forms to extract data on implementation strategies and grouped them into an implementation model called the "Four Es" framework (ie, engage, educate, execute, and evaluate). RESULTS In total, 125 studies met our inclusion criteria, but only 8 studies met the EPOC criteria, which limited our ability to identify best practices. Most studies used multifaceted strategies to improve adherence with evidence-based interventions. Engagement strategies included multidisciplinary work and strong leadership involvement. Education strategies included various approaches to introduce evidence-based practices to clinicians and patients. Execution strategies standardized the interventions into simple tasks to facilitate uptake. Evaluation strategies assessed adherence with evidence-based interventions and patient outcomes, providing feedback of performance to providers. CONCLUSIONS Multifaceted implementation strategies represent the most common approach to facilitating the adoption of evidence-based practices. We believe that this summary of implementation strategies complements existing clinical guidelines and may accelerate efforts to reduce SSIs.
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Abstract
BACKGROUND Surgical site infections are the most common hospital-acquired infection after colorectal surgery, increasing morbidity, mortality, and hospital costs. OBJECTIVE The purpose of this study was to investigate the impact of preventive measures on colorectal surgical site infection rates in a high-volume institution that performs inherent high-risk procedures. DESIGN This was a prospective cohort study. SETTINGS The study was conducted at a high-volume, specialized colorectal surgery department. PATIENTS The Prospective Surgical Site Infection Prevention Bundle Project included 14 preoperative, intraoperative, and postoperative measures to reduce surgical site infection occurrence after colorectal surgery. Surgical site infections within 30 days of the index operation were examined for patients during the 1-year period after the surgical site infection prevention bundle was implemented. The data collection and outcomes for this period were compared with the year immediately before the implementation of bundle elements. All of the patients who underwent elective colorectal surgery by a total of 17 surgeons were included. The following procedures were excluded from the analysis to obtain a homogeneous patient population: ileostomy closure and anorectal and enterocutaneous fistula repair. MAIN OUTCOME MEASURES Surgical site infection occurring within 30 days of the index operation was measured. Surgical site infection-related outcomes after implementation of the bundle (bundle February 2014 to February 2015) were compared with same period a year before the implementation of bundle elements (prebundle February 2013 to February 2014). RESULTS Between 2013 and 2015, 2250 abdominal colorectal surgical procedures were performed, including 986 (43.8%) during the prebundle period and 1264 (56.2%) after the bundle project. Patient characteristics and comorbidities were similar in both periods. Compliance with preventive measures ranged between 75% and 99% during the bundle period. The overall surgical site infection rate decreased from 11.8% prebundle to 6.6% at the bundle period (P < 0.001). Although a decrease for all types of surgical site infections was observed after the bundle implementation, a significant reduction was achieved in the organ-space subgroup (5.5%-1.7%; P < 0.001). LIMITATION We were unable to predict the specific contributions the constituent bundle interventions made to the surgical site infection reduction. CONCLUSIONS The prospective Surgical Site Infection Prevention Bundle Project resulted in a substantial decline in surgical site infection rates in our department. Collaborative and enduring efforts among multiple providers are critical to achieve a sustained reduction See Video Abstract at http://links.lww.com/DCR/A438.
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Zywot A, Lau CSM, Stephen Fletcher H, Paul S. Bundles Prevent Surgical Site Infections After Colorectal Surgery: Meta-analysis and Systematic Review. J Gastrointest Surg 2017. [PMID: 28620749 DOI: 10.1007/s11605-017-3465-3] [Citation(s) in RCA: 110] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Colorectal surgeries (CRS) have one of the highest rates of surgical site infections (SSIs) with rates 15 to >30%. Prevention "bundles" or sets of evidence-based interventions are structured ways to improve patient outcomes. The aim sof this study is to evaluate CRS SSI prevention bundles, bundle components, and implementation and compliance strategies. METHODS A meta-analysis of studies with pre- and post-implementation data was conducted to assess the impact of bundles on SSI rates (superficial, deep, and organ/space). Subgroup analysis of bundle components identified optimal bundle designs. RESULTS Thirty-five studies (51,413 patients) were identified and 23 (17,557 patients) were included in the meta-analysis. A SSI risk reduction of 40% (p < 0.001) was noted with 44% for superficial SSI (p < 0.001) and 34% for organ/space (p = 0.048). Bundles with sterile closure trays (58.6 vs 33.1%), MBP with oral antibiotics (55.4 vs 31.8%), and pre-closure glove changes (56.9 vs 28.5%) had significantly greater SSI risk reduction. CONCLUSION Bundles can effectively reduce the risk of SSIs after CRS, by fostering a cohesive environment, standardization, and reduction in operative variance. If implemented successfully and complied with, bundles can become vital to improving patients' surgical quality of care.
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Affiliation(s)
- Aleksander Zywot
- Department of Surgery, Saint Barnabas Medical Center, 94 Old Short Hills Rd., Livingston, NJ, 07039, USA.,Saint George's University School of Medicine, St. George, West Indies, Grenada
| | - Christine S M Lau
- Department of Surgery, Saint Barnabas Medical Center, 94 Old Short Hills Rd., Livingston, NJ, 07039, USA.,Saint George's University School of Medicine, St. George, West Indies, Grenada
| | - H Stephen Fletcher
- Department of Surgery, Saint Barnabas Medical Center, 94 Old Short Hills Rd., Livingston, NJ, 07039, USA
| | - Subroto Paul
- Department of Surgery, Saint Barnabas Medical Center, 94 Old Short Hills Rd., Livingston, NJ, 07039, USA.
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14
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Vu JV, Collins SD, Seese E, Hendren S, Englesbe MJ, Campbell DA, Krapohl GL. Evidence that a Regional Surgical Collaborative Can Transform Care: Surgical Site Infection Prevention Practices for Colectomy in Michigan. J Am Coll Surg 2017; 226:91-99. [PMID: 29111416 DOI: 10.1016/j.jamcollsurg.2017.10.013] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 10/12/2017] [Accepted: 10/13/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Surgical site infections (SSI) after colectomy are associated with increased morbidity and health care use. Since 2012, the Michigan Surgical Quality Collaborative (MSQC) has promoted a "bundle" of care processes associated with lower SSI risk, using an audit-and-feedback system for adherence, face-to-face meetings, and support for quality improvement projects at participating hospitals. The purpose of this study was to determine whether practices changed over time. STUDY DESIGN We previously found 6 processes of care independently associated with SSI in colectomy. From 2012 to 2016, we promoted a bundle of 3 care measures (cefazolin/metronidazole, oral antibiotics after mechanical bowel preparation, and normoglycemia) in 52 hospitals. Primary outcome was change in use of the 3-item SSI bundle. We also used a hierarchical logistic regression model to assess the association between 6-item compliance and SSI rate, morbidity, and health care use. RESULTS The use of cefazolin/metronidazole increased from 18.6% to 32.3% (p < 0.001), oral antibiotic preparation increased from 42.9% to 62.0% (p < 0.001). The increase in normoglycemia was not significant. Concurrently, the SSI rate fell from 6.7% to 3.9% in the 52 hospitals (p = 0.012). Patients receiving more bundle measures had decreased rates of SSI, sepsis, and pneumonia. Morbidity and health care use significantly decreased with increased bundle compliance. CONCLUSIONS These data show a significant increase in use of process measures promoted by a regional quality improvement collaborative, and an associated decrease in SSI after elective colectomy. These results highlight the promise of regional collaboratives to accelerate practice change and improve outcomes.
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Affiliation(s)
- Joceline V Vu
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Stacey D Collins
- Michigan Surgical Quality Collaborative, University of Michigan, Ann Arbor, MI
| | - Elizabeth Seese
- Michigan Surgical Quality Collaborative, University of Michigan, Ann Arbor, MI
| | | | - Michael J Englesbe
- Department of Surgery, University of Michigan, Ann Arbor, MI; Michigan Surgical Quality Collaborative, University of Michigan, Ann Arbor, MI
| | - Darrell A Campbell
- Department of Surgery, University of Michigan, Ann Arbor, MI; Michigan Surgical Quality Collaborative, University of Michigan, Ann Arbor, MI
| | - Greta L Krapohl
- Michigan Surgical Quality Collaborative, University of Michigan, Ann Arbor, MI.
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15
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Grant MC, Galante DJ, Hobson DB, Lavezza A, Friedman M, Wu CL, Wick EC. Optimizing an Enhanced Recovery Pathway Program: Development of a Postimplementation Audit Strategy. Jt Comm J Qual Patient Saf 2017; 43:524-533. [PMID: 28942777 DOI: 10.1016/j.jcjq.2017.02.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 02/24/2017] [Accepted: 02/26/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Enhanced recovery pathways (ERPs) are bundled best-practice process measures associated with reduction of preventable harm, decreased length of stay (LOS), and increased overall value of care. An auditing procedure was developed to assess compliance with 18 ERP process measures and establish a system for identifying and addressing defects in measure implementation. METHODS For a one-year period, the electronic health records of 413 consecutive patients treated on a multidisciplinary ERP for colorectal surgery at an academic medical center were evaluated with the audit procedure. Patients were stratified who both met the expected LOS, as defined by LOS less than the historical (pre-ERP) average LOS for the same procedure ("successes"), and exceeded the historical LOS ("outliers"). On the basis of the results of the audit process, a number of system-level interventions were developed. The results were then assessed for a three-month follow-up period to determine the impact on process measure compliance and LOS. RESULTS Detailed review of outliers identified several defects that improved following implementation of system-level changes, such as early mobility after surgery (44.4% vs. 59.5; p = 0.02). Although increased compliance through selective process measure optimization did not lead to a significant reduction in overall LOS (days; 5.2 ± 5.0 vs. 4.9 ± 3.0; p = 0.37), the audit procedure was associated with a significant reduction in outliers' LOS (days; 12.2 ± 6.8 vs. 9.0 ± 2.1; p = 0.03). CONCLUSION Concentrating audits in patients who fail to meet expectations on an ERP is an effective strategy to maximize identification of defects in and improve on pathway implementation.
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16
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Fisher JC, Godfried DH, Lighter-Fisher J, Pratko J, Sheldon ME, Diago T, Kuenzler KA, Tomita SS, Ginsburg HB. A novel approach to leveraging electronic health record data to enhance pediatric surgical quality improvement bundle process compliance. J Pediatr Surg 2016; 51:1030-3. [PMID: 26995516 DOI: 10.1016/j.jpedsurg.2016.02.080] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 02/26/2016] [Indexed: 11/29/2022]
Abstract
PURPOSE Quality improvement (QI) bundles have been widely adopted to reduce surgical site infections (SSI). Improvement science suggests when organizations achieve high-reliability to QI processes, outcomes dramatically improve. However, measuring QI process compliance is poorly supported by electronic health record (EHR) systems. We developed a custom EHR tool to facilitate capture of process data for SSI prevention with the aim of increasing bundle compliance and reducing adverse events. METHODS Ten SSI prevention bundle processes were linked to EHR data elements that were then aggregated into a snapshot display superimposed on weekly case-log reports. The data aggregation and user interface facilitated efficient review of all SSI bundle elements, providing an exact bundle compliance rate without random sampling or chart review. RESULTS Nine months after implementation of our custom EHR tool, we observed centerline shifts in median SSI bundle compliance (46% to 72%). Additionally, as predicted by high reliability principles, we began to see a trend toward improvement in SSI rates (1.68 to 0.87 per 100 operations), but a discrete centerline shift was not detected. CONCLUSION Simple informatics solutions can facilitate extraction of QI process data from the EHR without relying on adjunctive systems. Analyses of these data may drive reductions in adverse events. Pediatric surgical departments should consider leveraging the EHR to enhance bundle compliance as they implement QI strategies.
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Affiliation(s)
- Jason C Fisher
- Division of Pediatric Surgery, NYU Langone Medical Center, NYU School of Medicine, New York, NY.
| | - David H Godfried
- Division of Pediatric Orthopedic Surgery, NYU Langone Medical Center, NYU School of Medicine, New York, NY
| | - Jennifer Lighter-Fisher
- Division of Pediatric Hospital Epidemiology, NYU Langone Medical Center, NYU School of Medicine, New York, NY
| | - Joseph Pratko
- Medical Center Information Technology - Clinical Systems, NYU Langone Medical Center, New York, NY
| | | | - Thelma Diago
- Department of Nursing, NYU Langone Medical Center, New York, NY
| | - Keith A Kuenzler
- Division of Pediatric Surgery, NYU Langone Medical Center, NYU School of Medicine, New York, NY
| | - Sandra S Tomita
- Division of Pediatric Surgery, NYU Langone Medical Center, NYU School of Medicine, New York, NY
| | - Howard B Ginsburg
- Division of Pediatric Surgery, NYU Langone Medical Center, NYU School of Medicine, New York, NY
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17
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Benlice C, Gorgun E. Using NSQIP Data for Quality Improvement: The Cleveland Clinic SSI Experience. SEMINARS IN COLON AND RECTAL SURGERY 2016. [DOI: 10.1053/j.scrs.2016.01.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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18
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Rumberger LK, Vittetoe D, Cathey L, Bennett H, Heidel RE, Daley BJ. Improving Outcomes in Elective Colorectal Surgery: A Single-institution Retrospective Review. Am Surg 2016. [DOI: 10.1177/000313481608200417] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Our hospital, a Tennessee Surgical Quality Collaborative (TSQC) member, adopted a statewide colorectal care bundle intended to reduce surgical site infections (SSI) in elective colorectal cases. The bundle includes proper antibiotics/dosing, normoglycemia, normothermia, supplemental oxygen six hours postoperatively, and early enteral nutrition. A single-institution retrospective study of our National Surgical Quality Improvement Program (NSQIP) database for the rates of SSI before and after the colorectal bundle. We compared our SSI rates to TSQC hospitals as well as NSQIP datasets. Because of low case numbers in the NSQIP data, National Healthcare Safety Network (NHSN) data collected at our institution was used to compare our colorectal SSI before and after our colorectal bundle. From January 2010 to December 2011, 188 patients underwent nonemergent colorectal surgery in the NSQIP data. Of these, 5.4 per cent (10/188) developed superficial SSIs. During this same time, the rate of the TSQC superficial SSI was 7.1 per cent and NSQIP was 7.8 per cent. From January 2013 to October 2014, after the colorectal bundle started, 76 patients in NSQIP underwent nonemergent colorectal surgery. Of these, 6.5 per cent (5/76) developed superficial SSI, compared with 5.5 per cent in TSQC and 5.5 per cent in NSQIP. NHSN data showed a prebundle rate of 11 per cent and a postbundle rate of 3.5 per cent ( P < 00.1, χ2). After adopting a colorectal bundle aimed at reducing SSIs, we did not improve our SSI rates in NSQIP; however, our NHSN data demonstrated considerable improvement. Differences in data collection may affect SSI rates, and ultimately “quality” based reimbursement. Implementation of the bundle did improve outcomes in colorectal surgery.
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Affiliation(s)
- Lindsay K. Rumberger
- University of Tennessee Medical Center at Knoxville, Southeastern Surgical Congress, Knoxville, Tennessee
| | - Debra Vittetoe
- University of Tennessee Medical Center at Knoxville, Southeastern Surgical Congress, Knoxville, Tennessee
| | - Lorene Cathey
- University of Tennessee Medical Center at Knoxville, Southeastern Surgical Congress, Knoxville, Tennessee
| | - Harriet Bennett
- University of Tennessee Medical Center at Knoxville, Southeastern Surgical Congress, Knoxville, Tennessee
| | - Robert E. Heidel
- University of Tennessee Medical Center at Knoxville, Southeastern Surgical Congress, Knoxville, Tennessee
| | - Brian J. Daley
- University of Tennessee Medical Center at Knoxville, Southeastern Surgical Congress, Knoxville, Tennessee
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