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Haring CT, Heft Neal ME, Jaffe CA, Shuman AG, Rosko AJ, Spector ME. Association of preoperative thyroid hormone replacement with perioperative complications after major abdominal surgery. Am J Surg 2024; 232:107-111. [PMID: 38311517 DOI: 10.1016/j.amjsurg.2024.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 01/18/2024] [Accepted: 01/22/2024] [Indexed: 02/06/2024]
Abstract
OBJECTIVE To determine the association between preoperative thyroid hormone replacement and complications following major abdominal surgery. METHODS A retrospective case series was performed of patients enrolled in the Michigan Surgical Quality Collaborative (MSQC) who underwent major abdominal surgery at an academic institution over a 10-year period. The principal explanatory variable was preoperative thyroid hormone replacement. Primary outcomes were morbidity, mortality and length of stay. RESULTS 2700 patients were identified. On multivariate analysis correcting for established predictors of operative morbidity, patients on preoperative thyroid replacement had a 1.5- fold increased risk of serious morbidity(p = 0.01), and a 1.7- fold greater risk for serious sepsis(p = 0.04). Thyroid replacement was associated with longer length of stay(p < 0.001). While there was a high degree of missing data for surgical approach (31.1 % missing data), results suggest that patients on thyroid hormone replacement were more likely to undergo an open rather than minimally invasive surgery(p < 0.01). Open surgery was associated with greater risk of serious morbidity(p = 0.003) and longer length of stay(p < 0.001). CONCLUSIONS Preoperative thyroid hormone replacement independently predicts operative morbidity and length of stay following major abdominal surgery.
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Affiliation(s)
- Catherine T Haring
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, OH, USA
| | - Molly E Heft Neal
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor, MI, USA
| | - Craig A Jaffe
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Michigan Medicine, Ann Arbor, MI, USA
| | - Andrew G Shuman
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor, MI, USA
| | - Andrew J Rosko
- Promedica Toledo Hospital, University of Toledo, Toledo, OH, USA
| | - Matthew E Spector
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
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Hatharaliyadda B, Schmitz M, Mork A, Osman F, Heise C, Safdar N, Pop-Vicas A. Surgical Site Infection Prevention Using "Strike Teams": The Experience of an Academic Colorectal Surgical Department. J Healthc Qual 2024; 46:22-30. [PMID: 38166163 DOI: 10.1097/jhq.0000000000000412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2024]
Abstract
ABSTRACT Surgical site infections (SSIs) are healthcare-acquired infections with substantial morbidity. Surgical site infection persist because of low adherence to prevention bundles comprising multiple infection control elements. We propose the "Strike Team" as an implementation strategy to improve adherence and reduce SSI in colorectal surgery. At an academic medical center, a multidisciplinary Strike Team met monthly to review colorectal SSI cases, audit and discuss barriers to adherence to SSI prevention bundle, and propose actionable feedback. The latter was shared with frontline clinicians by the Strike Team's surgical leaders in everyday practice. Colorectal SSI rates and bundle adherence data were disseminated quarterly via the hospital intranet and reviewed with surgeons at departmental meetings. Trends in adherence and SSI rates were analyzed by regression analysis using a time series model. While the Strike Team was active, adherence to antibiotic prophylaxis, maintenance of normoglycemia, and standardized intraoperative skin preparation significantly increased (p < .05). There was a trend toward statistically significant reduction in SSI (p = .07), although it was not maintained once the Strike Team activity was disrupted by the COVID-19 pandemic. Colorectal SSI prevention requires a resource-intensive, multidisciplinary approach with numerous strategies to improve adherence to infection control bundles, as illustrated by our SSI Strike Team experience.
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Bertoy L, Harbaugh CM, Millis MA, Zhuo L, Gutsche N, Beck G, Panzer K, Howard R, Weng W, Singh K, Englesbe M, Hendren S. Positive margin rates for colorectal cancer vary significantly by hospital in Michigan: Can we achieve a 0 % positive margin rate? Surg Open Sci 2023; 16:37-43. [PMID: 37766798 PMCID: PMC10520503 DOI: 10.1016/j.sopen.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 09/04/2023] [Accepted: 09/08/2023] [Indexed: 09/29/2023] Open
Abstract
Background High quality surgical care for colorectal cancer (CRC) includes obtaining a negative surgical margin. The Michigan Surgical Quality Collaborative (MSQC) is a statewide consortium of hospitals dedicated to quality improvement; a subset of MSQC hospitals abstract quality of care measures for CRC surgery, including positive margin rate. The purpose of this study was to determine whether positive margin rates vary significantly by hospital, and whether positive margin rates should be a target for quality improvement. Methods We performed a retrospective cohort study of patients who underwent CRC resection from 2016 to 2020. The primary outcome was the presence of a positive margin. Univariate and multivariable analyses were performed to test the association of positive margins with patient, hospital, and tumor characteristics. Results The cohort consisted of 4211 patients from 42 hospitals (85 % colon cancer and 15 % rectal cancer). The crude positive margin rate was 6.15 % (95 % CI 4.6-7.4 %); this ranged from 0 % to 22 % at individual hospitals. In multivariable analysis, factors independently associated with positive margins included male sex, underweight BMI, metastatic cancer, rectal cancer (vs. colon), T4 T-stage, N1c/N2 N-stage, and open surgical approach. After adjusting for these factors, there remained significant variation by hospital, with 8 hospitals being statistically-significant outliers. Conclusions Positive margins rates for CRC vary by hospital in Michigan, even after rigorous adjustment for case-mix. Furthermore, several hospitals achieved near-zero positive margin rates, suggesting opportunities for quality improvement through the identification of best practices among CRC surgery centers.
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Affiliation(s)
- Lauren Bertoy
- University of Michigan, University of Michigan Medical School, 1301 Catherine Street, Ann Arbor, MI 48109, USA
| | - Calista M. Harbaugh
- Michigan Medicine, Department of Surgery, 1500 E Medical Center Drive, Ann Arbor, MI 48109, USA
| | - M. Andrew Millis
- Michigan Medicine, Department of Surgery, 1500 E Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Lucy Zhuo
- University of Rochester Medical Center, Department of Surgery, 601 Elmwood Avenue, Rochester, NY 14642, USA
| | - Nicholas Gutsche
- University of Michigan, University of Michigan Medical School, 1301 Catherine Street, Ann Arbor, MI 48109, USA
| | - Graham Beck
- University of Michigan, University of Michigan Medical School, 1301 Catherine Street, Ann Arbor, MI 48109, USA
| | - Kate Panzer
- University of Michigan, University of Michigan Medical School, 1301 Catherine Street, Ann Arbor, MI 48109, USA
| | - Ryan Howard
- Michigan Medicine, Department of Surgery, 1500 E Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Wenjing Weng
- Michigan Medicine, Michigan Surgical Quality Collaborative, 4251 Plymouth Road, Ann Arbor, MI 48105, USA
| | - Kushal Singh
- Michigan Medicine, Michigan Surgical Quality Collaborative, 4251 Plymouth Road, Ann Arbor, MI 48105, USA
| | - Michael Englesbe
- Michigan Medicine, Department of Surgery, 1500 E Medical Center Drive, Ann Arbor, MI 48109, USA
- Michigan Medicine, Michigan Surgical Quality Collaborative, 4251 Plymouth Road, Ann Arbor, MI 48105, USA
| | - Samantha Hendren
- Michigan Medicine, Department of Surgery, 1500 E Medical Center Drive, Ann Arbor, MI 48109, USA
- Michigan Medicine, Michigan Surgical Quality Collaborative, 4251 Plymouth Road, Ann Arbor, MI 48105, USA
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Levy BE, Wilt WS, Castle JT, McAtee E, Walling SC, Davenport DL, Bhakta A, Patel JA. Surgical Site Infections in Colorectal Resections: What is the Cost? J Surg Res 2023; 283:336-343. [PMID: 36427443 DOI: 10.1016/j.jss.2022.10.076] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 08/26/2022] [Accepted: 10/15/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Although surgical site infections (SSIs) associated with colectomy are tracked by the National Healthcare Safety Network/Center for Disease Control, untracked codes, mainly related to patients undergoing proctectomy, are not. These untracked codes are performed less often yet they may be at a greater risk of SSI due to their greater complexity. Determining the impact and predictors of SSI are critical in the development of quality improvement initiatives. METHODS Following an institutional review board approval, National Surgery Quality Improvement Program, institutional National Surgery Quality Improvement Program, and financial databases were queried for tracked colorectal resections and untracked colorectal resections (UCR). National data were obtained for January 2019-December 2019, and local procedures were identified between January 2013 and December 2019. Data were analyzed for preoperative SSI predictors, operative characteristics, outcomes, and 30-day postdischarge costs (30dPDC). RESULTS Nationally, 71,705 colorectal resections were identified, and institutionally, 2233 patients were identified. UCR accounted for 7.9% nationally and 11.8% of all colorectal resections institutionally. Tracked colorectal resection patients had a higher incidence of SSI predictors including sepsis, hypoalbuminemia, coagulopathy, hypertension, and American Society of Anesthesiologists class. UCR patients had a higher rate of SSIs [12.9% (P < 0.001), 15.2% (P = 0.064)], readmission, and unplanned return to the operating room. Index hospitalization and 30dPDC were significantly higher in patients experiencing an SSI. CONCLUSIONS SSI was associated with nearly a two-fold increase in index hospitalization costs and six-fold in 30dPDC. These data suggest opportunities to improve hospitalization costs and outcomes for patients undergoing UCR through protocols for SSI reduction and preventing readmissions.
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Affiliation(s)
- Brittany E Levy
- Division of Colorectal Surgery, University of Kentucky College of Medicine, Lexington, Kentucky.
| | - Wesley S Wilt
- Division of Colorectal Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Jennifer T Castle
- Division of Colorectal Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Erin McAtee
- Division of Colorectal Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Samuel C Walling
- Division of Colorectal Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Daniel L Davenport
- Division of Colorectal Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Avinash Bhakta
- Division of Colorectal Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Jitesh A Patel
- Division of Colorectal Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
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Faragher I, Tham N, Hong M, Guy S, Yeung J. Implementation of an organ space infection prevention bundle reduces the rate of organ space infection after elective colorectal surgery. BMJ Open Qual 2021; 10:bmjoq-2020-001278. [PMID: 33941539 PMCID: PMC8098924 DOI: 10.1136/bmjoq-2020-001278] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 04/12/2021] [Accepted: 04/19/2021] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Surgical site infections (SSIs) are morbid and costly complications after elective colorectal surgery. SSI prevention bundles have been shown to reduce SSI in colorectal surgery, but their impact on organ space infections (OSI) is variable. Adoption of an evidence-based practice without an implementation strategy is often unsuccessful. Our aim was to successfully implement an OSI prevention bundle and to achieve a cost-effective reduction in OSI following elective left-sided colorectal operations. METHODS The Translating Research into Practice model was used to implement an OSI prevention bundle in all patients undergoing elective left-sided colorectal resections by a single unit from November 2018 to September 2019. The new components included oral antibiotics with mechanical bowel preparation, when required, and use of impermeable surgical gowns. Other standardised components included alcoholic chlorhexidine skin preparation, glove change after bowel handling prior to wound closure with clean instruments. The primary outcome was OSI. Secondary outcomes included bundle compliance, unintended consequences and total patient costs. Outcomes were compared with all patients undergoing elective left-sided colorectal resections at the same institution in 2017. RESULTS Elective colorectal resections were performed in 173 patients across two cohorts. The compliance rate with bundle items was 63% for all items and 93% for one omitted item. There was a reduction in OSI from 12.9% (11 of 85) to 3.4% (3 of 88, p<0.05) after implementation of the OSI prevention bundle. The average cost of an OSI was $A36 900. The estimated savings for preventing eight OSIs by using the OSI bundle in the second cohort was $A295 198. CONCLUSION Successful implementation of an OSI prevention bundle was associated with a reduced rate of OSI after elective colorectal surgery. The OSI bundle and its implementation were cost-effective. Further study is required to investigate the sustainability of the OSI prevention bundle.
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Affiliation(s)
- Ian Faragher
- Colorectal Surgery, Western Health, Footscray, Victoria, Australia
| | - Nicole Tham
- Colorectal Surgery, Western Health, Footscray, Victoria, Australia
| | - Michael Hong
- Colorectal Surgery, Western Health, Footscray, Victoria, Australia
| | - Stephen Guy
- Infectious Disease Unit, Western Health, Footscray, Victoria, Australia
| | - Justin Yeung
- Colorectal Surgery, Western Health, Footscray, Victoria, Australia.,Department of Surgery, Western Precinct, University of Melbourne, Melbourne, Victoria, Australia
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Discussion: A Critical Examination of Length of Stay in Autologous Breast Reconstruction: A National Surgical Quality Improvement Program Analysis. Plast Reconstr Surg 2021; 147:34-36. [PMID: 33370045 DOI: 10.1097/prs.0000000000007421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Rivard SJ, Byrn JC, Campbell DS, Hendren S. Colorectal surgery collaboratives: The Michigan experience. SEMINARS IN COLON AND RECTAL SURGERY 2020. [DOI: 10.1016/j.scrs.2020.100781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Colorectal bundles for surgical site infection prevention: A systematic review and meta-analysis. Infect Control Hosp Epidemiol 2020; 41:805-812. [PMID: 32389140 DOI: 10.1017/ice.2020.112] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE In colorectal surgery, the composition of the most effective bundle for prevention of surgical site infections (SSI) remains uncertain. We performed a meta-analysis to identify bundle interventions most associated with SSI reduction. METHODS We systematically reviewed 4 databases for studies that assessed bundles with ≥3 elements recommended by clinical practice guidelines for adult colorectal surgery. The main outcome was 30-day postoperative SSI rate (overall, superficial, deep, and/or organ-space). RESULTS We included 40 studies in the qualitative review, and 35 studies (54,221 patients) in the quantitative review. Only 3 studies were randomized controlled trials. On meta-analyses, bundles were associated with overall SSI reductions of 44% (RR, 0.57; 95% CI, 0.48-0.65); superficial SSI reductions of 44% (RR, 0.56; 95% CI, 0.42-0.75); deep SSI reductions of 33% (RR, 0.67; 95% CI, 0.46-0.98); and organ-space SSI reductions of 37% (RR, 0.63; 95% CI, 0.50-0.81). Bundle composition was heterogeneous. In our meta-regression analysis, bundles containing ≥11 elements, consisting of both standard of care and new interventions, demonstrated the greatest SSI reduction. Separate instrument trays, gloves with and without gown change for wound closure, and standardized postoperative dressing change at 48 hours correlated with the highest reductions in superficial SSIs. Mechanical bowel preparation combined with oral antibiotics, and preoperative chlorhexidine showers correlated with highest organ-space SSI reductions. CONCLUSIONS Preventive bundles emphasizing guideline-recommended elements from both standard of care as well as new interventions were most effective for SSI reduction following colorectal surgery. High clinical-bundle heterogeneity and low quality for most observational studies significantly limit our conclusion.
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Duff SE, Battersby CLF, Davies RJ, Hancock L, Pipe J, Buczacki S, Kinross J, Acheson AG, Walsh CJ. The use of oral antibiotics and mechanical bowel preparation in elective colorectal resection for the reduction of surgical site infection. Colorectal Dis 2020; 22:364-372. [PMID: 32061026 PMCID: PMC8247270 DOI: 10.1111/codi.14982] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 12/24/2019] [Indexed: 12/12/2022]
Affiliation(s)
- S. E. Duff
- Wythenshawe HospitalManchester University NHS Foundation TrustManchesterUK
| | | | - R. J. Davies
- Cambridge Colorectal UnitAddenbrookes HospitalCambridge University NHS Foundation TrustCambridgeUK
| | - L. Hancock
- Wythenshawe HospitalManchester University NHS Foundation TrustManchesterUK
| | - J. Pipe
- Patient Liaison Group ACPGBISheffieldUK
| | - S. Buczacki
- Cambridge Colorectal UnitAddenbrookes HospitalCambridge University NHS Foundation TrustCambridgeUK
| | - J. Kinross
- Department of Surgery and CancerSt Mary's HospitalImperial CollegeLondonUK
| | - A. G. Acheson
- Gastrointestinal SurgeryNottingham Digestive Diseases CentreNational Institute for Health Research (NIHR)Biomedical Research CentreNottingham University Hospitals NHS TrustQueen’s Medical CentreUniversity of NottinghamNottinghamUK
| | - C. J. Walsh
- Wirral University Teaching Hospitals NHS Foundation TrustWirralUK
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Zheng XQ, Huang JF, Lin JL, Chen D, Wu AM. Effects of preoperative warming on the occurrence of surgical site infection: A systematic review and meta-analysis. Int J Surg 2020; 77:40-47. [PMID: 32198100 DOI: 10.1016/j.ijsu.2020.03.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 03/07/2020] [Accepted: 03/11/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To determine whether preoperative warming can reduce the risk of surgical site infection (SSI) after surgery. BACKGROUND Intraoperative hypothermia is a risk factor for the occurrence of SSI in patients after surgery. However, the effectiveness of preoperative warming in reducing the incidence of the condition remains unclear. MATERIALS AND METHODS A systematic review was conducted using Medline, EMBASE, and the Cochrane Library to identify randomized controlled trials (RCTs) that evaluated the risk of SSI after surgery with and without the use of a preoperative warming protocol. The primary outcome measure was the diagnosis of SSI within 10-90 days of surgery. The pooled risk ratio was estimated with a fixed-effect meta-analysis. Sensitivity analyses were performed to examine the impact of the structural design of preoperative warming on the pooled risk of SSI. RESULTS Of the 249 studies identified, seven RCTs representing 1086 patients were included in the present meta-analysis. The use of preoperative warming was associated with a significant decrease in SSI (RR = 0.60, 95% CI 0.42-0.87, P = 0.072). Specifically, we defined patients who used forced-air warming (FAW) and integrated measures such as liquid heating and warming blankets as the MIX group and patients who used only FAW as the FAW group. Patients who used MIX methods (temperature set <43 °C and 30-min prewarming) before surgery benefited more from prewarming. CONCLUSIONS The results of this study suggest that preoperative warming can reduce rates of SSI after surgery. We, therefore, recommend the application of MIX warming methods before surgery.
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Affiliation(s)
- Xuan-Qi Zheng
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou, Zhejiang, 325027, China
| | - Jin-Feng Huang
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou, Zhejiang, 325027, China
| | - Jia-Liang Lin
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou, Zhejiang, 325027, 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, Zhejiang, 325027, China
| | - Ai-Min Wu
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou, Zhejiang, 325027, China.
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Hospital Variations in Clinical Complications and Patient-reported Outcomes at 2 Years After Immediate Breast Reconstruction. Ann Surg 2020; 269:959-965. [PMID: 29489482 DOI: 10.1097/sla.0000000000002711] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Our objectives were to investigate case-mix adjusted hospital variations in 2-year clinical and patient-reported outcomes following immediate breast reconstruction. BACKGROUND Over the past few decades, variations in medical practice have been viewed as opportunities to promote best practices and high-value care. METHODS The Mastectomy Reconstruction Outcomes Consortium Study is an National Cancer Institute-funded longitudinal, prospective cohort study assessing clinical and patient-reported outcomes of immediate breast reconstruction after mastectomy at 11 leading medical centers. Case-mix adjusted comparisons were performed using generalized linear mixed-effects models to assess variation across the centers in any complication, major complications, satisfaction with outcome, and satisfaction with breast. RESULTS Among 2252 women in the analytic cohort, 1605 (71.3%) underwent implant-based and 647 (28.7%) underwent autologous breast reconstruction. There were significant differences in the sociodemographic and clinical characteristics, and distribution of procedure types at the different Mastectomy Reconstruction Outcomes Consortium Study centers. After case-mix adjustments, hospital variations in the rates of any and major postoperative complications were observed. Medical center odds ratios for major complication ranged from 0.58 to 2.13, compared with the average major complication rate across centers. There were also meaningful differences in satisfaction with outcome (from the lowest to highest of -2.79-2.62) and in satisfaction with breast (-2.82-2.07) compared with the average values. CONCLUSIONS Two-year postoperative complications varied widely between hospitals following post-mastectomy breast reconstruction. These variations represent an important opportunity to improve care through dissemination of best practices and highlight the limitations of extrapolating single-institution level data and the ongoing challenges of studying hospital-based outcomes for this patient population.
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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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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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