Quality improvement in surgery: introduction of the American College of Surgeons National Surgical Quality Improvement Program into New South Wales

Reducing unplanned general surgical readmissions: a review of the Australian and New Zealand National Surgical Quality Improvement Program Database

BACKGROUND

Unplanned surgical readmissions are an important indicator of quality care and are a key focus of improvement programs. The aims of this study were to evaluate the factors that lead to unplanned hospital readmissions in patients undergoing general surgical procedures and to identify preventable readmissions.

METHODS

A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program database from 2016 to 2020 at a tertiary hospital was conducted to identify patients undergoing a general surgical procedure. Various perioperative parameters were studied to identify risk factors and reasons for unplanned readmission. Preventable readmissions were identified.

RESULTS

A total of 3069 patients underwent a general surgical procedure. Of these, the overall unplanned readmission rate was 8.8% (n = 247). The most common reason for readmission was associated with surgical site infections (n = 112, 44.3%) followed by pain (n = 50, 20.2%), with over 45% deemed as preventable readmissions. Factors associated with increased risk of readmission included older age, longer index length of stay, prolonged operative time, elective procedures, higher ASA score and contaminated procedures.

CONCLUSION

Unplanned readmissions are more likely to occur in patients who develop postoperative complications. Understanding factors associated with readmissions may facilitate targeted quality improvement projects that reduce hospital readmission after surgery.

The effect of advanced recovery room care on postoperative outcomes in moderate-risk surgical patients: a multicentre feasibility study

Postoperative complications are common and may be under-recognised. It has been suggested that enhanced postoperative care in the recovery room may reduce in-hospital complications in moderate- and high-risk surgical patients. We investigated the feasibility of providing advanced recovery room care for 12-18 h postoperatively in the post-anaesthesia care unit. The primary hypothesis was that a clinical trial of advanced recovery room care was feasible. The secondary hypothesis was that this model may have a sustained impact on postoperative in-hospital and post-discharge events. This was a multicentre, prospective, feasibility before-and-after trial of moderate-risk patients (predicted 30-day mortality of 1-4%) undergoing non-cardiac surgery and who were scheduled for postoperative ward care. Patients were managed using defined assessment checklists and goals of care in an advanced recovery room care setting in the immediate postoperative period. This utilised existing post-anaesthesia care unit infrastructure and staffing, but extended care until the morning of the first postoperative day. The advanced recovery room care trial was deemed feasible, as defined by the recruitment and per protocol management of > 120 patients. However, in a specialised cancer centre, recruitment was slow due to low rates of eligibility according to narrow inclusion criteria. At a rural site, advanced recovery room care could not be commenced due to logistical issues in establishing a new model of care. A definitive randomised controlled trial of advanced recovery room care appears feasible and, based on the indicative data on outcomes, we believe this is warranted.

Post-operative Glycaemic Control Using an Insulin Infusion is Associated with Reduced Surgical Site Infections in Colorectal Surgery

BACKGROUND

The incidence of surgical site infection (SSI) in colorectal surgery (CRS) is higher than other forms of general surgery. Post-operative hyperglycaemia causes increased SSI in CRS. Post-operative hyperglycaemia control in cardiac surgery reduces SSI. The aim was to evaluate using a cohort comparison the effect of post-operative glycaemic control using an insulin infusion on SSI in CRS.

METHODS

Collection of data for the ACS-NSQIP was commenced in 2015. The CRS unit added post-operative glycaemic control to the SSI bundle in late 2016. The intervention was an insulin infusion to titrate blood glucose between 135 and 180 mg/Dl (7.5 and 10 mmol/l). The effect of glycaemic control on SSI was assessed comparing ACS-NSQIP raw data prior and after the intervention was commenced.

RESULTS

The NSQIP data from July 2015 to June 2016 revealed the incidence of SSI were 25%. From January 2017 to December 2017, there was a significant reduction in SSI to 6.1% (OR = 517 Cl = 1.92-16.08, p < 0.001). The incidence of organ/space SSI fell significantly from 13% to 1.0% (OR = 11.35, Cl = 1.62-488.7, p < 0.001). There was non-significant reduction in superficial SSI from 11 to 4.0% (OR = 2.93, Cl = 0.68-13.03, p = 0.06). There was no significant difference in other factors associated with SSI in CRS.

CONCLUSION

Post-operative glycaemic control in CRS reduces the rate of SSI. Post-operative glycaemic control should be included in SSI bundles for CRS and may be of benefit in other surgical specialties.

National Surgical Quality Improvement Program risk calculator validity in South Australian laryngectomy patients

BACKGROUND

Assessing an individual patient's post-operative risk profile prior to laryngectomy for cancer is difficult. The American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) risk calculator was developed to better inform preoperative decision-making. The calculator uses patient-specific characteristics to estimate the risk of experiencing post-operative complications within 30 days of surgery. We investigated the ACS-NSQIP risk calculator's performance for Australian laryngectomy patients.

METHODS

The ACS-NSQIP risk calculator was used to retrospectively calculate the 30-day post-operative predicted outcomes in patients who underwent laryngectomy for laryngeal, hypopharyngeal and thyroid cancers (with laryngeal involvement) in two institutions in South Australia. These data were compared against the actual mortality, morbidity, complications and length of stay (LOS) collected from a retrospective chart review.

RESULTS

A total of 144 patients underwent surgical intervention for malignancies with laryngeal involvement. The median LOS was 25 days (range 13-197) compared to the predicted LOS of 6.5 days (range 3.5-12.5). Overall mortality was 2.78% with post-operative complications occurring in 63% of patients. The most common complication was wound infection, occurring in 33% of patients. Hosmer-Lemeshow plots demonstrated good agreement between predicted and observed rates for complications.

CONCLUSION

The ACS-NSQIP risk calculator effectively predicted post-operative complication rates in South Australian laryngeal cancer patients undergoing laryngectomy. However, differences in predicted and actual LOS may limit the usefulness of the calculator's LOS predictions for Australian patients.

Reduced post-operative urinary tract infection using the National Surgical Quality Improvement Program

BACKGROUND

The incidence of post-operative urinary tract infection (UTI) is frequently unknown or underestimated. Failure to recognize a clinical problem results in no action occurring to improve outcomes. The aims of this study were firstly to define the incidence of post-operative UTI in general surgery patients using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Secondly to design and implement an intervention to reduce the incidence of post-operative UTI and assess the extent of improvement.

METHODS

ACS-NSQIP data were collected and analysed from June 2015 to June 2016 and reported in the Semi Annual Report (SAR). A quality improvement programme was designed and implemented to manage the high incidence of UTI. The outcomes were assessed by the subsequent ACS-NSQIP SAR.

RESULTS

The SAR in 2016 reported that Nepean Hospital as a significant outlier with an incidence of post-operative UTI of 3.62% (odds ratio 2.21, confidence limits 1.51-3.44, P < 0.001). A hospital-wide policy for catheter insertion in surgical patients was developed including: education, workshops, accreditation for aseptic technique for catheter insertion, reduced rates of insertion, reduced duration of use and improved catheter care. There was a significant improvement in the incidence of UTI (1.21%) reported by the 2018 SAR (odds ratio 1.01, confidence limits 0.64-1.60, P = 0.68).

CONCLUSIONS

ACS-NSQIP identified a 2.2-fold increased risk of post-operative UTI. There was no increased risk of UTI after the programme to reduce UTI was introduced.