Fifty-six hospitals from 50 states and U.S. territories, collaborating to improve surgical care, significantly cut the rate of surgical infections for more than 35,000 patients in a year-long, nationwide effort sponsored by the federal Centers for Medicare & Medicare Services (CMS) and led by Qualis Health, the Quality Improvement Organization (QIO) for Washington, Alaska, and Idaho.
Results of the National Surgical Infection Prevention Collaborative were reported today in an article published in the American Journal of Surgery. Forty-four hospitals that provided data throughout the collaborative reduced their surgical site infection rate by 27 percent.
Conducted in 2002-2003, the National Surgical Infection Prevention Collaborative also involved 43 Quality Improvement Organizations (QIOs) working under contract to CMS and laid the groundwork for ongoing QIO assistance to help groups of hospitals in every state prevent surgical infections.
A major cause of preventable morbidity and mortality in hospitals, surgical site infections complicate an estimated 780,000 operations each year.
Surgical complications lead to worse patient outcomes and higher health care costs, and this report provides evidence that we can do something about it by working together, said CMS Administrator Mark McClellan, MD, PhD. CMS will soon launch an initiative to expand QIO efforts to help hospitals make surgery safer.
Quality Improvement Organizations can be effective resources for quality improvement in the surgical arena, the article concludes.
The collaborative model for helping healthcare institutions deliver better care was pioneered by the Institute for Healthcare Improvement (IHI) of Cambridge, MA, which recently launched a nationwide campaign to save 100,000 lives by encouraging hospitals to implement a series of patient safety interventionsincluding techniques to avoid surgical infections.
This project shows how hospitals working together and with QIOs can quickly make changes that save lives. These are the kinds of improvements and results we expect to see over the next year in thousands of hospitals around the country that have signed up for the 100,000 Lives Campaign, said IHI president and CEO Don Berwick, MD. Most QIOs are supporting and working closely with the campaign.
Research has shown that compared to similar risk patients undergoing the same surgery, a patient who gets a surgical site infection is twice as likely to die, five to six times more likely to require re-admission, and likely to stay in the hospital twice as long. The costs of these complications may range from $30,000 to $50,000 per major surgery.
The collaborative focused on helping hospital teams adopt proven techniques for avoiding surgical infections, said Jonathan Sugarman, MD, CEO of Qualis Health. A co-author of the article and current president of the American Health Quality Association (AHQA), Sugarman noted that hospital teams generally assume they are already routinely using the best practices. The Collaborative helps teams measure what they are actually doing, provides guidance on systematically implementing processes known to cut the infection rate, and facilitates tracking of results.
The collaborative emphasized rapid testing of small changes in the work of surgical teams, then incorporating successful modifications into routine care. Surgical teams from the National Collaborative hospitals joined staff from state-based QIOs at a series of two-day learning sessions with Qualis Health over the course of a year. Most of the teams came from large, urban hospitals, although some small, rural institutions participated as well. Between sessions, the teams worked with their local QIOs and communicated frequently with each other to share information about implementing improvements, barriers encountered, and lessons learned.
All teams in the collaborative agreed to focus on improving performance on three processes that CMS uses as national quality measures: administration of antibiotics within 60 minutes of surgical incision, use of appropriate antibiotics, and discontinuation of antibiotics within 24 hours of the end of surgery.
Most of the teams also worked on improving performance on one or more of the following: control of glucose levels during surgery, avoiding hypothermia during surgery, use of supplemental oxygen during surgery and recovery, and clipping rather than shaving the surgical site.
Over the course of the collaborative, the median performance of participating hospital teams improved on all process measures. The overall infection rate fell more than a quarter, from 2.3 percent in the first three months of the collaborative to 1.7 percent in the last three months.
This effort resulted in statistically significant increases in the employment of proven surgical infection prevention practices and a trend towards reduction in surgical site infections, said E. Patchen Dellinger, MD, lead author of the article, who serves on the faculty of the department of surgery at the University of Washington in Seattle. The collaborative shows that hospitals can work together to improve compliance with evidence-based care guidelines known to reduce the risk of surgical infections and the emergence of antibiotic-resistant pathogens.
Evidence-based guidelines for preventing surgical infections are widely underutilized. Recent research shows, for example, that patients receive antibiotics in the 60 minutes prior to surgical incisiona key technique for avoiding infectionsonly a little more than half the time.
Hospitals participating in the collaborative began with a higher than average performance on this measure: a median 70 percent rate of administering antibiotics within 60 minutes prior to incision. By the end of the collaborative, median compliance had risen to 92 percent.
Many participating hospitals found there was no one person in the perioperative routine who had an acknowledged responsibility for administration of the prophylactic antibiotic; performance improved when responsibility was made clear, said authors of the study released today.
Hospitals achieved significant improvement in this measure, which may have had the greatest impact on reported infection rates, concluded Dellinger and his co-authors.
These are landmark achievements in getting individuals in hospitals to work with one another and with other hospitals to share their data and good ideas, said an American Journal of Surgery editorial that accompanied the article.
Training in the adoption of successful interventions identified in the National Surgical Infection Prevention Collaborative was subsequently conducted over the past three years by QIOs in every state.
While the final results of the national QIO effort have not yet been announced by CMS, QIOs in more than 30 states report hospitals taking part in this training have shown significant improvement. For example: 26 hospitals participating in California increased the proportion of surgical patients receiving antibiotics within one hour of incision from 73.8 percent to 84.3 percent. In Colorado, 16 hospitals increased the proportion receiving antibiotics within one hour of incision from 62 percent to 88 percent. In Maryland, 16 hospitals went from 72 percent to 91.9 percent. In New Mexico, 19 hospitals went from 47.6 percent to 68 percent. In Texas, 42 hospitals went from 61 percent to 84 percent.
Source: American Health Quality Association