Surgical site infections (SSIs) are distressing for patients and healthcare facilities alike. SSIs result in longer hospital stays and increased healthcare costs. Furthermore, they can trigger financial penalties for healthcare organizations.
At Becker's Hospital Review's 10th Annual Meeting in Chicago in April, Abbott hosted a workshop with William M. Thompson, MD, a general surgeon from Navicent Health in Macon, Ga. Dr. Thompson discussed how Navicent Health addressed a spike in colon SSIs through a comprehensive and mandatory enhanced recovery after surgery (ERAS) program.
Shifting from a voluntary to mandatory ERAS Program
In 2012, Navicent leaders asked surgeons to develop an ERAS program to improve surgical colon outcomes. With no full consensus on the new protocol elements, Navicent made ERAS program participation voluntary. Program compliance was at around 50 percent, and Navicent Health's colon SSI rates decreased to benchmark levels.
Fast forward to early 2016 when Navicent experienced a jump in colon SSIs. "For each case, we conducted a root cause analysis, but no clear contributors to the increase in infections emerged," explained Dr. Thompson. Despite close scrutiny, colon SSI rates of 11.3 percent persisted. Navicent Health realized it had a problem to address as financial penalties for surgical outcomes accrued.
In response, Navicent formed a committee led by National Surgical Quality Improvement Program personnel. This time, the group wasn't limited to surgeons. The committee included two surgeons and nurses from every clinical area, as well as representatives from nutrition, anesthesia, operating room (OR) administration, infection control, pharmacy, administration and the IT department.
The team decided to completely revamp the ERAS protocol. "Since the literature suggested high protocol compliance rates lead to the best results, the committee created a set of standardized protocols that would be mandatory for all surgeons performing colon surgery," explained Dr. Thompson. He stressed that the new protocol was comprehensive with an outpatient optimization arm, a day of surgery arm and a post-op arm.
Designing new protocols for every stage of the patient experience
The committee developed new protocols for three phases of the patient experience:
- Pre-operative outpatient orders. The revised pre-operative protocol is based on the American College of Surgeons' Strong for Surgery program, which includes medication optimization, smoking cessation, glucose control and five days of immunonutrition drinks, like Abbott’s Ensure Immunonutrition Shake. In addition, patients take oral nonabsorbable antibiotics after a mechanical colon prep and multimodal pain medications, and conduct other at-home preparations.
- Day of surgery orders. Two hours before anesthesia, patients consume a complex carbohydrate beverage, like Ensure Pre-Surgery Clear Nutrition Drink. To avoid penicillin allergies, the medical team administers IV Flagyl and Cefipime. Patients are ventilated with 100 percent oxygen during surgery and receive high-flow oxygen during recovery. Minimally invasive surgery is used in most cases. Surgical teams follow an isolation protocol.
- Post-operative orders. Patients are moved to a dedicated floor with nurses educated on the ERAS protocol. Deep venous thrombosis prophylaxis and immunonutrition shakes are continued. The day after surgery, patients ambulate and eat a regular diet as tolerated. NG tubes and foley catheters are not used.
The new ERAS program has dramatically reduced colon SSIs and length of stay (LOS) at Navicent. In the nine months after implementing the mandatory protocol, the colon SSI rate decreased from 11.3 percent to 2.1 percent, and LOS decreased from eight days to three days. This helped reduce healthcare costs resulting in over $1 million in savings.
Tips for implementing similar programs
Dr. Thompson detailed several lessons learned:
- Nurse navigators are essential for real-time quality improvement. At Navicent, nurse navigators call patients and review the pre-operative checklist. They resolve problems before they negatively affect patient outcomes. If patients don't comply with pre-operative orders, their procedures may be cancelled.
- Education is key for protocol adoption. The committee conducted nurse training in pre-op, OR and post-op settings. Resident education is extremely important, since residents handle post-op orders. Outpatient office staff was also trained.
- IT teams play a central role. Navicent's IT team developed workarounds so information flows from the outpatient EMR to the inpatient EMR. IT also monitors order sets for compliance.
- Rigorous and accurate outcomes measurement is required. Navicent uses the National Surgical Quality Improvement Program, which provides comparisons to like institutions.
- Ongoing monitoring sustains benefits. When program monitoring stops, quality improvements can disappear.
- Utilize resources from industry partners. For example, Abbott partners with hospitals and health systems to help address and support important priorities and challenges like reducing hospitalizations and improving patient outcomes.
Dr. Thompson summarized, "Through our ERAS program, we fixed a persistent SSI problem. Sustaining this improvement, however, requires culture change. We turbocharged the culture change by making the new protocols comprehensive and mandatory."