Surgical Quality Improvement: Reducing Surgical Site Infection Rates in Colon Procedures

Background: Surgical site infection (SSI) is the second most common healthcare associated infection, accounting for 17% of all HAI’s. Colon surgery has a high risk of SSI; NHSN colon surgery pooled means range from 4% - 11%,  but some studies have reflected rates up to 26%. In 2005, we began a series of interventions to reduce the colon SSI rates.

Objective: To reduce the SSI rates in colon surgical procedures using multidisciplinary quality improvement initiatives.

Methods: Our study took place between 2004 and June 2009 and included all patients undergoing colorectal surgery in the University Hospital who met the Surgical Care Improvement Project (SCIP) criteria. SSI was defined using NHSN criteria. Observations and rate feedback to the units began in 2005. Phase I took place during 2005-2006 and included participation in the Michigan Surgical Quality Collaborative and standardization of perioperative patient skin cleansing and preparation protocols. Phase II, during 2006-2007 included staff observation and education, surgeon performance related quality assurance measures, and a multidisciplinary quality improvement grand rounds conference. Phase III began in 2008 and targeted intraoperative bowel technique. Feedback led to the formation of a multidisciplinary clinician work group, which made recommendations for standardized practice for colon procedures. Weight based prophylactic antibiotic measures were strengthened and intensive staff education on bowel technique and skin preparation were launched. In 2009, resident physician asepsis training and nursing staff skin preparation technique competency assessments in the clinical simulation lab setting were developed and piloted.

Results: Between Jan 2004 and June 2009, 1299 total SCIP colon procedures were performed (average 236 procedures/year). The SSI rate was in 2004 was 26.5%, but  there has been a downward trend since phase I. From Jan through June 2009, there were  13 SSIs in 80 procedures, with a rate of 16.3%. The baseline rate for 2004-2006 was 26.73% and the rate for the follow up period (2008- June 2009) was 19.5%,representing a 27% decrease in SSI incidence (p= .015). In addition to fewer overall SSI’s, there have been fewer deep and organ space infections requiring readmission and reoperation. In 2008, 47% of SSIs were superficial, 21% were deep, and 28% were organ-space, compared to 2009, when 92% of SSIs were superficial and 8% were organ-space infections.

Conclusions: Standardization, best practices, and sustained multidisciplinary quality collaboratives have been successful in decreasing severe surgical site infections and reducing overall SSI in colon surgical procedures.