ACS NSQIP conference outlines quality gains
Texting, a simple walk among the successes
At the American College of Surgeons annual quality conference in New York in July, surgeons outlined some of the gains that data from the National Surgical Quality Improvement Program (NSQIP) database has helped them achieve. Among the headlines were a way to cut the risk of blood clots in surgical patients who are placed in isolation, creating a new bundle to cut surgical-site infections, and how texting patients to remind them of pre-operative showering protocols can help avoid infections later.
The project to decrease venous thromboembolism (VTE) came out of Carilion Clinic at Roanoke (VA) Memorial Hospital. VTE impacts more than half a million patients a year (http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6122a1.htm), according to the Centers for Disease Control and Prevention (CDC).
To Sandy Fogel, MD, FACS, the data from NSQIP indicated that patients who were in isolation were much more likely to develop a clot than others — almost six times as likely if they had general surgery or vascular operations or were trauma patients, and 3.5 times as likely if they had some specialty procedure.
Fogel also noticed that while VTE rates were very low in 2008, around 2010, they started to rise significantly. He and his team went looking for a reason. They found one in a hospitalwide focus on reducing Methicillin-resistant Staphylococcus aureus (MRSA). Patients who tested positive were being put in isolation. The MRSA rates went down. But those patients were also being much more left alone, less likely to do the walking and lung exercises that can help prevent dangerous blood clots, he says.
"It was one of those cases of unintended consequences," he explains, noting that VTE rates are now falling, and MRSA rates haven’t rebounded. "This is a case of holy cow!’ We had no idea why this was happening. We asked all sorts of questions about why the VTE rates were changing. We looked at nine months of data, and it turned out we had a new infectious disease doc who was responsible for the war on MRSA. That was the difference. We duplicated the findings with other patients, with trauma patients. But it all came down to asking the right questions."
As a result, they created a special place for patients in isolation to walk around, and hired specially trained aides whose job it was to get those patients up and about and to do the required lung exercises. They also have a specific nurse specialist who provides reports on those patients, and the patients and their families get education on reducing the risk of clots and the importance of ambulation post-surgery.
"Patients in isolation have fewer contacts with providers," he says. "We already knew they were more prone to depression and general complication rates. This is the first time we demonstrated that they had a higher risk of VTE, too."
If you have to have contact isolation precautions, you can’t let that stop patients from walking. "Prophylaxis against clots is not enough," he says. "They have to walk. We also found that the longer time they were without their meds, the higher their risk. So if the nurses were taking longer to get to them — because they were in isolation — and they missed a dose, their risk went up."
Another piece of data gleaned: Most of these patients — 80% of them, says Fogel — were asymptomatic for MRSA. They were carriers, not septic or sick. And one new piece of data not yet published: Patients who have a second operation are at a nine times greater risk for a clot. "We know that one of the risks of VTE is missing a dose of prophylaxis, but we have them skip it before going into the OR. We aren’t treating them. We should probably keep them on anticoagulants through their operations. But that may be a hard sell for some surgeons."
Patient satisfaction scores are usually lower for patients in isolation. Fogel thinks the change in procedure, which helps alleviate the loneliness and ensures that these patients have something productive to do, might improve those scores. If they do, the results may find their way into a paper.
Currently, partial results have been published in The American Surgeon,1 and full results will be submitted in the future.
New bundle, new results
Barbara Drake, RN, the quality and patient safety coordinator at Vancouver General Hospital in British Columbia, would like to think it is possible to get to zero surgical-site infections (SSI).
She knows there will always be cases that are hard to control — patients who can’t help but play with their dressings, or show their wounds to their friends. But her experience in driving down infection rates by 77% makes her very hopeful.
Using a best practice bundle that Drake and her QI team created with input from frontline staff by going through evidence-based measures that had already worked and adapting them to their own needs, they took a cardiac SSI rate of 7% — about twice that of other hospitals their size that participate in NSQIP — down to 1.6%, 0.4% beyond the initial goal, Drake says.
Gathering a team of frontline staff, they found some specific areas that were suggested as best practices by the literature, but were being missed at the hospital. Among them were using weight-based dosing of prophylactic antibiotics and giving a second dose if a surgery lasted more than the half-life of the medication — usually three or four hours; creating a better, standardized kind of wound care using different types of dressings that were kept on for longer; and warming patients back up to normal body temperature after they came off of bypass, she says.
While some of the ideas came from the Canadian Patient Safety Institute’s Safer Health Care Now program (http://www.saferhealthcarenow.ca/EN/Pages/default.aspx), others came from the American College of Surgeons or other elements of the team’s literature search.
They ended up creating an acronym for the entire bundle — CLEAN — that helped to encapsulate the main components, both old and new, Drake says:
• C: Clean hands before touching the dressing, chlorhexidine wipes applied to the body before surgery, clippers used for hair removal instead of shaving, and nasal decolonization (disinfecting the nostrils with ultraviolet light) performed.
• L: Leave the dressing on for 72 hours postoperatively, and leave the pink chlorhexidine disinfectant on the skin for six hours after the operation.
• E: Engage patients and staff on best practices for SSI prevention.
• A: Appropriately use antibiotics.
• N: Normothermia (normal body temperature), normal blood glucose (sugar), nutritious meals, and no smoking for patients.
Drake, who expects the findings to be published this fall, says one of the unexpected benefits of the program is that this multidisciplinary team approach to the problem was such a success that she believes it will be easier to introduce other changes in the future. "Before, the teams were not as mixed up as now. They did not always include the frontline staff. But when you think about how many departments touch a patient, it is so important that they all be included in efforts to improve care."
While initially this effort has been directed at cardiac patients alone and in one facility, she believes it will expand — both to other hospitals and within Vancouver General itself. Indeed, bits and pieces of CLEAN are already filtering throughout the facility. The hand-washing and chlorhexidine, the nasal decolonisation, and clippers for hair removal — those are already in use. Orthopedics was already using the 72-hour dressing, which is one reason the cardiac team adopted it. The redosing of antibiotics was also already a practice for other surgical departments.
With the success of the SSI reduction program, Drake says she and her colleagues have been talking about the possibility of "getting to zero." Part of that is patient engagement and finding ways to update and engage staff so that CLEAN is front and center in their mind.
"I think the reality is we will always have someone who is diabetic or a high BMI," Drake says. "But when we do have one, we research why now, to see if there are factors that are not in the bundle — or not yet in the bundle that might have an impact."
Of current interest is the issue of bathing after surgery, she notes. That seems to be a common thread with some of the infections that have occurred despite the use of the bundle. She’s also thinking of ways to keep the number of infections in front of staff — maybe build a little friendly competition between units, or have them invested in a "this many days since our last infection" run. Add a little more patient education to the mix and who knows, that zero may be attainable, even sustainable.
A good reason to stay connected
People are loath to let go of their phones these days, and that fact is helping one facility ensure patients are taking their pre-operative showers before coming to the hospital for elective surgeries.
At the Medical College of Wisconsin in Milwaukee, patients are required to take two consecutive showers using chlorhexidine gluconate (CHG) before they come in for their surgery. But, says Charles E. Edmiston, Jr., PhD, CIC, FSIS, FIDSA, FSHEA, a professor of surgery and director of the surgical microbiology research lab at the college, based upon some preliminary investigations, "we had discovered that not all patients were actually completing the task. I also have heard this concern raised by my colleagues at other institutions around the country."
He decided to see if texting, emails, or voicemail messages might be a way to get patients to comply with the directive. "There was some data in the literature that patient electronic alerts were an effective strategy, enhancing compliance to other health care tasks such as taking prescribed medications in a timely fashion." There is also data that flu vaccination rates increase with such protocols.
For Edmiston’s study — published in the Journal of the American College of Surgeons2 — the vast majority (80%) opted to receive a text message, while 5% wanted to get a voicemail.
Current literature is mixed on how effective showering is at reducing surgical-site infections, but Edmiston and his colleagues are firmly in the camp that done properly, according to a strict protocol, it could have a positive impact on reducing adverse events like infections: "Our team felt that this was an opportunity to empower the surgical patient by emphasizing the importance of this task and allowing them to be an active participate in this risk-reduction process."
The patients who participated in the study were either prompted to shower two or three times with the chlorhexidine solution, or not prompted to shower. The results showed much higher concentrations of the chlorhexidine on the skins of the patients who got the prompts than those who did not, suggesting that the prompts worked to remind them to adhere to the protocol they were given when they were making plans for their elective surgery.
Edmiston says they did not know what the results would show — although they had some idea that text messaging could work. The concept is not unique, he notes, but "it is the first time that it was used to improve compliance to an important preadmission risk-reduction strategy for surgical patients."
He thinks that along with preadmission showering, texting or other messaging strategies can also be used for other preadmission tasks for patients, such as encouraging them to bring all their medications with them to the hospital, or reminding them about scheduling requirements. It also could be used to remind them they can’t eat within 12 hours of their surgery.
"This technology could also be used to link patients to instructional materials related to pre- and postoperative requirements," says Edmiston.
It might also work post-surgery, he continues, for inquiring about pain or even taking a picture of the surgical site, he adds, noting that in a separate but related endeavor, one of the laparoscopic surgeons at the Medical College of Wisconsin — Matthew Goldblatt, MD, FACS — has a developed a "virtual follow-up clinic" where, for example, patients send smartphone photos of their postoperative surgical site for clinical evaluation with follow-up phone consultation, allowing the patient to respond to other physician or nursing queries.
- Reed CR, Furguson RA, Hammill ME, Fogel SL. Contact isolation is a risk factor for venous thromboembolism in surgical patients. Am Surg. 2014 Jul;80(7):723-4
- Edmiston CE, Krepel CJ, Edmiston SE, et al. Empowering the Surgical Patient: A Randomized, Prospective Analysis of an Innovative Strategy for Improving Patient Compliance with Preadmission Showering Protocol. J Am Coll Surg 2014;219:256e264
For more information on this topic, contact:
• Barbara Drake, RN, Quality and Patient Safety Coordinator, Vancouver General Hospital, Vancouver, BC, Canada. Email: Barbara.Drake@vch.ca
• Charles E. Edmiston, Jr. Ph.D., CIC, FSIS, FIDSA, FSHEA, Professor of Surgery, Director, Surgical Microbiology Research Laboratory, Department of Surgery, Division of Vascular Surgery, Medical College of Wisconsin, Milwaukee, WI. Email: firstname.lastname@example.org.
• Sandy Fogel, MD, FACS, Surgical Quality Officer and Medical Director of Operating Room Services, Carilion Clinic, Roanoke Memorial Hospital, Roanoke, VA. Email: email@example.com