What Was Done?
Global Problem Addressed
Surgical site infection (SSI) in colon surgery has been identified as a significant cause of morbidity and mortality in surgical patients. When outcomes were measured, SSI rates often were in the range of 10 to 20 percent, even at prestigious, high-volume institutions.1 Mandatory reporting of colon SSI rates ensued and financial penalties have been levied for outlier institutions.2 Enhanced Recovery after Surgery (ERAS) protocols were developed initially to decrease length of stay (LOS), but ultimately to lower SSI. The extent of the protocols and the compliance required to obtain optimal results is not clear.
Identification of Local Problem
At our institution we initiated a colon ERAS protocol in 2014 with limited elements and moderate compliance but saw a decrease in our colon SSI. After one year we saw a sharp spike in SSI, and an extensive root cause analysis (RCA) and examination of individual surgeon factors and other retrospective review was unable to identify a cause or decrease the incidence. We then implemented an extensive, evidence-based pre-op, day-of-surgery, and post-op colon protocol with mandatory compliance. This protocol resulted in a rapid decline in our colon SSI.
How Was the Quality Improvement (QI) Activity Put in Place?
Planning and Development Process
Our hospital is a 637-bed public/private facility affiliated with Mercer SOM. It is a teaching hospital with an associated Level 1 trauma center, and it serves as a tertiary referral center for much of middle and south Georgia.
Our hospital has had a quality department with infection surveillance programs for many years, and we have been an ACS NSQIP participant for nearly a decade.
A committee was formed with leadership being the ACS NSQIP surgeon champion and nurse. The membership consisted of several other surgeons; the infection control nurse; nurse leadership from the operating room, the pre-op clinic, and the dedicated post-op ward; anesthesia; and representatives from information technology (IT), pharmacy, and nutrition services. An extensive search of the literature was performed, and elements felt to improve outcomes in colon surgery were included. Order sets for the pre-op setting, the day of surgery/ anesthesia setting, and the post-op setting were designed to be comprehensive, and all entities were tasked with being compliant. In particular, all surgeons
were brought together for discussion and education on the order sets, and after much deliberation there was consent to use them in spite of some disagreement regarding some of the elements.
Description of the Quality Improvement Activity
The IT department developed three order sets. The surgical team, including doctors, nurses, and office personnel were educated in the order sets. A colon navigator nurse was utilized to guide patients through all three phases and ensure compliance.
Our go-live date was May 2017.
Pre-Op
- Optimization clinic visit if multiple comorbidities
- Smoking cessation
- Diabetes control, HgbA1c
- Nutrition assessment, pre-albumin, Rx as indicated
- Optimization of medications
- Patient given an incentive spirometer (IS) and instructed in its use
- Five days of immunonutrition shakes
- Mechanical prep of the colon
- Oral non-absorbable antibiotics
- Phisohex showers
Day of Surgery/Anesthesia
- Complex carbohydrate drink two hours before surgery
- Tylenol, Lyrica, Celebrex pre-op
- Alvimopam pre-op
- Maintain glucose 120-180
- Pre-treat for nausea and vomiting
- Maintain temperature> 36 degrees
- Ventilate at 100 percent 02 and for six hours post-op
- Judicious IVF Rx
- Rocephin/Flagyl IV
- Experienced, consistent OR team with limited breaks
- Emphasize minimally invasive techniques
- Isolation protocol-emphasize sterile technique, wound protector, sterile closing tray/change gown and gloves after anastomosis is closed
- Educate nurse/MD on proper wound classification
- Pre-op deep vein thrombosis (DVT) prophylaxis
- Regional pain blocks
Post-Op
- Dedicated surgical floor with nurses educated on protocol
- No nasogastric tube/no foley
- Soft diet evening of surgery, regular diet postoperative day (POD)#1
- In chair evening of surgery, ambulate with physical therapy POD#1
- Multimodal pain management with no/limited opioids
- IS every 12 minutes
- DVT prophylaxis
- Alvimopam if on opioids
- Wound nurse to assess wound
Resources Used and Skills Needed
Existing office staff, nurses at all levels of care, and anesthesia/surgeon involvement was required. The only new position was the colon navigator nurse who was already employed, but administration committed her to our program at 1/2 FTE.
What Were the Results?
Colon SSI dropped from 11.3 percent in the preceding 15 months to 2.1 percent in the subsequent nine months. ACS NSQIP raw data showed a 50 percent decrease in mortality, wound occurrence, septic shock, unplanned intubations, and vent > 48 hours in our colon surgery patients.
