ACS NSQIP Best Practices Case studies volume 2 July 2010

BEST PRACTICES
Case Studies
VOLUME 2
JULY 2010

2
The American College of Surgeons National Surgical Quality Improvement Program (ACS
NSQIP) Best Practices Case Studies have been developed for quality improvement purposes. The
Best Practices Case Studies do not include all potential options for quality improvement care.
The documents may be downloaded and printed for personal use by health care professionals
at participating hospitals. The documents may also be used in conjunction with ACS NSQIP-
related initiatives or programs. The documents may not be distributed for non-ACS NSQIP
related activities or for profit without the written consent of the American College of Surgeons.

1
TABLE OF CONTENTS
ACS NSQIP PROGRAM OVERVIEW......................................................... 3
INTRODUCTION TO ACS NSQIP BEST PRACTICES CASE STUDIES.... 5
CASE STUDIES.......................................................................................... 7
ACS NSQIP High Outlier: Using the FMEA Process
to Improve Postoperative Renal Outcomes........................................................... 7
ADVOCATE GOOD SAMARITAN HOSPITAL
Optimizing Glucose and Temperature Control
in the Operating Room............................................................................................ 19
KAISER SUNNYSIDE MEDICAL CENTER
Promoting a Culture of Safety in the Operating Room:
Prevention of Surgical Site Infection .....................................................................35
MORRISTOWN MEMORIAL HOSPITAL
Reducing Surgical Site Infection Rates in Vascular Surgery................................49
SCRIPPS GREEN HOSPITAL
Cost Implications of Reducing Surgical Site Infections
Related to Breast Surgery.......................................................................................63
SURREY MEMORIAL HOSPITAL
ACKNOWLEDGMENTS.......................................................................... 80

3
The American College of Surgeons
National Surgical Quality Improvement
Program (ACS NSQIP) is the first
nationally validated, risk-adjusted,
outcomes-based program to measure
and improve the quality of surgical
care. The program prospectively
collects clinical data to quantify 30-
day risk-adjusted surgical outcomes,
and allows for external benchmarking
of outcomes among participating
hospitals. Hospital administrators,
quality improvement officials, and their
clinical staff are provided with the
tools, reports, analyses, and support
necessary to make informed decisions
about improving the quality of care.
The ACS NSQIP collects data on
variables, including preoperative
risk factors, intraoperative variables,
and 30-day postoperative mortality
and morbidity outcomes for patients
undergoing major surgical procedures
in both inpatient and outpatient settings.
The data are collected, validated,
and submitted by a trained surgical
clinical reviewer (SCR) at each site.
Once trained, the SCR submits data to
the ACS NSQIP through a secure Web-
based system with built-in software checks
and prompts to ensure completeness,
uniformity, and validity of the data.
Data automation tools are also available
to lower the data entry burden on the
SCRs and to improve the quality of data
being captured. In addition, inter-rater
reliability audits are conducted to ensure
the data quality on a routine basis.
Using stepwise logistic regression,
30-day risk-adjusted morbidity and
mortality outcomes are computed for
each participating hospital. Outcomes
are reported as observed versus expected
(O/E) ratios. An O/E ratio less than
one indicates the hospital is performing
better than expected given the complexity
ACS NSQIP PROGRAM OVERVIEW

A C S N S Q I P B E S T P R A C T I C E S C A S E S T U D I E S4
of its patient population and surgical
cases. An O/E ratio greater than one
indicates the hospital is not performing
as well as would have been expected.
ACS NSQIP hospitals obtain feedback
on their performance via two avenues:
a comprehensive semiannual report
and real-time, continuously updated,
online benchmarking reports. Through
the ACS NSQIP website, participants
can view their non–risk-adjusted
data and produce reports by surgical
subspecialty and specific procedures.
Thus, participants can continually
monitor their quality improvement efforts
and compare, on a blinded basis, their
surgical outcomes with those of peer
hospitals and with national averages.
The ACS NSQIP provides feedback and
information to participants through
IRR audits, support services, online
training, and testing. Beyond the
technical and data collection elements of
the program, the ACS NSQIP supports
participants in achieving their quality
improvement goals. SCR and surgeon
champion conference calls, local and
regional collaboratives, and the annual
ACS NSQIP National Conference serve
as forums for participants to share
their impediments to and triumphs
in achieving quality surgical care.
Through the ACS NSQIP Best Practices
Case Studies and Guidelines, the ACS
NSQIP presents participants with tools
for implementing initiatives in quality
improvement. Finally, the ACS NSQIP
encourages participants, surgical
specialty groups, and other quality
improvement organizations to share
their experience and expertise so as to
advance the quality of surgical care.
For more information regarding the
application process, requirements, or
benefits of ACS NSQIP, or to apply
online, visit our website at www.acsnsqip.
org or e-mail acsnsqip@facs.org.

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The goal of the ACS NSQIP Best
Practices Case Studies is to showcase
how participating hospitals have used
ACS NSQIP data to improve their
performance and outcomes. It is
hoped that this volume, second in a
series of ACS NSQIP Best Practices
Case Studies publications, will allow
ACS NSQIP participants to learn from
the experiences of other hospitals and
develop similar quality improvement
initiatives within their own facilities.
The idea for this guide was conceived
after feedback from ACS NSQIP sites
via the annual conference. Additional
feedback indicated that some hospitals
were looking for information on how
to more specifically use ACS NSQIP in
their efforts to improve surgical care
and outcomes. The ACS NSQIP Best
Practices Case Studies were designed
to be one of several initiatives intended
to aid hospitals in getting started with
local quality improvement efforts. To
this end, the case studies in this guide
outline not only the objectives and
end results of the improvement effort,
but also the planning, development,
and troubleshooting process.
Each case study was developed as a
collaborative effort between the American
College of Surgeons and the participating
hospital’s surgical clinical reviewer (SCR)
and/or surgeon champion, as well as
other surgical and quality improvement
professionals. The case studies follow a
structured outline, including sections on
the description of the problem addressed,
the context of the quality improvement
process, the planning and development
process, a description of the activity, the
resources needed, the results, and tips
for others. ACS staff held an interview
with each hospital loosely following the
case study outline. The documents were
written by ACS NSQIP hospital staff
in conjunction with the ACS staff.
INTRODUCTION TO
ACS NSQIP BEST PRACTICES CASE STUDIES

As previously mentioned, the case studies
are meant to provide easily accessible
information to hospitals starting
their own quality improvement efforts
using ACS NSQIP data. While quality
improvement is not an exact science,
these examples may provide a starting
point to assess what kind of activities
could be applied locally. Many times, a
successful quality improvement activity
can begin by talking to the right people
and getting their buy-in and assistance.
Each case study provides information on
the details of the quality improvement
effort that the reader can envision using
at his or her own hospital. If necessary,
more information can be obtained
by contacting the SCR at the hospital
where the case study has taken place.
The ACS NSQIP is continually looking
for participant feedback on making
the program more conducive to the
participating hospital’s surgical care
goals. Please contact us if you have
comments or questions regarding
the case studies, or if you would like
information on how to submit your
own best practices case study for
publication in a future volume.

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ACS NSQIP CASE STUDIES
ADVOCATE GOOD SAMARITAN HOSPITAL

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ADOVCATEGOODSAMARITANHOSPITAL • DOWNERSGROVE,IL
A . G E N E R A L I N F O R M AT I O N
1. INSTITUTION NAME:
Advocate Good Samaritan Hospital, Downers Grove, IL
2. NAME OF THE CASE STUDY:
ACS NSQIP High Outlier: Using the Failure Made and Effect Analysis
(FMEA) Process to Improve Postoperative Renal Outcomes
B . W H AT WA S D O N E ?
1. Global problem addressed
Acute kidney injury is often an under-reported complication of surgery. ACS
NSQIP data estimates that approximately one percent of general surgery cases
result in such an injury in patients without preoperative renal problems.1
Recent
studies have explored the hypothesis that bowel preparation using oral sodium
phosphate purgatives is associated with acute kidney injury.2

2. Identification of local problem
Advocate Good Samaritan Hospital began its ACS NSQIP membership
in March 2007. The first two semiannual reports showed that the hospital
was a high outlier in renal failure outcomes, which raised awareness
that the hospital had a problem in this area of surgical outcomes.

C . H OW WA S T H E Q UA L I T Y I M P ROV E M E N T (Q I )
AC T I V I T Y P U T I N P L AC E ?
1. Context of the QI activity
Advocate Good Samaritan Hospital is a 333-bed community hospital located in
Downers Grove, a suburb of Chicago. It is a member of Advocate Health Care,
the largest health care system in Illinois. In 2008, Advocate Good Samaritan was
recognized nationally as one of the Thompson Reuters 100 Top Hospitals®
for
overall excellence, and in 2009 was awarded Magnet Recognition for Excellence
in Nursing Services. A 50,000-square foot, state-of-the-art surgical pavilion was
opened in 2008, and more than 8,500 operations are performed there annually.
This QI project was initiated by the surgical department, in collaboration with the
QI, anesthesiology, and nephrology departments, and was supported by the hospital
administration’s clinical performance improvement committee (CPIC). It is a stand-
alone project, the direct result of the hospital’s ACS NSQIP high outlier results.
2. Planning and development process
An interdisciplinary team was formed in August 2008, led by the ACS NSQIP
surgeon champion (SC) and the QI manager, who also facilitated the team’s process.
The team included the head of the department of anesthesiology, a nephrologist,
the ACS NSQIP SCNR, and four additional RNs representing intensive care,
postanesthesia care, nursing administration, and cardiovascular services education.
The team followed the Failure Mode and Effect Analysis (FMEA) methodology
to identify possible points along the surgical process where renal status could be
monitored and potential renal stressors alleviated. FMEA was originally developed in
the manufacturing industry but is being used increasingly in health care to analyze
where and when a medical process may fail, assess the relative affect of the failures
on the patient, and subsequently identify the points that are most in need of change.3
This methodology was used to identify failure points in patient care by tracing
the progression of an outpatient surgical patient from the time the operation was
scheduled through recovery. The team closely analyzed ACS NSQIP cases in which
renal failure had occurred and identified five possible failure points for development

11
of renal failure along the surgical process. One case of a healthy patient who came
in for elective colorectal surgery and ended up with renal failure particularly
resonated with the team in terms of the necessity of improving surgical outcomes.
The five identified areas needing improvement included:
• Identifying preoperative risks or problems: Preoperative testing is based
on nurses’ collection of a patient’s health history, and certain conditions
trigger preoperative testing. Not all patients undergo a full panel of
laboratory tests, so some conditions may be missed prior to the operation.
• Bowel preparation: Patients are instructed to complete the mechanical
bowel preparation at home when undergoing elective colon procedures.
However, patients were not properly instructed on the importance
of hydration since dehydration may lead to renal problems.
• Surgical holding: Patients may be given inadequate amounts of fluid in
the holding area, as the rate or volume of IV fluids is simply “keep open,”
without specifications in the standing preoperative anesthesia orders.
• Patient intake and output: Patient’s intake and output of fluids prior,
during, and after the operation are not adequately recorded.
• Communication: Surgical staff, surgeons, and anesthesiologists
need better communication on fluid balance (including
blood loss) during and after the operation.
The team worked on identifying changes that could be implemented to solve
these problems. The hospital SCR contacted ACS NSQIP hospitals that were
identified as low outliers for renal outcomes for any advice on what was being
done to attain their good renal outcomes. However, this investigation did not
bear fruit, as those low outlier hospitals could not point to specific processes that
result in a low incidence of renal failure. The anesthesiologists also examined
their records to see what could be improved. Literature on nephrotoxicity was
reviewed, but ultimately most of the activities implemented came from consensus
of staff experience regarding good renal care and surgical preparation.

D. D E S C R I P T I O N O F T H E Q I AC T I V I T Y
The team implemented the following changes in the surgical process:
1. Patients undergoing colorectal surgery were educated on bowel preparation
and hydration. Initially, the team had recommended that the nurses doing
the preoperative history also provide information on the bowel preparation
procedure, but the team then felt this timing was too far removed from
the actual operation. Instead, this responsibility was transferred to the day
surgery nurses, who developed a telephone script to instruct patients on bowel
preparation and hydration on the day before the scheduled operation.
Interestingly, in December 2008, while this QI activity was being
implemented, the FDA issued a safety alert for consumers of oral sodium
phosphate products (for example, Fleet®
or Phosphor-soda®
).4
The alert
was in response to reports of increased risk for kidney damage (acute
phosphate nephropathy) and warned it not be used for bowel cleansing.
Anesthesia’s standing preoperative orders were changed to conduct preoperative
creatinine and BUN labs on all colorectal surgery patients in the surgical
holding area to assess if preoperative fluid intake should be adjusted.
Standing anesthesia orders were approved so that IV fluids in
the surgical holding area were administered with specified
amounts and rates of infusion for adequate hydration.
Reeducation on documentation of all patient fluid intake and output was
implemented and incorporated into patient hand-off communications.
The surgeon champion sent out a letter to all surgeons detailing
the changes involved in order to raise awareness on communication
issues regarding fluid balance during an operation.
Implementation of the standing orders started in April 2009.

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E . R E S O U RC E S U S E D A N D S K I L L S N E E D E D
1. Staff involved in the program:
The FMEA team members were highly involved in implementing the program.
The team’s anesthesiologist and nephrologist were especially helpful in
determining the necessary changes and incorporating these changes into the
standing orders for hydration. Additionally, the hospital’s standing orders
and forms committee was involved in reviewing and approving the requested
changes. The SC is also the surgery medical director and was instrumental in
obtaining cooperation from the surgeons for this initiative. The QI facilitator
kept the team on target while instructing the team on the FMEA process.
2. Costs
No additional costs were involved in this program.

F. W H AT W E R E T H E R E S U LT S ?
1. Description of the overall results
The first semiannual report showed an observed versus expected (O/E) ratio of
2.89 for renal failure outcomes (in other words, acute renal failure and progressive
renal insufficiency), and the latest (7/01/08 to 6/30/09) O/E ratio was 0.85.
O/E Ratio for Renal Failure Outcome.
2. Estimate of financial savings realized
The cost of caring for the patients with renal failure from the ACS NSQIP sample
analyzed in the FMEA process was estimated using MS-DRG. The total cost
assessed was $1.1 million, while the cost of caring for the same patients without
renal failure would be $489,163. Therefore, if these cases of postoperative renal
failure were prevented, the hospital could realize a cost savings of $612,516.
3. Setbacks
The review by the standing orders and forms committee brought up legitimate
questions, resulting in changes to the standing orders. For example, the
committee wanted the preoperative labs and holding area standing orders to
be the same for both inpatient and outpatient colorectal surgery patients.

15
Other changes included modifying the amount of fluids given for extremely
obese patients. Since IV fluid amount is based on weight, there needed to
be an upper limit for total amount of fluids given. Additionally, in order
to avoid fluid overload, fluid amounts needed to be individually adjusted
by the anesthesiologist for patients with a previous cardiac condition.
Per the procedural changes, anesthesiologists were adjusting fluid intake orders
based upon preoperative lab results provided by the nursing staff in the surgical
holding area. This extra step resulted in some pushback from the anesthesiologists.
Although the multidisciplinary team included nursing representatives,
nurses involved in presurgical testing and day surgery were not included
in the initial FMEA development process. This fact was considered
a setback because nurses in these areas ended up being responsible
for implementing some of the surgical process changes.

G . T I P S F O R OT H E R S
1. Getting started
A key step to starting the project was that the SC worked intensively to
raise awareness of the renal failure problem by presenting the ACS NSQIP
report to a variety of hospital staff, including the hospital president,
administrators, and medical staff. This report set the stage for the quality
improvement process and ensured that everyone was aware of the findings.
The involvement of the QI department was also instrumental in this
process. The QI staff was well versed in the FMEA methodology and other
quality methods (for example, Six Sigma™), which may be out of the realm
of knowledge of most surgeons. By using the FMEA methodology, the
appointment of a specific team with a specified goal kept the group focused
through to the project’s completion within a relatively short timeframe.
The multidisciplinary group that worked together on the improvement
project was very important to the success of the program. During
the implementation phase, the group learned that it was essential for
departmental representatives to be involved from the beginning.
2. How to sustain the activity
A report on the FMEA process and the O/E ratio results has been presented
after each subsequent ACS NSQIP semiannual report. The SC has presented
these results to the medical staff and hospital administration, while the SCR
has shared the results with the operating room staff and the nursing units.
The online reports are continuously being monitored to check the absolute
numbers and individual cases. In addition, the team is exploring the possibility
of expanding the FMEA-identified process changes to all surgical patients having
mechanical bowel preparations (for example, hysterectomy and spinal surgery
patients), not just patients having colorectal surgeries. The success of this
quality improvement activity has inspired examination of other opportunities
for the empowerment of outcome, such as respiratory failure and pneumonia.

17
REFERENCES
1. Kheterpal S, Tremper KK, Heung M, et al. Development and validation of
an acute kidney injury risk index for patients undergoing general surgery:
results from a national data set. Anesthesiology. Mar 2009;110(3):505-515.
2. Brunelli SM. Association between oral sodium phosphate bowel
preparations and kidney injury: a systematic review and meta-
analysis. Am J Kidney Dis. Mar 2009;53(3):448-456.
3. Institute for Healthcare Improvement. Failure Modes and Effects Analysis
(FMEA) Tool (IHI Tool). Available at: http://www.ihi.org/IHI/Topics/
Improvement/ImprovementMethods/Tools/Failure+Modes+and+Effects+Ana
lysis+%28FMEA%29+Tool+%28IHI+Tool%29.htm. Accessed January 7, 2010.
4. Oral Sodium Phosphate (OSP) Products for Bowel Cleansing (marketed
as Visicol and OsmoPrep, and oral sodium phosphate products available
without a prescription). Available at: http://www.fda.gov/Drugs/
DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/
ucm103354.htm. Accessed January 7, 2010.

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KAISER SUNNYSIDE MEDICAL CENTER

21
KAISERSUNNYSIDEMEDICALCENTER • CLACKAMAS,OR
Kaiser Sunnyside Medical Center, Clackamas, OR
Optimizing Glucose and Temperature Control in the Operating Room*
Temperature control is an issue for all patients, as most of the general anesthetic
agents lead to hypothermia. Mild hypothermia increases the risk of many
complications, including surgical site infections1,2
and cardiac events.3,4
As
many as 46 percent of abdominal surgery patients have a temperature greater
than 36 degrees Celsius at the beginning of the operation, and a third of
these patients remain hypothermic on arrival in the recovery room.5,6
Patients with diabetes require hospitalization and surgical procedures more
often than patients with normal glucose tolerance.7-10
ACS NSQIP data shows
that in 2006, approximately 15 percent of surgical patients were chronic users
of insulin or oral agents for diabetes on admission. Importantly, these patients
suffered from nearly all ACS NSQIP-recorded complications at rates at least
double those of patients without diabetes. Additionally, many patients may
have undiagnosed diabetes, impaired glucose tolerance, or impaired fasting
glucose. A recent U.S. epidemiologic study showed a crude prevalence of
diabetes of 12.9 percent in people aged 20 or older, among which 40 percent
of this population was undiagnosed (Cowie 2009). Undiagnosed diabetes or
prediabetes can be problematic in terms of surgical treatment and outcomes.

ACS NSQIP online reports at Kaiser Sunnyside Medical Center (KSMC)
from data for the first six months of 2006 showed higher rates of total
morbidity events when compared with other hospitals. Most common were
surgical site infections and urinary tract infections. Although the overall
mortality rate was low, further investigation showed that patients with
diabetes had higher death rates when compared with other participating
hospitals. Additionally, KSMC was able to demonstrate that diabetic patients
had higher overall rates of complications at the hospital when compared
with other hospitals with similar demographics in the Kaiser network.
Kaiser Sunnyside is a 200-bed HMO community hospital. Quality improvement
(QI) was on the agenda in several forms. First, hospital staff was aware of
the SCIP measures and their effect on quality of care, although the hospital
had not yet enrolled in SCIP at the time this ACS NSQIP initiative took
place. In addition, in September 2006 the surgeon champion (SC) was a
founding member of a work group using the Society for Hospital Medicine
Glycemic Control Implementation Guide11
as a basis for improving protocols
and processes for the entire hospital outside the operating room (OR)
environment. This effort occurred in parallel to the ACS NSQIP initiative.
The SC assembled a group of opinion leaders, including anesthesiologists and
nurse anesthetists; OR, pre-, and postoperative nurses; and OR technicians
to look at ACS NSQIP data and review SCIP information as initial prudential
guidance about what dimension of care might be important. This group was
composed of staff perceived by the SC to excel in their field and be influential
among their peers. None of the group members had managerial roles that
might give the appearance of agendas other than improving quality.

23
The group reviewed the SCIP literature and literature on glucose control in
cardiac surgery. The SC conveyed the theory developed by Everett Rogers on
“Diffusion of Innovations”—an intervention should be simple, cheap, easy to
try out, and compatible with the needs, values, and beliefs held by the staff.12
Additionally, a QI initiative should be brief and affect a large number of people.
The group came to consensus to try to improve both glucose control and
thermal control in the immediate perioperative period as a way to decrease
many different complications and specifically mortality rates. The literature
they reviewed showed that improved glucose control reduces many different
complications in cardiac surgery patients. A key study on this outcome was
Furnary’s work in cardiac surgery,7
and the working group believed these results
could be applied to general and vascular surgery patients. In addition, the Society
of Thoracic Surgeons practice guidelines (updated in 2009)13
also encouraged
the practitioners to more aggressively manage hyperglycemic patients.
Based on ACS NSQIP data showing high overall morbidity rates,
poor outcomes in diabetics, and literature demonstrating decrease
in complication rates in cardiac surgery patients when glucose is
controlled, the group set two objectives for glucose control:
1. Engage anesthesiologists to try to replicate the improvements in care noted
previously in cardiac surgery patients through better glucose control.
2. Engage the hospital CEO to fund part-time QI staff focused on hospital
glucometrics in order to measure improvement over the hospital stay.
The committee agreed that the first step prior to implementing these
activities would be to conduct an ongoing audit to assess the status of
glucose control and thermal control in current hospital procedures.
The University of Minnesota’s protocol14
was selected for maintaining glucose
levels between 80 and 100mg/dL. Individual anesthesiologists and anesthetists
would use clinical judgment for the timing of starting the insulin, but the
upper limit for glucose levels would be 140mg/dL, in keeping with the upper
target glucose range for a fasting patient used in the rest of the hospital. As
a practical matter, the protocol was started earlier in patients known to be
insulin dependent and was started later in newly hyperglycemic patients.

In addition, the anesthesiologists had already started implementing thermal
control (one of the SCIP measures), believing from their clinical experience that
patients who were warm during the operation fared better. The group agreed
that the patient’s core temperature (not only the operating room temperature)
needed to be maintained in the appropriate range to affect change. The influence
of the SCIP measure on patient normothermia encouraged the committee to
set an objective for implementing a warming protocol for surgical patients.
Implementation of the activity began in September 2006.
1. Voluntary audit
An audit sheet was created to track preoperative, intraoperative, and postoperative
glucose levels and temperature. Preoperative nurses checked glucose levels
for patients with a BMI higher than 30 or a history of hyperglycemia. The
audit established baseline performance in terms of glucose control and
temperature and created a feedback loop so that the staff could see changes
in these measures. Weekly reports were prominently displayed in the OR.
2. Educational efforts
The results of the analysis of ACS NSQIP and Kaiser Network data were
presented in the form of a poster, which was put up in the entrance to the OR.
The SC conducted approximately 20 in-service talks to educate staff about the
problem and show the ACS NSQIP data. Potential solutions were presented via
the SCIP literature and the results of Furnary’s glucose control study in cardiac
surgery. This study was especially influential because it was conducted in a
familiar, geographically close hospital by a peer that was familiar to many staff.
In addition, staff was required to complete a free CME on Medscape
(Inpatient Insulin Therapy: Benefits and Strategies for Achieving Glycemic
Control). The director of continuing education for nurses required all
medical/surgical nurses to take the course as part of their yearly continuing

25
education. The chief and assistant chief of staff who led the credentials
committee required hospital-based physicians to show that they had
done the CME course as part of their renewal of hospital privileges.
3. Implementation of glucose control and warming
GLUCOSE CONTROL
First, glucometers had to be purchased so that one could be kept in each OR.
Implementation of the glycemic control protocol was essential to maintain
continuity of care since anesthesiologists may switch off during an operation.
In addition, the anesthesiologists needed to work with the pharmacy to provide
pre-made IV insulin infusions and infusion pumps that would be available
for immediate use in the OR. An internal hospital protocol for continuous
intravenous infusion of insulin to keep glucose levels between 90 to 140 mg/
dL was used in the step-down unit after an operation. The adoption of the
glucose control protocol by anesthesiologists would not have been a successful
initiative for the patients if there was no follow up of glucose control using
continuous IV infusion (or some similar transfer of control in the PACU).
THERMAL CONTROL
For accurate thermal control, temperatures had to be measured in a consistent
manner over time. Temporal artery probes had to be purchased for pre- and
postoperative use. The probes were also used intraoperatively, unless core
temperatures were already being monitored. The nurse anesthesiologists
were able to convince the administrative head of the OR that better warming
blankets were needed to effectively “prewarm” patients preoperatively.

1. Staff: No dedicated staff was added, but a few hours of clerical help
were needed to compile and distribute the weekly audits of preoperative,
intraoperative, and PACU temperature and glucose data.
2. Costs: Additional costs included purchasing glucometers for every
OR and thermometers for the pre- and postoperative areas. Better
blankets to allow active prewarming cost on the order of $100,000.
3. Funding sources: No outside funding was obtained. Better warm-
air heating blankets for use in the pre- and postoperative area were
paid for by addition to the surgical operations budget.

27
1. Overall results
Over an 18 month period, ACS NSQIP online reports showed overall complications
were reduced by 47 percent (non–risk-adjusted data. See Figure 1). In addition,
a number of complications reported in the NSQIP observed versus expected
(O/E) ratios (UTI, renal, DVT/PE, and cardiac) were reduced when comparing
2006 and 2007 data. Diabetic patients specifically had a rate of 56 complications
per 100 cases in the first six months of 2006. By 2007, the rate of complications
was reduced to 27 per 100 cases (see Figure 2). After implementation of this
program, length of stay also steadily declined by approximately 0.8 days.
In terms of glucose control, the percent of patients in the OR with glucose
values between 70 and 180 mg/dL started out at 72.7 percent prior to the quality
improvement activity. Over the next eight months, the percentage of patients
with controlled glucose increased and reached a high of 95.4 percent. Once
transferred to the surgical floor, the percentage of patients with controlled
glucose also remained high (85.4 percent) after implementation of the protocol.

Figure 1. Overall Morbidity Events over Time for Surgical Patients
Figure 2. Morbidity over Time for Diabetic/Nondiabetic Surgical Patients

29
2. Setbacks
Most of the barriers encountered in this quality improvement activity
included equipment requirements. There were only two glucometers for 12
ORs, and temperatures were measured differently in the surgical prep unit,
OR, and PACU. Although purchasing the glucometers and implementing
the insulin protocol required an up-front investment by the hospital,
the task force was able to use the existing literature to convince the OR
leadership that the investment would easily pay for itself through reduced
complications and length of stay. A similar argument was used for the
purchase of temporal artery probes and higher-quality warming blankets.
Once hyperglycemia was treated by anesthesia with IV insulin protocols, there was
an overflow of patients to the step-down unit, where they could continue to receive
infusion to target 90 to 140 mg/dl glucose levels since there was no IV insulin
protocol available on the surgical floors. To solve this problem, in June 2007, the
glycemia work group provided the education needed to allow an IV insulin protocol
to be used on all hospital floors. The protocol targeted patient glucose levels from
90 to 140 mg/dL and was disseminated and tested for safety. The protocol allowed
surgical patients to remain on IV insulin on any medical/surgical ward so that
they did not need immediate conversion to subcutaneous basal bolus insulin.

1. Getting started
Obtaining buy-in from staff members who were interested in improving their
outcomes was imperative for the success of the program. The SC did not have
the authority to impose this quality improvement activity on the staff, so it
was important to present the project as a collaborative effort. Oftentimes, the
hospital middle management hands down directives without obtaining buy-
in from the staff; this practice is usually not a highly successful strategy.
The choice of interventions also contributed to the success of the program.
Glucose and thermal control were actions that reflected beliefs that some of
the anesthesiologists already held and had been thinking about individually
for some time. Bringing the anesthesiologists and perioperative nurses
together as a group and showing that the ACS NSQIP morbidity and mortality
data confirmed the need to act to improve outcomes was a key step to
getting everyone on board. The anesthesiologists complied because they felt
ownership of the program and also like they were part of a larger effort.
Another powerful tool in this project was the glucose and temperature
audit. These measurements provided a framework for reference
before and during the quality improvement initiative, and provided a
feedback loop that helped get staff on board with the program.

31
2. Sustaining the activity
Since the ACS NSQIP glucose and thermal control program was implemented,
additional hospital resources have been added to expand the program to other
surgical services and sustain the activity. A glycemia control team (led by a
clinical pharmacist and endocrinologist) has been formed to help transition
patients from the IV insulin protocols to the outpatient setting. Region-wide
efforts to make more reliable the transition from the outpatient setting to the
hospital and then back again are also underway. In addition, a new obligatory
preoperative clinic has been introduced to screen for all comorbidities that
can affect surgical outcomes. A specific focus of the clinic is to find all of the
patients at risk for hyperglycemia by checking HbA1c on everyone older than
45 and everyone 18 to 45 with a BMI higher than 25 and any other risk factor for
diabetes. The glycemia team and preoperative clinic create a larger constituency
for improving glycemia care than existed at the start of this project. The
most important part of putting the patients on the IV insulin drip may be the
improved communication between caregivers about the needs of the patient.
3. Continual improvement
As of submission of the first 750 cases in 2009, there have been a total of two deaths
at KSMC. The morbidity rate in diabetic patients is down to 18 complications
per 100 cases (from 56 per 100 cases in early 2006) and in “nondiabetics” to
12 unique complications per 100 cases (from 17 per 100 cases in early 2006).

REFERENCES
1. Melling AC, Ali B, Scott EM, Leaper DJ. Effects of preoperative warming
on the incidence of wound infection after clean surgery: a randomised
controlled trial. Lancet. Sep 15 2001;358(9285):876-880.
2. Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the
incidence of surgical-wound infection and shorten hospitalization. Study of Wound
Infection and Temperature Group. N Engl J Med. May 9 1996;334(19):1209-1215.
3. Frank SM, Fleisher LA, Breslow MJ, et al. Perioperative maintenance
of normothermia reduces the incidence of morbid cardiac events. A
randomized clinical trial. JAMA. Apr 9 1997;277(14):1127-1134.
4. Vaughan MS, Vaughan RW, Cork RC. Postoperative hypothermia
in adults: relationship of age, anesthesia, and shivering to
rewarming. Anesth Analg. Oct 1981;60(10):746-751.
5. Forbes SS, Stephen WJ, Harper WL, et al. Implementation of evidence-
based practices for surgical site infection prophylaxis: results of a pre- and
postintervention study. J Am Coll Surg. Sep 2008;207(3):336-341.
6. Hedrick TL, Heckman JA, Smith RL, Sawyer RG, Friel CM, Foley EF.
Efficacy of protocol implementation on incidence of wound infection
in colorectal operations. J Am Coll Surg. Sep 2007;205(3):432-438.
7. Furnary AP, Gao G, Grunkemeier GL, et al. Continuous insulin infusion
reduces mortality in patients with diabetes undergoing coronary artery
bypass grafting. J Thorac Cardiovasc Surg. May 2003;125(5):1007-1021.
8. Neumayer L, Hosokawa P, Itani K, El-Tamer M, Henderson WG, Khuri
SF. Multivariable predictors of postoperative surgical site infection
after general and vascular surgery: results from the patient safety
in surgery study. J Am Coll Surg. Jun 2007;204(6):1178-1187.
9. Umpierrez GE, Isaacs SD, Bazargan N, You X, Thaler LM, Kitabchi AE.
Hyperglycemia: an independent marker of in-hospital mortality in patients
with undiagnosed diabetes. J Clin Endocrinol Metab. Mar 2002;87(3):978-982.

33
10. Vriesendorp TM, Morelis QJ, Devries JH, Legemate DA, Hoekstra
JB. Early post-operative glucose levels are an independent risk factor
for infection after peripheral vascular surgery. A retrospective
study. Eur J Vasc Endovasc Surg. Nov 2004;28(5):520-525.
11. SHM Glycemic Control Task Force. Workbook for Improvement: Improving
Glycemic Control, Preventing Hypoglycemia, and Optimizing Care of the
Inpatient with Hyperglycemia and Diabetes. Society of Hospital Medicine
website, Glycemic Control Quality Improvement Resource Room. Available
at: http://www.hospitalmedicine.org. Accessed June 24, 2009.
12. Diffusion of Innovations (from Wikipedia, the free encyclopedia). Available at:
http://en.wikipedia.org/wiki/Diffusion_of_innovations. Accessed June 24, 2009.
13. Lazar HL, McDonnell M, Chipkin SR, et al. The Society of Thoracic
Surgeons practice guideline series: Blood glucose management during
adult cardiac surgery. Ann Thorac Surg. Feb 2009;87(2):663-669.
14. University of Minnesota Medical Center. UMMC Continuous
Intravenous Insulin Infusion Orders; Adult (<45 kg). Available at:
http://www.apsf.org/resource_center/newsletter/2006/summer/
Insulin%20Infustion%20Orders.pdf. Accessed June 24, 2009.
*For a more in-depth version of this case study, please go to www.acsnsqip.org.

35
MORRISTOWN MEMORIAL HOSPITAL

37
MORRISTOWNMEMORIALHOSPITAL • MORRISTOWN,NJ
Morristown Memorial Hospital, Morristown, NJ
Promoting a Culture of Safety in the Operating Room:
Prevention of Surgical Site Infection (SSI)
Surgical site infection (SSI) is the second leading cause of nosocomial
infections. The effect on patients is significant, as those patients with SSIs
have a mortality rate two to 12 times higher than those patients without
SSIs.1,2
SSIs also represent a financial burden to the health care system;
published attributable costs per infection range from $6,000 to $29,000.3
In its first semiannual ACS NSQIP report (7/06 to 6/07), the SSI observed
versus expected (O/E) ratio for general and vascular surgery at Morristown
Memorial Hospital (MMH) was approaching high outlier status. As a
result of this report, the ACS NSQIP hospital staff participation in NSQIP
created a SSI task force to implement specific measures that have proven
efficacy in reducing SSIs. The goal of the task force was to identify all
process changes that could potentially reduce SSI. The task force began to
compare hospital practice for prevention of SSIs from other institutions.

Morristown Memorial Hospital is a private, not-for-profit community hospital that
is part of Atlantic Health System. The campus includes the main hospital, cancer
center, heart hospital, and children’s hospital and currently totals 629 beds.
Atlantic Health System (AHS) participates in several quality improvement
initiatives throughout the system, with targeted projects aimed at improving
performance on prospective national quality and patient safety measures
promoted through various quality and governmental organizations. Some
of the ongoing quality initiatives across the system include participation in
the 5 Million Lives Campaign, CMS regulations for present on admission
(POA) indicators, Medicare outpatient quality data reporting programs,
and residency programs that focus on medication safety as part of the
Accreditation Council for Graduate Medical Education (ACGME) initiatives.
The task force was created in September 2007 and met three times.
Members of the task force were chosen as a multidisciplinary group of hospital
administrators and experienced staff, which include attending surgeons and
residents, operating room (OR) education staff, anesthesiology, radiology, ICU
care, PACU, infection control, surgical services, ambulatory services, Institute
of Bioskills and Training lab, and plant engineering. Each member had a
voice in identifying processes that would be put in place to affect change.

39
Members reviewed the current processes in place for SSI prevention
and considered changes3-8 and additions to surgical practices. Using
published guidelines,3-8 best practices, and staff suggestions, the task
force came to a consensus on the necessary changes, including:
• Appropriate selection and timing of perioperative antibiotic therapy.
• Reduction of hair removal and exclusive use of clippers.
• Reduction of hypothermia by extending the use of body/head warmers to the
holding area and PACU, and by raising the temperature of the operating rooms.
• Preferential use of chlorhexidine over Betadine™ when possible.
• Perform skin preparation in order to allow time for the
Chlorhexidine to dry prior to scrubbing by the surgeon.
• Reinforcement of appropriate behavior regarding scrub attire,
personal belongings, and foot traffic in the OR.
Some of the processes identified by the committee were already in place as
part of other QI efforts (for example: antibiotic therapy and hair removal),
but the team members felt there was room for increased staff compliance.
As a part of the planning process, a survey was distributed to surgical attendings,
residents, nurses, and anesthesia staff to assess staff perceptions on the SSI
problem and preventative measures. The survey results showed that 37 percent
of the respondents agree that SSIs were a significant problem within the ORs; 22
percent were neutral, 19 percent disagreed, and 22 percent chose not to answer.
Staff reported their top priorities for preventative measures to decrease the
incidence of SSI as perioperative antibiotic use, ability for any member of the team
to speak up during surgery for breaks in technique, involvement of all members
of the team in case preparation to adjust technique to patients’ individual risk
factors, surgical skin prep prior to scrubbing, and skin prep with chlorhexidine.

The task force adopted the following changes to surgical
practices (listed in order of importance):
1. Skin preparation: Chloraprep™ was made available to replace Betadine, and the
operative field was to be prepped prior to scrubbing to allow the Chloraprep solution
to dry before draping. An additional benefit noticed was significantly fewer breaks
in sterile technique when the skin prep and draping was done before scrubbing.
2. Patient body temperature: The task force discovered early in the planning
process that most patients who were hypothermic when exiting the OR were
also hypothermic on arrival to the OR. Hypothermia was particularly evident
in patients who had received bowel preparation. Since the combination of
dehydration with rapid fluid resuscitation induced preoperative hypothermia,
the task force instituted the use of warming blankets, Bair Huggers™, and hats
(Mylar™ caps) in the preop holding area and the use of IV fluid warmers for
all patients who had bowel prep. The task force also recommended keeping the
operating room temperature between 68 degrees and 72 degrees Fahrenheit
until the patient is fully covered and has a body warmer in place. The circulating
nurse was responsible for raising the room temperature prior to patient arrival
and then regulating the temperature throughout the case. This method kept the
room warm for the patient prior to the operation but at a comfortable level for
staff once the operation started. The use of IV fluid warmers during the operation
became unnecessary once the OR room temperatures were raised as described.
3. Scrubs: A new policy deemed home laundering of scrubs unacceptable.
Inventory of scrubs was conducted to ensure that there would be an adequate
stock of scrubs available for all surgeons and OR personnel. Staff were
discouraged from wearing MMH scrubs outside of the OR and forbidden to
wear scrubs outside of the hospital. Signs were posted on all entrances/exits
of the hospital to enforce this new policy. Hospital security was informed to
issue reminders to staff who were seen leaving the hospital wearing scrubs.
4. White coats inside of OR: A new policy was instituted forbidding
white coats in the OR. Coat hangers were placed at various points
of entry to the ORs and signs were posted at the scrub sinks.

41
5. Personal belongings inside of OR: Only personal items essential to the
procedure would be allowed into the OR (for example, loops).
6. Prophylactic IV antibiotics: Documentation of the SCIP measures for
administration of antibiotics, re-dosing during the operation, and discontinuation
of antibiotics within 24 hours postoperatively was already in place. However,
staff were further educated on this process, and residents were assigned the
responsibility of discontinuing antibiotics within 24 hours of the operation.
7. Hair removal: Clippers were made available to minimize trauma
to the skin whenever hair removal was necessary.
8. Hats: The use of personal cloth hats was discouraged and disposable
hats were made available for all surgeons and OR personnel.
In addition, thermal hats were purchased for patient use as an
additional measure for preventing heat loss in the OR.
9. Draping: Minimal-access surgery presented new challenges in draping due to the
need to extend the sterile field with different pieces of equipment. Planning prior to
the operation for best placement of equipment was key to ensure proper draping.
10. Foot traffic in and out of OR during an operation: Foot traffic interferes
with the air exchanges programmed for each room and has the potential
to bring microorganisms into the OR environment. Foot traffic was to
be minimized by (1) preoperative planning between the surgeon and
the team, (2) planning of breaks around turnover times, (3) use of
telephone for communication, and (4) ensuring that students/learners
who come into the OR remain in the OR for the duration of the case.

The following educational processes were put into place to
ensure awareness of the quality improvement activity:
1. A memo from the task force (chair of the department of surgery and manager of
surgical services) with the recommendations was circulated to all OR personnel,
residents, attendings, and department of surgery members in January 2008.
2. Signs were posted at all scrub sinks and bulletin boards within
the OR and lounges as reminders of the new policies for scrubs,
white coats, and personal belongings in the OR.
3. The changes were announced in staff meetings, in-services, and morbidity
and mortality meetings. Nurse managers also educated their staff on protocol
changes that would fall under their responsibility. Staff was encouraged to
speak up if they saw a break in technique and were reminded that reporting
breaks in tequnique to the nurse managers would remain confidential.

43
1. Staff involved: The task force members and the OR staff were highly involved
in the program. In addition, at various points in implementation of the
program, it was necessary to involve relevant hospital committees in order to
gain approval for specific changes. For example, the change from Betadine
to Chloraprep had to be approved by the OR technology committee, due
to cost. Similarly, the purchase of hats and warming blankets needed to go
through a purchasing committee, as these items are paid for by the hospital.
2. Costs: Several items needed to be purchased to implement this QI activity.
Patient charge item:
• Chlorhexadine: Two single-patient-use sizes were approved for stock in the OR.
10.5-ml bottles—$3.53 each
26-ml bottles—$6.53 each
For comparison, the 10-ml Betadine bottles (single-patient use) that were
standard use in the OR for preoperative skin prep cost $0.14 each.
Patient charge item:
• Bair electric heating gowns:
Regular gown—$367.50/30 ($12.25 each)
XL gown—$315/20 ($15.75 each)
• Thermolite adult silver hats:
$132/100 ($1.32 each)
3. Funding sources: None

1. Description of overall results
After the implementation of the task force recommendations, O/E ratios
showed a downward trend in SSIs. Results from the most recent semiannual
report demonstrate O/E ratios below one across various surgical specialties.
The results for colorectal surgery SSIs are particularly impressive, as the O/E
ratio was reduced from 1.37 in the first report period to 0.5 in the last reported
period, resulting in MMH becoming a low outlier for this surgical specialty. The
results are encouraging, as they validate the measures taken to reduce SSIs.
O/E Ratios for SSI Over Time

45
2. Setbacks
The only barrier in the development process for the initiative was obtaining
approval for purchase of additional items. However, it was easy to convince the
administrators that incurring relatively small costs to the hospital’s operating
budget could significantly impact cost savings in terms of reduced complications.
As far as implementation of the program, all of the steps included in the
activity were successfully incorporated into regular practice. However, one area
that still needs work is foot traffic. High foot traffic is due to substitutions of
operating team members to relieve support staff during operative procedures
inquiries about the course of the operation. In an effort to continue the
downward trend with SSI occurrences, the task force will continue to explore
methods for decreasing foot traffic in and out of the operating room.

1. Getting started
Forming a multidisciplinary committee is imperative for obtaining buy-in from
staff. It is important that the initiative represents all staff that will be carrying
out the initiative, and not just administrative staff. In addition, consensus
for the changes implemented should be reached at the planning stage.
2. Sustaining the activity
The department chair provides updates on improvement in SSI rates via
in-services, distribution e-mails, and meetings with the director of the QI
department. The surgical attendings receive updates on the status of SSI in
the department, but the task force is working on providing feedback to the
staff that is instrumental in implementing the changes. A special in-service
will be conducted to convey the improvements to this group and to keep
momentum up so that future initiatives can be successfully implemented.

47
REFERENCES
1. Kirkland KB, Briggs JP, Trivette SL, Wilkinson WE, Sexton DJ. The impact of
surgical-site infections in the 1990s: attributable mortality, excess length of
hospitalization, and extra costs. Infect Control Hosp Epidemiol. Nov 1999;20(11):725-730.
2. Klevens RM, Edwards JR, Richards CL, Jr., et al. Estimating
health care-associated infections and deaths in U.S. hospitals,
2002. Public Health Rep. Mar-Apr 2007;122(2):160-166.
3. Anderson DJ, Kaye KS, Classen D, et al. Strategies to prevent surgical site infections
in acute care hospitals. Infect Control Hosp Epidemiol. Oct 2008;29 Suppl 1:S51-61.
4. Bratzler DW, Houck PM. Antimicrobial prophylaxis for surgery: an
advisory statement from the National Surgical Infection Prevention
Project. Clin Infect Dis. Jun 15 2004;38(12):1706-1715.
5. Dellinger EP. What is the ideal time for administration of antimicrobial
prophylaxis for a surgical procedure? Ann Surg. Jun 2008;247(6):927-928.
6. Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the
incidence of surgical-wound infection and shorten hospitalization. Study of Wound
Infection and Temperature Group. N Engl J Med. May 9 1996;334(19):1209-1215.
7. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention
of surgical site infection, 1999. Hospital Infection Control Practices Advisory
Committee. Infect Control Hosp Epidemiol. Apr 1999;20(4):250-278; quiz 279-280.

51
SCRIPPSGREENHOSPITAL • LAJOLLA,CA
Scripps Green Hospital, La Jolla, CA
Reducing Surgical Site Infection Rates in Vascular Surgery
Postoperative surgical site infections (SSIs) are the most common
nosocomial infections in surgical patients; SSIs occur in 38 percent of
this population.1
Each infection can result in up to four additional days
in the hospital and up to $27,631 in associated excess costs.2
SSI has been
targeted by the Center for Medicare and Medicaid Services as an area for
performance improvement. Proposed processes to accomplish this goal
include proper selection, timing, and administration of antibiotics; avoiding
hypothermia and hyperglycemia; and proper hair removal technique.1
In 2006, the American College of Surgeons National Surgical Quality Improvement
Program (ACS NSQIP) was implemented at Scripps Green Hospital (SGH). In June
2008, the semiannual report (including data from 1/2007 to 12/31/2007) identified
SGH as a high outlier for vascular surgery SSI with a rate of 8.76 percent, compared
to the average rate of 2.9 percent among participating hospitals. Prior to receiving
the semiannual report, the surgical staff was concerned that the hospital’s SSI rate
may be high; however, the report provided unequivocal evidence of the SSI problem.
The ACS NSQIP result was then compared to the Center for Disease Control and
Prevention National Healthcare Safety Network (CDC NHSN) surveillance system.
According to this data system, SGH recorded a vascular surgery SSI rate of 5.6
percent, compared with the NHSN benchmark of 0.90 percent to 4.34 percent.

Both of these benchmarking systems raised enough concern at SGH to lead to the
formation of an Interdisciplinary Process Improvement Team (IPIT) with the goal
of reducing the frequency of surgical site infection in vascular surgery patients.
C . H OW WA S T H E Q UA L I T Y I M P ROV E M E N T (Q I ) AC T I V I T Y
P U T I N P L AC E ?
Scripps Green Hospital (SGH) is a not-for-profit community
institution with 173 beds. It has served the La Jolla and greater
San Diego communities with distinction since 1977.
The IPIT was formed to address the high SSI rate. The ACS NSQIP surgeon
champion and epidemiology manager led the effort. The medical director
of the QI department, the infection control department, anesthesiologists,
operating room (OR) nurses, interventional radiology (IR)/OR
technicians, and ACS NSQIP SCNR also participated in the initiative.
Prior to the first meeting, literature on SSI prevention was reviewed to evaluate
evidence-based opportunities for process improvement. In addition, ACS
NSQIP detailed reports, including postoperative occurrences and postoperative
current procedural terminology (CPT) lists, were analyzed as part of the
planning process. The analysis of the reports demonstrated that many wound
occurrences resulted from the IR segment of the surgical procedure (see Figure
1) and led the team to focus on sterile technique in the IR department.

53
The team met multiple times to review, discuss, and prioritize the
initiatives for SSI reduction. Each initiative was assigned to an individual
or subgroup for further implementation. The initiatives were based on
SSI prevention literature, published cases studies from other institutions,
and team discussions regarding the potential impact of glycemic control.
The team set two goals for the quality improvement activity:
1. Eliminate preventable surgical site infections.
2. Reduce the frequency of vascular surgery surgical site infection.
Figure 1. ACS NSQIP Vascular Surgery CPT List with SSI Outcomes

1. Monitoring of glucose levels during the operation
Anesthesia closely monitored intraoperative patient glucose levels with a glycemic
target between 150 to 200 mg. New protocols were developed and implemented
for monitoring glucose levels and intervention, if necessary. The anesthesiologists
and nurse anesthesiologists received ongoing education on the new protocols.
2. Maintenance of adequate prophylactic antibiotic blood serum levels
• The SCIP measure for prophylactic antibiotics administration
within 60 minutes of surgical incision was reinforced.
• The Cefazolin dose was increased from one to two
grams for patients weighing more than 80 kg.
• Antibiotics were re-dosed three hours following incision to
maintain the serum level if the operation was ongoing.
• If MRSA was suspected or demonstrated, vancomycin
was to be used preoperatively.
3. Maintenance of normothermia during the operation
The use of a Kimberly Clark pad under the patient to maintain patient
intraoperative temperature at a minimum of 36.5 degrees Celsius was increased.
4. Limiting unnecessary traffic in the OR
Signs were posted in the entrances into the OR to raise staff awareness.
5. MRSA preoperative screening
All high-risk patients were prescreened for MRSA prior to the operation.
Infection Control educated the medical staff and personnel on the criteria
of high-risk patients, including any patients with implantable prostheses
and patients who have at least two risk factors (such as advanced age,
hypertension, diabetes, peripheral vascular disease, and so on).

55
6. Decreasing the length of time for wound closure
Surgeons agreed to increase oversight of residents and fellows
to prevent excessive time lapsing for wound closure.
7. Addressing surgical technique in interventional radiology
• Only two people in addition to the IR tech should be on the patient’s
right side during an operation. OR technicians feel that with more
than three people on this side, there is inadequate space to maintain
sterile technique. If the need arises for another physician to be on
this side, someone is asked to move to the patient’s left side.
• The anesthesia equipment and surgigraphic table should be moved toward the
patient’s head. This change allows the IR techs more freedom to move and gives
them the ability to angle their bodies to avoid brushing against the table.
• Surgical scrub technicians are to remain standing
due to lack of space for their chairs.
• The contrast injector should be moved to the patient’s left, which is north
of the c-arm. The tubing can subsequently remain on the field, and the
IR technicians will not need to reach around the physician’s back.
• The method of draping out the palm control for the surgigraphic table should
be changed. All cases in which the table is used will require this change.
The team will look into companies that provide drapes and see if they can
create one that will be applicable for SGH. Also, adding a telestator would
allow the stent representative to transpose his markings from a small screen
onto the c-arm screen without having to be close to the sterile field.

Educational activities included the following:
1. Education on proper sterile technique in the operating room was
provided to interventional radiology medical staff and personnel.
2. The operating room educator collaborated with Infection
Control to present a competency/educational module to all
OR staff for standardized practice of aseptic technique.
3. The anesthesia department and RNs were educated on the
implementation of new protocols for monitoring glucose levels.

No additional costs were incurred during this performance improvement
process. The infection control nurse and ACS NSQIP SCR completed a
monthly surveillance on vascular surgery SSI. The findings were compared
to the ACS NSQIP benchmark reports and to the semiannual reports.

57
1. Description of the results
The quantifiable improvements are demonstrated by the ACS NSQIP semiannual
report results. Figure 2 shows the observed versus expected (O/E) ratios for vascular
surgery SSI. The O/E ratios improved markedly from December 2007 to a year
later. The colored bars indicated SGH’s high outlier status before implementation
of the team’s recommendations. The excellent outcome for the year 2008 (O/E
= 1) was attributed to the implementation of the team’s recommendations.
Figure 2. O/E Ratios for Vascular Surgery over Time
Although not quantifiable, the staff involved has reported positive feedback since the
implementation of the changes. The initiative appears to have improved the overall
vascular surgery process, including communication between surgeons, anesthesia,
radiology staff, and nursing; documentation; and ongoing education for all staff.

2. Setbacks
• Medical and SGH staff: The staff were resistant to change at first,
but since they were aware that SSI was a problem within the hospital,
the resistance was very minimal. Once awareness of the problem was
increased via the semiannual report, they were fully on board with
incorporating the changes needed to improve their outcomes.
• Space issues in the operating room: Staff expectations needed to be changed
when the new procedures were put in place since personnel were accustomed to
doing things a certain way. Everyone involved needed to be reassured that the
measures implemented were preventative processes to reduce SSI occurrence.
• OR traffic: Expectations needed to be reset so that people
not directly involved in the operation would not feel free to
enter and exit the OR while the case was in progress.
The hospital stakeholders and SC in particular should be involved. Usually the
SC is in a position of influence in the hospital and can use the power of the
high-quality, risk-adjusted data to convince others of a potential problem.

59
REFERENCES
2. Dimick JB, Chen SL, Taheri PA, et al. Hospital Cost associated with
surgical complications: a report from a private-sector National Surgical
Quality Improvement Program. J Am Coll Surg. 2004;199:531-537.

63
SURREYMEMORIALHOSPITAL • SURREY,BC
Surrey Memorial Hospital, Surrey, BC
Cost Implications of Reducing Surgical Site
Infections Related to Breast Surgery
Globally, surgical site infection (SSI) rates after breast surgery are higher
than would be anticipated for a clean surgical procedure. A literature review
demonstrates infection rates after breast cancer reconstructive surgery range from
six percent to 28 percent. After mastectomy, SSI rates range from 2.8 percent to
25 percent based on 22 studies. Only two studies have published SSI rates of less
than five percent.1
Because each infection results in additional costs and extended
lengths of stay, reducing the risk of SSIs should be a priority for hospitals.
SSIs have become a worldwide concern among medical practitioners, as
indicated in the American Journal of Infection Control (AJIC). Infection Prevention
and Control, a book published in 20072
, zeroes in on current research and
practice regarding the prevention and control of infection. It also highlights
articles published in the Joint Commission Journal on quality and patient safety.

Based on the 2007 ACS NSQIP semiannual report (SAR), Surrey
Memorial was identified as a high outlier for SSIs.
By providing workable parameters, the data served as a useful tool in identifying
specific risk factors that may account for infections in patients undergoing specific
surgeries. Postoperative reports and SSI rates stratified by wound classification
reports yielded this incontrovertible result: patients undergoing breast surgery
with immediate reconstruction had high SSI rates. This result was relatively
unexpected. Although SSI rates were shown to be high in breast surgery, surgical
staff were not aware of the findings. Putting data in the forefront increased
awareness and elicited commitment among the stakeholders. Identifying the
problem served as a good start toward accomplishing a comprehensive SSI project.

65
Fraser Health Authority (FHA), located in British Columbia, is one of Canada’s
largest and fastest growing health authorities. Comprised of 12 hospitals, FHA has
more than 23,000 employees, 2,300 physicians, and nearly 5,000 volunteers. Surrey
Memorial Hospital (SMH) is the largest hospital in Fraser Health. FHA’s Surgical
Safety Collaborative (SSC) meets several times a year to discuss initiatives that can
be implemented to achieve the shared goal of improving the quality of surgical
care. The ACS NSQIP is an integral part of FHA’s SSC and surgical program.
Led by the surgical program director, a multidisciplinary team was created to
address the issue of SSIs in breast surgery. The team included a general surgeon who
specializes in breast surgery, a plastic surgeon, an operating room (OR) educator,
and nurses. A number of implementations were explored to address SSI from
different angles, including Dr. Campbell’s3
review of high and low performers in SSI.
The team went through the plan-do-study-act (PDSA) process and included the
following steps: (a) identified all variables that can cause infections and identified
patients with infections or showing signs of infections; (b) made critical analysis and
performed an objective evaluation and came up with impartial judgment as to kind
of infection, what caused this specific infection, and how infection could be treated/
avoided; (c) planned, developed, and implemented evidence-based action plans.
The PDSA cycles are important in order to continually monitor the problem,
evaluate if the situation is improving, and determine if additional changes
or new interventions are called for. The ACS NSQIP reports are integral to
this process, as they provide feedback to the team on monthly basis.

In October 2009, the SSC of FHA was a recipient of a British Columbia Patient
Safety and Quality Control Award. Specifically, the Collaborative received the award
for implementing a set of evidence-based interventions and quality improvement
activities aimed at reducing the likelihood of infection. These activities include:
1. Preoperative risk factors and comorbidity review: Patients with preoperative
risk factors such as smoking, diabetes, and high BMI are identified.
2. Surgical safety checklists, briefings, and crew resource management:
Initially proposed and sanctioned by the World Health Organization,
these tools are helping to encourage discussion, improve planning,
maximize the use of resources, and improve teamwork.4
3. Changes in skin preparation, sutures, scrubs, and sponge washes: The OR
nurse educator is instrumental in materials review and practice transition.
Alcohol-based materials are now being used in preadmission and in the OR.
4. Appropriate use of antibiotics: When the team studied the process for antibiotic
administration, they found several areas where improvements could be made.
• Create a standard practice for ordering and administering
antibiotics prior to the operation.
• Provide IV insertion training for all nursing staff.
• Improve accessibility to premixed antibiotics.
• Better assess the timing of antibiotic administration.
Due to the fact that surgical cases are frequently delayed, determining the
appropriate time to administer antibiotics can be difficult. This fact means
that these changes required a collective effort from the entire OR team in
determining who is responsible and when is the appropriate time, ranging
from the time of surgical admission up until the operation itself. Order sets
have been developed to improve communication regarding administration
between the nurses and surgeons. In addition, pharmacy provides the surgical
team with premixed antibiotics that are conveniently available “off the shelf.”

67
5. Use of appropriate hair removal: The use of clippers instead
of razors is the norm. The preadmission team instructs women
not to shave their armpits prior to breast surgery.
6. Dialogue between plastics and general surgeons: Surgeons
have increased their discussion of skin flap handling and
management, ensuring quality skin edges prior to closing.
7. Maintenance of perioperative normothermia: As part of a hospital-wide
initiative, the use of warm air and/or blankets has been implemented.
8. Creation of wound care champions: Nurses classified as “wound care
champions” advocate for improved wound assessment, documentation, and
management. The wound care champions emphasize that all staff should be
consciously examining all wounds and reporting their condition accurately.
This process is hardwired into the information management system.
9. Enhancing preadmission: Pamphlets have been updated, and preoperative teaching
has ensured that patients are well-informed and prepared for the operation.
10. Creation of a breast care improvement team: A multidisciplinary team
has been created to reduce variability of care by developing an order
set for all breast surgical patients from preadmission to discharge.
11. Enhanced staff education: Staff has been actively involved in the practice changes
and participates in education, with emphasis on teamwork and shared responsibility.
12. Continuous reporting of data and improved communication: Interim reports of
the ACS NSQIP data are continuously shared with many different groups in the
hospital so that improvements are apparent to hospital staff and management.

Resources both in terms of personnel and skills almost always overlapped with
this particular project. As noted earlier, medical practitioners, among them
doctors and nurses, make up close to 100 percent of the team. Input from a
financial analyst was obtained as the task of calculating the costs averted was
faced. Overall, no additional costs were involved. The SCR spent approximately 40
hours on researching costs that may be impacted by SSI infections, a malady that
could have been avoided if appropriate strategic actions were taken.

69
1. Overall results
This chart, “Mastectomy SSI Trends over Time,” shows the SSI rates
from the ACS NSQIP quarterly online reports over time.
Mastectomy SSI Trend over Time
In terms of qualitative results, the staff feels that the hospital’s participation in
quality improvement initiatives results in increased patient satisfaction, improved
health and quality of life for their patients, and increased morale of the surgical
team. Presenting real data to the practicing surgeons increases their appreciation
of quality measures and makes the quality measures seem less theoretical.
Feedback provides a sense of ownership and collective responsibility among staff.

2. Averted costs
The SCR reviews the rates for SSI in mastectomy cases on a quarterly basis, which
allows SMH to realize the differences in rates preinitiative and postinitiative. Each
breast SSI was estimated to add $4,0915
to hospital costs. Approximately 34 SSIs were
avoided in 2008 and 41 in 2009, resulting in averted costs of approximately $300,000.
Recommended methodology in calculating the cost of an occurrence:
• Calculate occurrence rate by trend over time.
• Calculate averted occurrence rate by subtracting current rate with baseline rate.
• Multiply averted occurrence rate with the total number of surgical
cases to obtain the number of averted occurrences.
• Calculate average cost of an occurrence.
• Multiply average cost of occurrence with the number of averted occurrenc
Cost of Complication $4,091
Baseline Rate 13.3%
Averted Breast SSI 75
Savings
(2008 and 2009) ~ $300,000

71
Important tips and notes for costing the occurrence:
• Make sure that the cases used for costing have a single occurrence,
rather than multiple postoperative occurrences, for easy calculation.
• Keep in mind that in the Canadian health care setting, averted costs present
opportunities to do more cases with existing resources (assuming there is
spare bed capacity) or to reallocate resources to other hospital areas.
• Averted cost is easier to isolate if it is attributable to a
readmission due to an occurrence rather than an occurrence
during the original surgical stay of the patient.
• Identify what is included or excluded in the costing data. The FHA costing
methodology provides full costing for inpatient cases, which includes all direct
care, direct support, and overhead costs. However, a significant portion of
physician fees is excluded mainly because doctors’ services are paid out of a fund
apart from the hospital’s general operating budget. This fund is managed by
the BC Medical Services Plan (MSP). Doctors’ costs reflected in the cost data are
mostly for physicians employed by FHA as hospitalists, pathologists, or radiologists.
• For surgical day care cases, cost information is limited and does not include
nursing costs. This limitation is due to an inadequate workload collection system in
the SDC area. Physician fees are excluded in the Canadian hospital costing system.

3. Challenges and unresolved issues
A major barrier to implementing this QI activity was changing the staff’s
attitude. Each staff member felt that individually, he or she was performing
at a high level. However, the collective results showed that there was a real
problem with SSI. The great benefit from the ACS NSQIP was the ability
to show high-quality, unbiased data to the staff and instill a sense that
everyone must work together to improve the departments’ results.
Since SMH has no case costing at present, a similar hospital type with costing
information was used as a surrogate to put some perspective on the averted
cost. It is common that some SSI cases are treated as an outpatient and cost
management is unable to capture the cost associated in an outpatient setting.
The team plans to address the following challenges:
• Competing departmental priorities. Multiple initiatives
lessen time commitments from team members.
• Lack of consistent technical support in areas of data
collection, analysis, and clerical support.
• Timeliness in accomplishing assigned tasks to team members.
• Creating a statistical model that averts skewed conclusions caused by
variations in practices and difficulties in capturing a representative group.

73
G . V I S I O N /G OA L S
1. Achieve a zero incidence rate for SSI.
2. Embed all ACS NSQIP variables into the preoperative assessment.
3. Reduce length of stay for inpatient mastectomies.
4. Increase accessibility and capacity by performing more mastectomy cases in an
outpatient setting. This initiative alone would save approximately $3,500 per case.
5. Create a breast care clinic for patient optimization.
H . L E S S O N S L E A R N E D
The SSI data speaks for itself. Practitioners have an imperative
to implement evidence-based interventions that can reduce SSI.
Teamwork is an essential key to achieving this goal.
Sustained activities can be contagious. When this project was applied to general
and vascular surgery, other disciplines strived for the same progress. The
culture that elicits commitment to improving the quality of surgical services
and aims at a zero tolerance for SSI is a necessity worth striving for.

BIBLIOGRAPHY
1. Campbell DA, Jr., Henderson WG, Englesbe MJ, et al. Surgical site infection
prevention: the importance of operative duration and blood transfusion—results
of the first American College of Surgeons-National Surgical Quality Improvement
Program Best Practices Initiative. J Am Coll Surg. Dec 2008;207(6):810-820.
2. Cohen M, et al. Risk adjustment in the American College of Surgeons National
Surgical Quality Improvement Program: a comparison of logistic versus hierarchical
modeling. Journal of American College of Surgeons. Dec 2009;209(6):687-693.
3. Dingle D, et al. Practice analysis for infection control and epidemiology in
the new millennium. American Journal of Infection Control. Dec 2002;30(8):437-
448. Six contributors make up the 2001 Advisory Committee, The
Certification Board of Infection Control and Epidemiology, Inc.
4. Mahmoud N, et al. Surgical Infections: Impact of Surgical Site
Infections on Length of Stay and Costs in Selected Colorectal
Procedures. Published by Mary Ann Liebert, Inc. Dec 2009;10(6).
5. Mangram Alicia J, et al. Guideline for Prevention of Surgical Site Infection,
1999. Infection Control and Hospital Epidemiology. 20(4):247-266.
6. Okotinsky L, Financial Planning and Reporting, Fraser Health Authority.
7. Olsen MA, Chu-Ongsakul S, Brandt KE, et al. Hospital-associated costs due
to surgical site infection after breast surgery. Arch Surg. Jan 2008;143(1):53-60;
discussion 61.
8. Porempbka M, et al. Quantitative weighting of postoperative complications
based on the accordion severity grading system: demonstration of potential
impact using the American College of Surgeons National Surgical
Quality Improvement Program. JACS. March 2010;210(3):286-298.
9. Scheckler W, et al. Requirements for infrastrature and essential
activities of infection control and epidemiology in hospitals: A
Consensus Panel report. AJIC. Feb 1998;26(1):47-60.

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10. Vilar-Compte D, et al. Surveillance, control, and prevention of surgical site infections
in breast cancer surgery: a 5-year experience. AJIC. Oct 2009;37(8):674-679.
11. Canadian Institute for Health Information, The Cost of Hospital Stays: Why Costs
Vary. Ottawa:CIHI, 2008.
12. Hospital-Associated Cost Due to Surgical Site Infection After Breast
Surgery. Division of Infectious Disease. Washington University 2004.
13. Infection Prevention and Control: Current Research and Practice, 2007, 176
pages. A compendium of articles published in The Joint Commission Journal
on Quality and Patient Safety. Published by Joint Commission Resources, Inc.
14. http://www.safesurg.org/uploads/1/0/9/0/1090835/surrey_memorial.pdf

ACS NSQIP BEST PRACTICES CASE STUDIES
ACKNOWLEDGMENTS
The ACS NSQIP would like to acknowledge the
participating hospitals and their SCRs, surgeon
champions, surgeons, and quality improvement
professionals for their contributions to the ACS NSQIP
Best Practices Case Studies. We greatly appreciate
their willingness to share their experiences and their
endeavors toward advancing the art and science
of high-quality surgical care. They share in ACS
NSQIP’s hope that the information provided will
inspire others to critically evaluate and make efforts
to improve the quality of their own surgical care.

79
Advocate Good Samaritan Hospital
Downers Grove, IL
SCR: Patricia Tasic, RN, MSN
SURGEON CHAMPION: Bruce C. Dillon, MD, FACS
Marty Dietrich, MPH, RHIA, CPHQ; Samir Kumar, MD; John P. Martucci, MD;
Peggy Guastella, MAOL, RN, CGRN; Filipinas Munoz, RN, BSN; JoAnne Pouliot, RN, MS;
Frances Wilk, RN, BSN; Margie Winfield, RN, BC, MAOL
Kaiser Sunnyside Medical Center
Clackamas, OR
SCRS: Juliann Breen, RN; Sharon Emery, RN; Laura Liedtke, RN
SURGEON CHAMPION: James Schwarz, MD, FACS
Jeannie Lewis, RN; Stephen Bachhuber, MD; Mark Gilbert, MD; Kathleen Agee, RN;
Sahra Rahimtoola, MD; Hank Dougherty, RN
Morristown Memorial Hospital
Morristown, NJ
SCR: Patricia L. Vorel, RN, CCRC
SURGEON CHAMPION: Rolando H. Rolandelli, MD, FACS
Scripps Green Hospital
La Jolla, CA
SCR: Melanie S. Alano, BSN, RN, PHN, LNC
SURGEON CHAMPION: Ralph B. Dilley, MD, FACS
Kathryn Wilson, RN, BSN, CIC
Surrey Memorial Hospital
Surrey, BC
SCR: Angela R. Tecson, RN, BSN
SURGEON CHAMPION: Peter J. Doris, MD, Msc, FRCSC, FACS
Lorraine Gillespie, RN, BSN, MEd; Ric Canizares, BBA, CPA, AAT, CMA

w w w . a c s n s q i p . o r g
633 N. Saint Clair St.
Chicago, IL 60611-3211
Phone 312-202-5213
Fax 312-202-5062
E-mail acsnsqip@facs.org
©2010 AMERICAN COLLEGE OF SURGEONS

ACS NSQIP Best Practices Case studies volume 2 July 2010

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