Pilot programme cuts colorectal surgery infections

Johns Hopkins patient safety pilot programme slashes colorectal surgical site infections by a third

A patient safety team reported a one-third cut in the rate of costly and potentially lethal surgical site infections following colorectal operations after requiring use of a simple safety checklist and urging caregivers to speak up if they see potentially unsafe practices.

The decreased incidence of infection, described by Johns Hopkins researchers in the August issue of the Journal of the American College of Surgeons, suggests that systematic creation of a culture of patient safety in which front-line staff members are encouraged to challenge anyone and anything that puts patients at risk can effectively address complex safety concerns in high-risk patients.

Researchers estimate that, if applied to all types of surgical procedures, locally developed checklists and similar culture change programs could reduce the total number of surgical site infections by 170,000 and result in a nationwide cost savings in the United States of $102 million to $170 million annually.

“Applied to other areas of medicine, that cost savings could make a sizable dent in medical inflation while saving lives,” says senior author Martin Makary, an associate professor of surgery at the Johns Hopkins University School of Medicine.

As the most common complication after colorectal operations, surgery site infections occur in 15 to 30 per cent of these patients, resulting in longer hospital stays, frequent readmissions and subsequent need for treatment, at an estimated cost of $1 billion annually. In addition, disability and quality of life often are affected.

“We’re thrilled to see such a positive outcome in an area where it has traditionally been very tough to move the needle,” says study leader Elizabeth Wick, an assistant professor of surgery at the Johns Hopkins University School of Medicine. “Until now, there’s been little evidence on how to effectively address surgical site infections among this group of patients,” Dr. Wick explained, adding that the nature of colorectal procedures — cutting in the bacteria-rich environment of the bowel — lends itself to a high risk of infection.

The Johns Hopkins study reflects increasing pressure on hospitals to reduce preventable harm, Dr. Wick notes. The US Centres for Medicare and Medicaid Services already is using surgical site infection rates as a quality indicator and, in some instances, the agency is refusing to reimburse hospitals for the costs associated with treating these infections. But despite heightened attention and required reporting on process measures, surgical site infection rates remain high, even among hospitals with near-perfect compliance with national guidelines, Dr. Wick says.

Using a pilot study protocol for high risk patients set by the American College of Surgeons National Surgical Quality Improvement Programme, Dr. Wick and her colleagues collected baseline surgical site infection rates after colorectal surgeries at the Johns Hopkins Hospital for one year leading up to and following the Hopkins safety team’s checklist and “speak up” interventions.

In the first year of the study, beginning in July 2009, 76 of 278 patients at Johns Hopkins Hospital or 27.3 per cent, developed a surgical site infection after colorectal surgery. The rate dropped to 18.2 per cent in the subsequent year after interventions were in place, with 59 of 324 patients contracting an surgical site infection. Procedures for which data was collected include colectomies and proctectomies, removal of part of or the entire colon and rectum, respectively.

Researchers estimate that 28 infections were prevented in 2010 to 2011, resulting in an estimated cost savings of between $168,000 and $280,000 for the hospital in just one year. Assuming a nationwide annual incidence of 1.7 million total surgical site infections per year, researchers estimate widespread application of the Johns Hopkins safety program across all surgical specialties could save more than $100 million annually.