Using Bundled Interventions to Reduce Surgical Site Infection After Major Gynecologic Cancer Surgery.

OBJECTIVE: To investigate whether implementing a bundle, defined as a set of evidence-based practices performed collectively, can reduce 30-day surgical site infections. METHODS: Baseline surgical site infection rates were determined retrospectively for cases of open uterine cancer, ovarian cancer without bowel resection, and ovarian cancer with bowel resection between January 1, 2010, and December 31, 2012, at an academic center. A perioperative bundle was prospectively implemented during the intervention period (August 1, 2013, to September 30, 2014). Prior established elements were: patient education, 4% chlorhexidine gluconate shower before surgery, antibiotic administration, 2% chlorhexidine gluconate and 70% isopropyl alcohol coverage of incisional area, and cefazolin redosing 3-4 hours after incision. New elements initiated were: sterile closing tray and staff glove change for fascia and skin closure, dressing removal at 24-48 hours, dismissal with 4% chlorhexidine gluconate, and follow-up nursing phone call. Surgical site infection rates were examined using control charts, compared between periods using χ or Fisher exact test, and validated against the American College of Surgeons National Surgical Quality Improvement Program decile ranking. RESULTS: The overall 30-day surgical site infection rate was 38 of 635 (6.0%) among all cases in the preintervention period, with 11 superficial (1.7%), two deep (0.3%), and 25 organ or space infections (3.9%). In the intervention period, the overall rate was 2 of 190 (1.1%), with two organ or space infections (1.1%). Overall, the relative risk reduction in surgical site infection was 82.4% (P=.01). The surgical site infection relative risk reduction was 77.6% among ovarian cancer with bowel resection, 79.3% among ovarian cancer without bowel resection, and 100% among uterine cancer. The American College of Surgeons National Surgical Quality Improvement Program decile ranking improved from the 10th decile to first decile; risk-adjusted odds ratio for surgical site infection decreased from 1.6 (95% confidence interval 1.0-2.6) to 0.6 (0.3-1.1). CONCLUSION: Implementation of an evidence-based surgical site infection reduction bundle was associated with substantial reductions in surgical site infection in high-risk cancer procedures.

Balancing venous thromboembolism and hematoma after breast surgery.

PURPOSE: The purposes of this study are (1) to determine our institution's rate of venous thromboembolic events (VTE) and hematomas following breast surgery, and (2) to compare our breast surgery VTE rate with both our general surgery population and the National surgical quality improvement program (NSQIP) dataset. METHODS: Prospectively collected NSQIP data from April 2006 to June 2010 were analyzed. Our institution's VTE rates, pharmacologic prophylaxis (PCP) utilization, and hematomas were reviewed for patients undergoing breast surgery. The VTE rate was compared with NSQIP patient populations. RESULTS: Among 4,579 breast operations at our institution over this time period, 988 (21.6 %) were analyzed through NSQIP. The VTE rate following breast operations was 4/988 (0.4 %): 0/236 for those with benign disease and 4/752 (0.5 %) for those with breast cancer (p = 0.58). PCP was received by 147/752 (19.5 %) cancer patients. In cancer patients, the hematoma rate requiring reoperation was 3/147 (2.0 %) in those receiving PCP and 12/605 (2.0 %) in those not receiving PCP (p = 1.0). Breast surgery patients had a similar VTE rate compared with the institutional general surgery population (0.7 %, p = 0.254) and versus national general surgery patients from NSQIP (0.7 %, p = 0.29). Our institution's VTE incidence for patients with breast cancer undergoing mastectomy was significantly higher than "like" NSQIP centers. CONCLUSIONS: Our breast surgery VTE rate was similar to our general surgery population. Our mastectomy population had a higher VTE incidence compared with other NSQIP sites. Patients undergoing mastectomy, especially if combined with axillary lymph node dissection or reconstruction, should be considered for routine PCP.

How best to measure surgical quality? Comparison of the Agency for Healthcare Research and Quality Patient Safety Indicators (AHRQ-PSI) and the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) postoperative adverse events at a single institution.

BACKGROUND: Evaluating surgical outcomes is an important tool to compare providers and institutions and to drive process improvements. Differing methodologies, however, may provide conflicting measurements of similar clinical outcomes making comparisons difficult. ACS-NSQIP is a validated, risk-adjusted, clinically derived data methodology to compare observed to expected outcomes after a wide variety of operations. The AHRQ-PSI are a set of computer algorithms to identify potential adverse in-patient events using secondary ICD-9-CM diagnosis and procedure codes from hospital discharge abstracts. METHODS: We compared the ACS-NSQIP and AHRQ-PSI methods for hospital general surgical (n = 6565) or vascular surgical inpatients procedures (n = 1041) at a tertiary-care academic institution from April 2006 to June 2009 on 7 adverse event types. RESULTS: ACS-NSQIP inpatient adverse events were identified in 564 (7.4%) patients. AHRQ-PSIs were identified in 268 (3.5%) patients. Only 159 (2.1%) patients had inpatient events identified by both methods. Using ACS-NSQIP as the clinically based standard the sensitivity of the specific AHRQ-PSI ranged from 0.030 for infections to 0.535 for PE/DVT. Positive predictive values of AHRQ-PSI ranged from 18% for hemorrhage/hematoma to 89% for renal failure. Greater agreement at greater ASA class and wound classification was observed. CONCLUSION: AHRQ-PSI algorithms identified less than a third of the ACS-NSQIP clinically important adverse events. Furthermore, the AHRQ-PSI identified a large number of events with no corresponding clinically important adverse outcomes. The sensitivity of the AHRQ-PSI for detecting clinically relevant adverse events identified by the ACS-NSQIP varied widely. The AHRQ-PSI as applied to postoperative patients is a poor measure of quality performance.