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Implementation of Quality Measures to Reduce Surgical Site Infection in

Colorectal Patients

Article  in  Diseases of the Colon & Rectum · August 2008

DOI: 10.1007/s10350-007-9142-y · Source: PubMed

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 Implementation of Quality Measures
to Reduce Surgical Site Infection
in Colorectal Patients
ORIGINAL Elizabeth C. Wick, M.D.,1  Laurel Gibbs, M.A.T.,2  Lois Ann Indorf, N.P.,1 
CONTRIBUTION Madhulika G. Varma, M.D.,1  Julio Garcia-Aguilar, M.D., Ph.D.1
1 Department of Surgery, University of California, San Francisco, California
2 Department of Infection Control, University of California, San Francisco, California
PURPOSE: The goal of this study was to determine the rate
of surgical site infection and compliance with process
measures designed to prevent infection in a defined
population of patients undergoing colorectal operations.
METHODS: A task-force consisting of surgeons, hospital
infection control personnel, anesthesiologists, and nurses
was convened to enforce the use of process measures to
prevent infections. We monitored antibiotic selection,
dosage, timing, redosing and discontinuation, hair re-
moval technique, intraoperative and postoperative body
temperature, and perioperative glucose control for
12 months by using electronic medical records. Patients
underwent a minimum of 30 days of postoperative
follow-up and the attending surgeon diagnosed infections.
RESULTS: Between April 2006 and March 2007, 298
patients underwent abdominal colorectal operations.
The overall infection rate was 20 percent for colon
procedures and 11 percent for small-bowel procedures.
Compliance for most process measures improved from
the first to the fourth quarter, and during the final
quarter, correct antibiotic dose and hair removal with
clippers exceeded 90 percent.
CONCLUSIONS: The rate of surgical site infection after
colorectal surgery is likely to be higher than that reported
in national quality improvement programs. Perfect
compliance with performance measures may be difficult
to attain.
KEY WORDS: Wound infection; Process measures;
Perioperative; Normothermia; Antibiotics; Glucose;
Quality improvement; Surgical care improvement project.
n an effort to reduce complications, national health
I care quality initiatives have focused on reducing the
rate of surgical site infections (SSI). Currently, quality
Presented at the meeting of The American Society of Colon and Rectal
Surgeons, St. Louis, Missouri, June 2 to 6, 2007.
Address of Correspondence: Julio Garcia-Aguilar, M.D., Ph.D., 2330
Post Street Suite 260, San Francisco, California 94115. E-mail:
garcia-aguilarj@surgery.ucsf.edu
1004 DOI: 10.1007/s10350-007-9142-y  VOLUME 51: 1004–1009 (2008)  ©THE ASCRS 2007  PUBLISHED ONLINE: 16 APRIL 2008
initiatives are focusing on compliance with process
measures known to reduce the rate of SSI. In the years
to come, compliance with process measures and the
development of SSI will be linked to reimbursement. It is
imperative that surgeons establish realistic expectations
for compliance with quality measures and SSI rates in
patients undergoing abdominal colorectal surgery.
Surgical site infection, the leading cause of postoper-
ative morbidity after colorectal operations, increases
health care costs and lengthens hospital stay.1 Colorectal
surgical patients inherently have higher infection rates
because of frequent entry into the alimentary tract, which
leads to bacterial contamination. Most colorectal proce-
dures are Class 2 or 3, based on the Centers for Disease
Control and Prevention (CDC) risk stratification system.2
Since the 1970s, the National Nosocomial Infections
Surveillance (NNIS), a program of the CDC, has moni-
tored the rates of hospital-acquired infections and further
stratified those rates based on a scoring system that
considers American Society of Anesthesiology (ASA) score,
wound classification, operative duration, and the presence
or absence of laparoscopy. Currently, the NNIS serves as a
benchmark of the quality of care. NNIS rates for SSI after
colorectal surgery range from 6 percent for risk index
category (RIC) 1, to 12 percent for RIC 3.3 In contrast, a
recent single retrospective study and a multi-institution
prospective study have reported infection rates of 28
percent and 26 to 43 percent, respectively.4,5
Perioperative process measures have been found to
reduce the rate of SSI.6 There is Level I evidence that
thoughtful use of antibiotics improves patient safety and
leads to better clinical outcomes.4 Studies also have
demonstrated that both hair removal with clipper and
perioperative normothermia (maintenance of body tem-
perature between 36°C and 38°C) decrease infections in
general surgery patients.7 Tight glucose control in cardiac
patients improves recovery,8 but this finding has not been
extended to include the general surgery population.
Quality improvement initiatives, including the Surgical
Care Improvement Project (SCIP)9 and the Institute for
Healthcare Improvement (IHI),10 have endorsed these
process measures as ways to decrease SSI and improve
patient outcomes.
W ICK ET AL .: Q UALITY M EASURES AND SURGICAL SITE INFECTION 1005

Pay-for-performance and increased public reporting (dirty), according to the guidelines of the American
of hospital quality data is imminent.11 On a trial basis, the College of Surgeons and adapted by the Centers for
incentive of public reporting and pay-for-performance Disease Control and Prevention.2 All procedures involv-
has led to improved quality of care in the treatment of ing placement or removal of a stoma were considered to
medical diseases. In the surgical arena, nosocomial be Class 3.
infections, specifically SSI, will be an immediate target.
The first wave of change will affect reimbursement based Measures
on compliance with quality measures. The Centers for Process measures (Table 1) included the appropriate
Medicare and Medicaid Services has proposed rule CMS- antibiotic selection, dose, administration of prophylaxis
1488-P, which will cease all reimbursement for additional within one hour of incision, redosing when applicable,
care associated with certain hospital acquired infections as discontinuation of antibiotics within 24 hours, appropri-
of October 1, 2008.12 Surgeons must establish accurate ate or no hair removal, and maintenance of normother-
expectations for both compliance with process measures mia. At the time of this study, cefoxitin was administered
and SSI rates in colorectal surgery. for colorectal surgery prophylaxis; ciprofloxacin and flagyl
We hypothesized that 1) the rate of surgical site were used in patients with allergies to penicillin or
infection in patients undergoing abdominal colorectal cephalosporin. This antibiotic regimen was based on the
surgery is higher than that reported by the CDC-NNIS, 2) SCIP and IHI list of approved antibiotics for colorectal
a dedicated task-force is imperative for high level of surgery and internal UCSF guidelines. Compliance infor-
compliance with process measures, and 3) high levels of mation was gathered from the anesthesia record and
compliance with interventions are not easily attained. patient chart. Antibiotic treatment was considered to be
“noncompliant” with process measure if documentation
was lacking, a nonapproved drug was used, or the dose
PATIENTS AND METHODS
was inadequate.
Task Force
A committee was formed to implement and monitor both
new and established process measures to decrease SSI.
The group included surgeons, anesthesiologists, infection Table 1. Definition of process measures
control personnel, and perioperative nurses. An infection Definition of
control professional (LG) devoted 10 percent of a full- Process measure compliant Notes
time equivalent (FTE) position to the project. Meetings Antibiotic Cefoxitin If penicillin allergy
were held monthly to monitor compliance and address choice Ciprofloxacin and
obstacles. flagyl
Study subjects consisted of 298 consecutive patients Antibiotic dose 1 g<80 kg Ciprofloxacin 400 mg
who underwent abdominal colorectal operations for small 2 g>80 kg and Flagyl 500 mg
Timing of Within 1 hour
bowel and colon procedures (ICD-9 codes in the NNIS antibiotic before
categories “small bowel” and “colon”) by three surgeons incision
(Julio Garcia-Aguilar, M.D., Ph.D., Madhulika Varma, Hair removal Clipper
M.D., and Laura Goetz, M.D.) at Center for Colorectal Discontinuation 24 hours In combined cases
Surgery, University of California, San Francisco, a 600- of antibiotics after with plastic surgery,
operation antibiotics continued
bed teaching hospital, between April 2006 and March to be given as long as
2007. Two patients died within days of the surgery and the drains were in
were excluded from the cohort. All subjects were followed place (this was
for a minimum of 30 days postoperatively. considered
Patient characteristics (age, gender, weight, diagnosis, “noncompliant”)
Appropriate Cefoxitin Ciprofloxacin/Flagyl
diabetes, American Association of Anesthesiologists (ASA) redosing of 3 hours 6 hours
as established by the anesthesiologist) were obtained from antibiotics
the electronic medical record. Preoperative <200 mg/dl
Every patient undergoing a colon resection received a glucose
mechanical bowel preparation with polyethylene glycol Postoperative <200 mg/dl Maximum value
glucose recorded on
or Fleet® Phospho-soda® (C.B. Fleet Co., Inc., Lynchburg, postoperative Day 1
VA) on the day before surgery. Per operating room Intraoperative 36–38°C All intraoperative
policy, skin was prepared with chlorohexidene scrub or normothermia values must be
betadine paint. When the operation was completed, the within range
attending surgeon determined the wound classification: 1 Postoperative 36–38°C Based on first value in
normothermia recovery room
(clean), 2 (clean-contaminated), 3 (contaminated), or 4
1006
Blood glucose levels were measured before surgery and
within 24 hours after surgery. A glucose level > 200 was
considered noncompliant.
Normothermia was defined as body temp 36°C to 38°C.
The nadir in the operating room and the first recovery
room value were analyzed. Temperatures outside the
optimal range were deemed noncompliant. Compliance
rates for all measures were collected on a weekly basis, as
available.
Surgical Site Infections
Surgical site infection was determined by using the CDC
criteria and included superficial, deep, and organ space
infections. During the study time period, the attending
physician or the dedicated, trained, colorectal surgery
nurse practitioner diagnosed infections in the hospital or
during follow-up clinic visits.13 All patients had at least
30 days of follow-up.
Statistics
Each risk factor was screened by using a bivariate logistic
regression involving the putative risk factor and adjusting
for individual surgeon. Logistic regression was used to
identify risk factors for SSI. Risk factors that were
statistically significant at a 0.05 level were entered into a
multivariate model to test their joint effects.
RESULTS
During the one-year study period, 298 patients underwent
small-bowel and colon operations by three colorectal
surgeons. The mean age of patients was 54±17 years.
Operations were performed for benign disease (23 percent
or 69 patients), cancer (48 percent or 146 patients) and
inflammatory bowel disease (28 percent or 87 patients). A
subset (30 percent or 43 patients) of patients with cancer
underwent preoperative chemotherapy and radiation
therapy. Most cases were primarily large bowel (80
percent or 232 patients). Stomas were involved in 170
cases (57 percent), most (69 percent or 118) of which
were ileostomies. The average procedure length was 221±
119 minutes, and 36 percent (104 cases) included a
laparoscopic portion.
Overall, we had an 18 percent rate (54 patients) of SSI
(Table 2). Colon operations had a 20 percent (47 patients)
chance of SSI compared with 10 percent seen in small
bowel (7 patients) cases. Only half (53 percent or 26
patients) of SSIs were diagnosed in the hospital. Most
infections were superficial (76 percent or 39 patients)
according to the CDC criteria and required only opening of
the wound at the bedside. A few patients developed deep
space infections (10 percent or 5 patients) and organ space
infections (14 percent or 7 patients). Most organ space
infections were treated with interventional radiology
drainage. Five patients (10 percent of patients with SSI)
W ICK ET AL .: Q UALITY M EASURES AND S URGICAL SITE I NFECTION
returned to the operating room for drainage of an abscess
(3 patients) or fascial dehiscence (2 patients). No correla-
tion was observed between hospital, surgeon, diagnosis,
diabetes mellitus, or laparoscopy. Length of surgery was
related to the risk of SSI. The risk of infection was greater
for operations lasting more than 180 minutes than for those
lasting less than 180 minutes (24 vs. 11 percent; P<0.0042).
As expected, creation or takedown of stomas were also
associated with increased SSI (P<0.03).
Each quarter, we noted improvement in compliance for
most measures (Fig. 1). We observed improvement in the
appropriate use of antibiotics. Correct drug (90 percent),
dose (97 percent) and timing (90 percent), and hair
removal (100 percent) reached high levels of compliance
by the fourth quarter.
More challenging was the maintenance of intraopera-
tive normothermia and control of blood glucose. Tem-
perature values were documented in most patients but
were frequently out of range (36–38°C) of compliance.
Despite our deliberate efforts at improving normothermia
intraoperatively, compliance remained unchanged
through the study period. Interestingly, recovery room
temperature measurements more frequently ranged be-
tween 36°C to 38°C (in 62–74 percent of patients) than
intraoperative temperatures.
We observed a steady improvement in preoperative
glucose compliance. Many of the “failures” in the early
months were patients without documented glucose levels
rather than hyperglycemia. For preoperative glucose, in the
first quarter, 65 percent (54 patients) were noncompliant
based on having no recorded value; this improved by the
fourth quarter, when only 23 percent (13 patients) of
cases had no recorded value. In 97 percent of patients
(168 patients) with documented preoperative values, the
glucose was < 200 mg/dl. In contrast, although postoper-
ative glucose values were documented more consistently
during the study period (4th quarter 96 percent of cases
had glucose levels), there was also greater incidence of
noncompliance because of abnormal glucose values than
was true for preoperative findings. Only 86 percent of the
subset (209 patients) with glucose levels charted had levels
< 200 mg/dl.
DISCUSSION
The first objective of this study was to identify prospec-
tively the rate of surgical site infection in patients
undergoing abdominal colorectal procedures. During the
12-month study period, we found an 18 percent infection
rate (20 percent colon and 10 percent small bowel).
Infected patients incurred morbidity; 11 percent of
patients with postoperative infections required reopera-
tion for fascial dehiscence or deep space infection. In line
with recent retrospective and prospective reports, our SSI
rate significantly exceeds that of the NNIS.3 We suspect
W ICK ET AL .: Q UALITY M EASURES AND SURGICAL SITE INFECTION 1007

Table 2. Patient characteristics and surgical site infection rates

SSI Yes SSI No Total P value
Gender Male 30 (18) 140 (82) 170 (57) 0.88
Female 24 (19) 104 (81) 128 (43)
Diabetes mellitus Yes 3 (10) 28 (90) 31 (10) 0.23
No 51 (19) 215 (81) 266 (90)
ASA score ≤2 33 (18) 152 (82) 185 (65) 1
>2 18 (18) 84 (82) 102 (36)
Diagnosis Benign disease 11 (16) 58 (84) 69 (23) 0.8
Cancer 17 (17) 86 (84) 103 (35)
Cancer + radiation/chemotherapy 9 (21) 34 (79) 43 (15)
Inflammatory bowel disease 17 (21) 65 (79) 82 (28)
Intestine Colon 47 (20) 185 (80) 232 (78) 0.1
Small bowel 7 (11) 59 (89) 66 (22)
Stoma Yes 38 (22) 132 (77) 170 (57) 0.03
No 16 (13) 111 (87) 127 (43)
Laparoscopy Yes 18 (17) 151 (82) 104 (36) 1
No 33 (18) 86 (83) 184 (64)
Wound classification 1 0 4 (100) 4 (1.3)
2 15 (15) 87 (85) 102 (34)
3 36 (20) 142 (80) 178 (60)
4 3 (21) 11 (79) 14 (5)
Length of procedure (min) ≤180 16 (11) 125 (89) 141 (47) 0.0042
>180 38 (24) 119 (76) 157 (53)
ASA = American Society of Anesthesiologists; SSI = surgical site infection  Data are numbers with percentages in parentheses unless otherwise indicated

that this is a result of increased detection. The attending
surgeon or a dedicated trained nurse practitioner identi-
fied infections.13 Cases were re-reviewed on a monthly
basis to ensure that all SSIs were included. All patients
had at least 30 days of follow-up. In contrast to our
approach, the NNIS depends on hospital infection control
departments to identify SSIs. Infection control personnel
rely heavily on microbiology culture data to diagnose
infection. Few wound cultures are sent on colorectal SSIs.
These practices bring into question the reliability of the
NNIS reports. Nonetheless, because ours was a small-scale
study, we must extend our meticulous method of data
collection to establish a valid baseline rate for SSI after
colorectal procedures.
In an effort to reduce our rate of SSI, we focused on
improving compliance with established quality measures:
antibiotic delivery, hair removal, perioperative glucose, and
normothermia, because these are the measures embraced
by SCIP and IHI. We found compliance varied. Hair
removal was straightforward (100 percent compliance once
razors were removed from operating rooms), whereas
appropriate antibiotic use, maintenance of normothermia,
and prevention of hyperglycemia have been more complex.
For many years, antibiotics have been used to prevent
surgical infections.14,15 Despite Level I evidence of
effectiveness,16 adherence has generally been suboptimal.
For example, only 55 percent of Medicare patients
undergoing operations in 2001 received antibiotic pro-
phylaxis within one hour of incision.11 The 87 percent
compliance rate with antibiotic selection that we achieved
by the final quarter may have been because of assistance
from the task-force in identifying and surmounting
simple obstacles, such as difficulty obtaining appropriate
antibiotics. In our study, the stock location was changed
from the pharmacy to the operating room. In-service
education for nurses and anesthesia faculty and residents
also heightened project awareness and educated them on
the proper use of drugs. These efforts led to 90 percent
compliance for drug selection, dose, and timing. Education
was particularly helpful in curbing the use of piperacillin-
tazobactam, an agent not approved by the IHI or SCIP.
Intraoperative antibiotic redosing (78 percent compliance
by the 4th quarter) and discontinuation of antibiotics (65
percent compliance by the 4th quarter) have been more
challenging. A recent study demonstrated successful use of
ertapenem for prophylaxis prior to colorectal surgery.4 The
use of ertapenem would obviate the need for weight-based
dosing or redosing. The advent of preprinted postoperative
order sets may, within the next few months, also improve
compliance with the timely discontinuation of antibiotics.
In the next phase of the study, we will determine why
antibiotics continue to be given beyond 24 hours after
surgery. We suspect that the presence of drains placed by
plastic surgeons or suspicion of early wound infections is
frequently leading to noncompliance.
Both the SCIP and IHI emphasize normothermia to
reduce SSI in colorectal patients because intraoperative
hypothermia promotes vasoconstriction and reduced
oxygen levels in the tissue leading to immune suppression
and poor wound healing.7 Four small, randomized studies
demonstrated improvement in SSI with normothermia.
Patients in the lithotomy position are especially prone to
heat loss. Efforts to control temperature include the use of
warming blankets (placed in the preoperative area and left
1008
in place throughout the operation and into the recovery
room), heated operating rooms, and reflective bonnets for
patients. We easily improved use of these techniques and
noted improvement in maintaining normothermia based
on the initial temperature taken in the recovery room.
However during the fourth quarter, we noted that 28
percent of the patients were still hypothermic on arrival to
the recovery room. We found that noncompliance was
higher in intraoperative temperatures than in recovery
room temperatures. Currently, SCIP monitors normother-
mia by the first recovery room temperature,9 but we
question whether doing so is truly indicative of intraopera-
tive normothermia. To improve intraoperative normother-
mia, warming efforts must focus on the preoperative and
intraoperative periods.
In 2001, van den Berghe et al.8 demonstrated that
maintaining a glucose level between 80 to 120 mg/dl
decreased mortality in critically ill patients (diabetic and
nondiabetic). Strict perioperative glucose control is a pro-
cess measure for patients undergoing cardiac surgery. In
the future, this measure will likely be extended to general
surgery patients. Hence, we included perioperative glucose
as a process measure. The initial obstacle in monitoring
both preoperative and postoperative levels was documen-
tation. We worked with perioperative nurses to track the
glucose reading in the nursing flowsheet, culminating in 98
percent documentation in the final quarter. In addition to
monitoring preoperative glucose levels, we also recorded
FIGURE 1. Compliance with process measures and surgical site infection rate by quarter.
Compliance Rate
(Percent)
100
90
80
70
60
50
40
30
20
10
Correct Dose Within Redosed Discon- Recovery
Antibiotic 1 hr of Appro- tinued
Incision priately at 24 hr Temper-
W ICK ET AL .: Q UALITY M EASURES AND S URGICAL SITE I NFECTION
the maximum value on postoperative Day 1. We found
more frequent hyperglycemia postoperative (Day 1) than
preoperative (Day 0). As we expand our study, we will
determine whether preoperative or postoperative hyper-
glycemia contributes to infections in colorectal surgery.
Our study has two important limitations. First,
although we clearly identified the challenges with imple-
menting and documenting process measures, the antibi-
otic, normothermia, and hair removal measures were
initiated to varying degrees in the hospital before the
study. Consequently, the study period only reflects
improvement but not introduction of processes. Second,
because only 60 patients developed infectious complica-
tions, our study is currently too small to draw any
conclusions regarding the role of process measures in the
development of infections. In our expanded study, we
plan to determine the relationship between noncompli-
ance with process measures and development of SSI.
During the one-year study, we significantly improved
compliance for all measures except normothermia. The
outstanding performers were 100 percent for hair removal
with clippers and 91 percent for selection of correct
antibiotic dose. This high-level of compliance in all
measures required significant commitment of hospital
resources, including 10 percent of a full-time equivalent
(FTE) person to monitor compliance and educate
perioperative care givers. The SSI rate continues to exceed
nationally reported standards.
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
Intra- Glucose Glucose Clipper Wound
Room operative Preop- Postop- Hair Infection
Temper- erative erative Removal
ature ature
 W ICK ET AL .: Q UALITY M EASURES AND SURGICAL SITE INFECTION
CONCLUSIONS
The landscape of surgical care is changing. In the years to
come, public reporting of compliance with process
measures, complication rates, and overall clinical out-
comes will increase. The first wave of change will be in
October 2008, with the implementation of CMS-1488-P,
which will end additional reimbursement for the care
associated with SSI. Therefore, realistic expectations must
be set for both consumers and payers regarding compli-
ance with process measures and rate of SSI after colorectal
surgery.
ACKNOWLEDGMENTS
The authors thank Dr. Charles McCulloch and Chengshi
Jin for statistical assistance.
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