A Focus on Patient Safety: Reducing Colorectal Surgical Site Infection
I recently completed the American Hospital Association-National Patient Safety Foundation Comprehensive Patient Safety Leadership Fellowship program. The learning fellowship focused on establishing and implementing long-term strategic plans for patient safety and quality improvement.

The program featured some of the top thought leaders in healthcare quality measures, including Drs. Lucian Leape and Atul Gawande. Leape is one of the authors of To Err is Human: Building a Safer Health System, a report that arguably led to the push for improving quality in healthcare. Gawande, a professor in the Department of Health Policy and Management at the Harvard School of Public Health, is a respected and influential researcher focusing on innovations to improve safety and performance in surgery, childbirth and care of the terminally ill.

Quality has always been a focus at Premier Surgical Associates, and I was honored to be one of 30 physicians and clinical and administrative leaders from across the nation selected to participate in this learning fellowship. I also believe the fellowship served a valuable purpose in giving us an opportunity to compare best practices for improving quality and challenging us to put these measures into practice.

As part of the program, participants formed teams to develop an action learning project. I was paired with two Tennessee participants – Barbara Martin, from the quality division of the Department of Surgery at Vanderbilt, and Chris Clarke, a senior vice president at Tennessee Hospital Association. Both of these ladies have tremendous experience and intelligence, and as a team we each brought a unique background and perspective. As an added benefit, the three of us have a five-year history of working together in the TSQC (Tennessee Surgical Quality Collaborative), a consortium of hospitals participating in the NSQIP (National Surgical Quality Improvement Program).

In putting together a project to help patients in Tennessee, our team devised the Colorectal SSI (surgical site infection) Reduction Project, aimed at reducing wound infections in colon surgery patients. Wound infections in colorectal surgery are very common and a significant cause of morbidity and added cost after surgery.

Based on lengthy literature review, we created a four-point bundle for the project, including: normothermia, tight glucose control, supplemental oxygen and proper prophylactic antibiotic selection. We considered other topics, but omitted some because there was less consensus about their potential benefit.

When our program launched in January 2012, it included 10 hospitals throughout the state that perform colorectal surgeries. The program is now being followed in 21 hospitals in 13 Tennessee cities and towns, including Memphis, Jackson, Nashville, Knoxville, Chattanooga and the Tri-Cities. Feedback from the hospitals has been mixed. Some hospitals overtly refuse to implement the protocol, some aggressively and enthusiastically implement it, and others show a more neutral response.

The patients studied will include all those who were entered in the TSQC database as cases abstracted through NSQIP. These number approximately 1,500 per year. We include all colon and rectal resections in the database, which includes about 28 different CPT codes. None are excluded. The study is likely to be published at some point, but the goal was not just to get data and publish. The underlying goal focuses on improvement in patient care, which will be an ongoing effort even if we find data that can be published.

At present, there are no preliminary figures available, as NSQIP data are generally reported on a 12-18 month lag. We do, however, have good baseline data for 2010 and 2011, and look forward to analyzing 2012 data later this year. It has been well documented that NSQIP as a whole is reducing costs and saving lives. While I cannot yet definitively say this for the colorectal wound reduction project, I am optimistic about its potential impact.

This project is the first “boots on the ground” effort from the TSQC to improve patient outcomes. Our collective NSQIP data have shown gradual improvement over the last three years, but we have not had an active performance improvement project before this. Nor have we had an explanation why our results are getting better other than the possibility of the Hawthorne effect.

This project has been slower and more difficult to implement than I expected, which has been an important lesson to me in terms of having realistic expectations about taking on projects of this magnitude. The majority of hospitals that are involved have been receptive, but this has been a lesson in the old adage that “all politics are local.” Surgeon leaders have had to navigate channels within their individual institutions to generate enthusiasm and buy-in for this project. It has been interesting to see the different approaches utilized.

The future of the TSQC looks very bright. We have strong leadership and an experienced core group that is committed to continuing to pursue better outcomes for patient care in our state. This Colorectal Wound Infection Reduction Project is intended to be the first of many projects to come out of this group.


William C. Gibson, MD, FACS, is a general surgeon at Premier Surgical Associates in Knoxville. He is board certified in general surgery by the American Board of Surgery and a fellow of the American College of Surgeons. For more information, visit www.premiersurgical.com.