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Reducing Surgical Site Infections in a Children’s Hospital: The Fuzzy Elements of Change
From the Hospital for Sick Children, Toronto, ON.
Abstract
- Objective: To describe the iterative and adaptive process used in implementing strategies to reduce surgical site infections (SSI) in a pediatric academic health science center.
- Methods: A multidisciplinary group was tasked with implementing strategies to reduce SSI with a focus on evaluating the use of a guideline for the use of prophylactic antibiotics and determining the rate of SSI.
- Results: The task force initially addressed surgical preparation solution, hair removal, oxygenation, and normothermia. The task force subsequently revised a guideline for the use of prophylactic antibiotics and implemented the guideline iteratively with multiple strategies including audit and feedback, communication and dissemination, and computerised order entry. The appropriate use of the guideline was associated with a 30% reduction in the rate of SSI.
- Conclusion: Using iterative and adaptive strategies over many years, the SSI rate was reduced by 30%.
Improving quality of care is a prime concern for clinicians, patients, families, and health systems [1]. Quality improvement methods are used widely in medicine for studying and addressing problems with care and have successfully addressed gaps in quality. The challenges include defining quality, obtaining complete and accurate data about quality, developing meaningful and cost-effective interventions to improve quality, and to successfully change clinician’s behaviour with commensurate improvement in quality of care.
Quality improvement in health care involves effecting and assessing change in a setting of complexity and uncertainty. Whereas the randomized trial may be used to measure the effectiveness of a particular treatment, quality improvement implementation involves an iterative and adaptive process in response to local events as the implementation proceeds [2]. These context-specific iterative changes to the implementation process are the fuzzy elements of change. This article describes a quality improvement initative to to reduce surgical site infections at an academic health science center with a focus on the fuzziness inherent in the process and our iterative responses to local events.
Setting
The Hospital for Sick Children (Sickkids) is a childrens’ academic health science center in Toronto, Ontario, Canada. The largest children’s hospital in Canada, with 8000 health care professionals, scientists, trainees, administrative and support staff, it has approximately 300 beds, 15,000 inpatient admissions, 12,000 surgical procedures, 70,000 emergency visits, and 300,000 outpatient visits annually. The hospital is a Level 1 trauma unit and performs the full spectrum of pediatric surgical care including transplant and cardiac procedures. The hospital and physician staffs are affiliated with the University of Toronto. The hospital has 16 theatre operating rooms, with 11 perioperative divisions and departments.
The departmental and divisional structure of the hospital, which emulates the university organizational structure, does not represent the size and level of clinical activity of the groups. For example, the department of otolaryngology, head and neck surgery has 5 surgeons whereas the division of orthopedics (as one of 6 divisions in the department of surgery) has 9 orthopedic surgeons. Furthermore, a divisional and departmental structure arguably does not match the institutional operational aims related to patient care delivery. Thus, in 2007 the 3 departments of surgery, the departments of critical care, anaesthesia and pain medicine, and dentistry were clustered together as “perioperative services,” reporting to a chief of perioperative services who in turn reported directly to the CEO. The chief of perioperative services, responsible for all operational issues, was concurrently the surgeon-in-chief.
Physicians at Sickkids are not paid fee-for-service. Each division/department receives compensation according to their specific speciality on a full-time equivalent (FTE) basis. While clinical and academic productivity is measured, physicians do not receive activity-based compensation. The perioperative service chiefs have primary responsibility for the clinical operations and academic activity. A perioperative care unit (POCU) executive has primarily responsibility for policy and financial oversight of the operating rooms.
As this was primarily a quality improvement initiative, we obtained institutional approval through that process.
Defining the Target for Quality improvement
To determine shared objectives for quality improvement, the surgeon-in-chief organized a daylong retreat in 2005 of all physicians (of the 11 divisions and departments that was later called perioperative services), nurses, and other disciplines involved in delivering surgical care. All scheduled clinics and OR activity were cancelled. The start and end of the retreat day matched the nursing day shift with a voluntary social event at the end. In the morning after meeting together, the 3 disciplines of nursing, surgery and anaesthesia met to discuss speciality-specific issues. In the afternoon, the 3 disciplines reconvened in small multidisciplinary groups of 8 to 10 individuals to discuss the objectives for improvement using the Institute of Medicine framework [1]. Outcomes of the small group discussions were presented to, and discussed by, the entire group, and those initiatives that achieved general endorsement were approved. A report summarising all recommendations arising from the day was widely circulated for comment. Recommendations were grouped, where appropriate, and assigned to task forces. Task forces were multidisciplinary groups co-led by 2 disciplines, with specific objectives arising from the retreat recommendations with measurable goals and a timeline of 12 to 18 months for completion of the recommendations.
The retreat of the perioperative services group recognized that many aspects of high quality care were hampered by variable diagnoses, comorbidities, and multiple and complex interventions with a critical lack of easily measured and cogent outcomes. The 4 areas that were relevant to all disciplines, most amenable to evaluation, and where significant quality gains were perceived to be necessary and possible were safety, perioperative pain, access to surgery, and surgical site infection (SSI). This paper reports on the SSI QI program.
Initial Task Force Work
An SSI task force initially addressed surgical preparation solution, hair clipping, oxygenation and normothermia. All razors were physically removed from the ORs and replaced by electric clippers. Multi-use proviodine preparation solution was replaced by single-use 70% isopropyl alcohol with 2% chlorhexidene (except for open wounds and neonates). Pilot studies of patients arriving in the POCU revealed that hypoxia was not an issue and normothermia was seldom an issue. Thereafter the prime focus shifted to the use of prophylactic antibiotics to reduce SSI.
Compliance with Antibiotic Prophylaxis Guideline
Guideline Update Process
A guideline for the use of prophylactic antibiotics to prevent SSI had been in place at Sickkids for many years. However, a chart review revealed only 40% of patients were receiving the correct drug, dose, duration, and time of administration relative to the incision, and few patients were receiving appropriate intraoperative top-ups [3]. In addition, the existing guideline was incomplete for all specialities and procedures, did not consider the issue of beta-lactam antibiotic allergy, and had no specific dosing for neonates. Therefore, the guideline needed to be updated and be more comprehensive before any attempts to increase compliance with the guideline was initiated. The infection control specialist and pharmacist reviewed evidence-based guidelines from the literature on adults to create a guideline comprehensive for speciality and procedure with specific dosing for neonates and alternative antibiotics for patients allergic to penicillin [3]. Updating the guidelines took almost a year.
The next step was to seek endorsement of all the surgical subspecialities. The guidelines were circulated to all specialities for comments. While a few specialists provided minor comments, as discussed further below, this step did not result in substantive feedback and again took almost a year.
The final guidelines were discussed at multiple meetings of the members of perioperative services and approved by the hospital drug and therapeutics committee. A date was set to introduce the new guideline and announced at departmental meetings, in emails, and on banners in the OR.
The revised guidelines replaced the old guidelines on the e-formulary. Hard copies were attached to the anaesthetic machine in each OR and the need for antibiotics was made part of the “time-out” before commencement of the procedure.
Early Monitoring of Guideline Use
To monitor the use of the guidelines, the use of an antibiotic and the timing related to the surgical incision became part of charting by nurses. Nurses charted many aspects of the surgical procedure through a surgical information management system (SIS, Alpharetta, GA). While documentation of the specific drug and dose was considered important information, the additional charting burden for nurses was considered to be too great. Thus the compromise was to chart if a drug was given and the time of administration to allow determination if the drug was given within an hour of the surgical incision.
Early results from monitoring of antibiotic administration revealed that drugs often were given well in advance of the 1-hour target. To address this issue, first, antibiotics given “on call to OR” was eliminated (because the duration from the call to go to the OR and until the surgical incision was never less than 1 hour) and thereafter all antibiotics were given in the OR. Second, due to prolonged anesthetic times prior to surgical start for complex cases, anesthetists changed their practise to give antibiotics as one of the final steps prior to start of surgery.
The next step was to monitor the use and timing of antibiotics by surgical division/department automatically using data from SIS. Concurrent with the efforts to improve the use of prophylactic antibiotic, a score card had been created to monitor quality and efficiency activities within perioperative services. The use and timing of prophylactic antibiotics became part of that monthly report. While the appropriate use of antibiotics improved over 6 months, a repeat audit revealed that compliance with the guideline for patients to receive, or not receive, antibiotics was only moderately improved [5]. Furthermore, whereas the guideline stated that antibiotics were needed only intra-operatively for the majority of procedures, antibiotics were extended postoperatively for periods ranging from 24 to 72 hours.
Addressing Compliance Issues
First, semi-annual mandatory lectures were presented to residents and fellows delineating the importance of the guidelines, with a specific focus on correct duration of antibiotics. Furthermore a “stop warning” was added to the computerized physician order entry system (orders are completed almost exclusively by house staff). In addition, we introduced an individual audit and feedback mechanism (see below).
Automated Audit and Feedback Process and Results
Each surgeon and anesthetist received an automated email the morning after the procedure detailing whether antibiotics had been indicated and whether they had been given or held appropriately. To accomplish this required that all surgical procedures (entered on SIS by the nurses) were matched to the guidelines. With the assistance of each division and department, each SIS procedural code was matched to the guideline as to whether antibiotics were indicated or not. In the case of multiple procedures, if any of the procedures warranted antibiotics then antibiotics were indicated for that patient. The automatic email sent to the staff acknowledged potential errors due to incorrect matching of the surgical procedure to guideline, incorrect charting by nurses, and incorrect indication of the guideline to receive (or not receive) antibiotics.
The response to this email had several impacts. First, the response identified many errors related to matching of SIS procedure to guidelines. Second, the email served as impetus to improve nurse charting. Third, through the automated emails we determined that some patients were on antibiotics for a pre-existing infection. Thus a separate notation in the SIS charting by the nursing staff was added to indicate a pre-existing infection (to prevent an automated email). Fourth, while circulation of the guidelines to all divisions and departments had provided little feedback to the final draft of guideline, responses to the emails resulted in refinement of ambiguities in guideline related to procedure description, and in some cases changes to the guideline based on the use of antibiotics. Fifth, the emails improved compliance with the guideline [3].
While audit and feedback resulted in a substantial rise in the appropriate use and timing of antibiotics, the nurses were often harassed about their charting, placing them in the uncomfortable position of seen to be enforcing the guideline. Also, some surgeons vehemently disliked the emails, pointing to occasional inaccuracies of the emails. Finally, the audit and feedback provided feedback after the surgical event, and while increasing attention on the guideline, did nothing for the individual patient. An alternative proposed strategy was that at the time of SIS charting of the procedure that SIS could serve as a decision tool and indicate whether antibiotics were indicated, and indicate the correct antibiotic. However SIS is proprietary software and we were unable to make the necessary programming changes.
Measuring SSI Rate
Concurrently with focusing on the process measures of the appropriate use of antibiotics, we also developed a mechanism to measure SSI [4]. Prior to this quality improvement initiative, the existing mechanism to measure institutional SSI was based on daily visits to surgical wards by infection control practitioners (ICPs) supplemented by identification of patients by positive wound cultures in microbiology. Due to the expense of active monitoring across all surgical disciplines, this program had been restricted to neurosurgery, cardiac surgery, and spine surgery (areas of high risk for SSI identified in the past). Because the hospital did not have the resources to expand ICP monitoring to all surgical areas, an alternative strategy of using health record coders was explored as a means to provide comprehensive rates of SSI for all disciplines.
The first step in using health records as a means to identify SSI was to perform a review of all SSIs identified by health records in the 3 priority areas monitored by the ICPs. All health records identified “SSI” were reviewed by a surgeon to determine which were and were not SSI, according to the Centers for Disease Control criteria [5]. The review identified that the International Classification of Disease (ICD−10) coding for SSI included, in addition to SSI, multiple types of infections such as sepsis and central line infections. The review also identified that the health record coders had no specific criteria and therefore were variable in how they coded “SSI.” The review identified that the ICPs missed some true infections that were identified by health record coders.
To address the ambiguity of ICD coding, extension codes to the ICD codes were added to code specifically for SSI. To address the lack of criteria for SSI, the health record coders were trained by ICPs to use Centers for Disease Control criteria for SSI [5]. While both of these steps improved the identification of SSI by health record coders, a subsequent chart audit identified false positive and false negative recording of SSI by both ICPs and health record coders. The task force accepted that no method was completely accurate and that health record coding for SSI was financially feasible and provided SSI rates for all surgical disciplines. The task force concluded that health record coding would serve the purpose of monitoring trends in SSIs.
Impact of Guideline Compliance
The final step in the quality improvement initiative of reducing SSI was to evaluate trends in use of prophylactic antibiotics and the relationship with SSI. Through the multiple iterative strategies described above, the administration of an antibiotic within an hour of the incision increased to over 80% of patients. To evaluate the impact of guideline compliance, approximately 9000 procedures were reviewed over a 21-month period [4]. In the approximately 4500 patients who had a guideline-based indication to receive antibiotics, the 80% who received correct administration of an antibiotic within 1 hour of the incision had a reduction in the rate of SSI by one third compared with the 20% who didn’t receive antibiotics. Of the approximately 4500 patients who did not have an indication for antibiotics, 80% did not receive antibiotics (20% did receive despite no indication) and had a (statistically insignificant) lower rate of SSI compared to the 20% who received antibiotics inappropriately. In summary, only 50% of children having surgery had an indication for antibiotics, and not receiving antibiotics saved money, reduced antibiotic exposure, and did not increase the rate of SSI. In the 50% of patients who received antibiotics according to the guidelines the rate of SSI was reduced by 30% [6].
Discussion
Duration of Project
The total duration of the Sickkids effort to measure and reduce the rate of SSI and thereby improve the quality of surgical care took almost 8 years. The duration, which ideally should have been about one quarter of that time, was due to multiple issues. First, there were many simultaneous competing demands to improve quality in other IOM domains such as safety and efficiency. Second, no one on the task force had protected time and thus meetings could be no more than monthly because people could not complete tasks in a shorter time frame. Third, many of the steps relied on wider physician involvement such as reviewing the revised guidelines. The physicians were slow to respond and only after all 9 surgical disciplines had signed off on the guidelines could implementation proceed. Finally, many of the important issues came up only after implementation of a specific step. For example, the recognition of the need for an individual audit and feedback mechanism created the need of mapping the procedures to guidelines to SIS procedures, a process that took more than a year to complete. Also the responses to the emails created the need for revisions to the guideline with subsequent delays for re-approval with hospital and IT support for eformulary changes.
Success Factors and Impediments
The factors that in retrospect seem critical to effecting positive change started with a general endorsement of the perioperative services group for improving quality and specifically SSI. The retreat and an open forum involving multiple disciplines was critical in creating a mandate for change. Second, the task force not only had multiple and key discipline representation for each aspect of the change management strategy, but the task force members were passionate about the importance of reducing SSI. Third, the multiple strategies used for change needed to be adaptive and iterative to new findings as they arose. While the task force attempted to anticipate barriers to change, only once the quality initiative started did the task force truly understand the barriers and respond in turn. Finally, the need for relentless energy by the leaders and task force was critical to seeing the project to completion.
While the appropriate use of antibiotics increased with a reduction in SSI, several aspects of this initiative were not successful. First, despite the surgeon-in-chief’s semi-annual lectures, this initiative did not successfully engage the majority of the house staff manifested by their continued habit of prescribing postoperative antibiotics for hours to days despite the guideline advice. Second, because nurses were tasked with asking about and recording the use of antibiotics, an unintended consequence was that they took the brunt of disgruntled physicians. Despite all our attempts, many nurses felt this initiative brought negative responses of physicians toward their charting duties. Third, while audit and feedback was an important strategy to improve guideline compliance, many physicians saw the daily emails in response to noncompliance with the guidelines as intrusive and irritating. Also we could not program SIS to make it a decision support in real time rather than documenting an event after the fact and, thereby, not enhancing care for that individual patient. Finally, we adopted a strategy of health record coding for SSI due to the prohibitive expenses of a comprehensive active monitoring strategies by ICPs.
Exportability
The strategies used in this quality improvement project to reduce SSI may be exportable to other hospitals with similar results. However, the emphasis on which element of change management strategy is most important would likely vary by context [2,6]. The elements most essential for success were a mechanism to develop group buy-in, a dedicated multidisciplinary task force with leader(s) with relentless commitment to achieving meaningful change, and a mechanism to evaluate both the process measures and the final outcome. The elements of change would vary by site and including consideration of the mechanism for physician compensation, commitment of physicians to institutional initiatives to enhance quality, and institutional resources to support quality initiatives.
None of the observed changes in this quality improvement initiative can be confidently attributed to any of the specific interventions. The interventions were completed in stages, but most importantly were constantly changed, emphasized and de-emphasized according to the responses. This is the fuzzy nature of change whereby leaders take reasonable steps to effect change but have to constantly adapt to barriers to change. While a specific change strategy generalizable to all contexts would be ideal, in the end at an institutional level, positive change is the ultimate aim rather than determining which interventions are effective. This response to events as they arise as illustrated in our quality improvement journey, is the fuzzy side of change management.
Conclusion
In conclusion, through a long period with a multitude of strategies, use of a guideline for prophylactic antibiotics increased and was associated with a reduction in SSI. Future directions need to consider cost-effective strategies to actively monitor SSI and testing of other strategies to reduce SSI. Institutions embarking on change need to consider that initiatives will likely need to adapt to specific contextual responses.
Corresponding author: James G. Wright, MD, PMH, FRCS, Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford Botnar Research Centre, Windmill Road, Oxford, OX3 7LD, UK, james.wright@ndorms.ox.ac.uk.
Funding/support: RB Salter Chair in Paediatric Surgical Research.
1. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press; 2001.
2. Grol R, Wensing M, Eccles M, Davis D, editors. Improving patient care: the implementation of change in health care. 2nd ed. Wiley Blackwell; 2013.
3. So JP, Aleem IS, Tsang DS, et al. Increasing compliance with an antibiotic prophylaxis guideline to prevent pediatric surgical site infection: before and after study. Ann Surg 2015;262:403–8.
4. Khoshbin A, So JP, Aleem IS, et al. Antibiotic prophylaxis to prevent surgical site infections in children: a prospective cohort study. Ann Surg 2015;262:397–402.
5. Mangram AJ, Horan TC, Pearson ML, et al. Guideline for prevention of surgical site infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. Am J Infect Control 1999;27:97–132.
6. Curran JA, Grimshaw JM, Hayden JA, Campbell B. Knowledge translation research: the science of moving research into policy and practice. J Contin Educ Health Prof 2011;31:174–80.
From the Hospital for Sick Children, Toronto, ON.
Abstract
- Objective: To describe the iterative and adaptive process used in implementing strategies to reduce surgical site infections (SSI) in a pediatric academic health science center.
- Methods: A multidisciplinary group was tasked with implementing strategies to reduce SSI with a focus on evaluating the use of a guideline for the use of prophylactic antibiotics and determining the rate of SSI.
- Results: The task force initially addressed surgical preparation solution, hair removal, oxygenation, and normothermia. The task force subsequently revised a guideline for the use of prophylactic antibiotics and implemented the guideline iteratively with multiple strategies including audit and feedback, communication and dissemination, and computerised order entry. The appropriate use of the guideline was associated with a 30% reduction in the rate of SSI.
- Conclusion: Using iterative and adaptive strategies over many years, the SSI rate was reduced by 30%.
Improving quality of care is a prime concern for clinicians, patients, families, and health systems [1]. Quality improvement methods are used widely in medicine for studying and addressing problems with care and have successfully addressed gaps in quality. The challenges include defining quality, obtaining complete and accurate data about quality, developing meaningful and cost-effective interventions to improve quality, and to successfully change clinician’s behaviour with commensurate improvement in quality of care.
Quality improvement in health care involves effecting and assessing change in a setting of complexity and uncertainty. Whereas the randomized trial may be used to measure the effectiveness of a particular treatment, quality improvement implementation involves an iterative and adaptive process in response to local events as the implementation proceeds [2]. These context-specific iterative changes to the implementation process are the fuzzy elements of change. This article describes a quality improvement initative to to reduce surgical site infections at an academic health science center with a focus on the fuzziness inherent in the process and our iterative responses to local events.
Setting
The Hospital for Sick Children (Sickkids) is a childrens’ academic health science center in Toronto, Ontario, Canada. The largest children’s hospital in Canada, with 8000 health care professionals, scientists, trainees, administrative and support staff, it has approximately 300 beds, 15,000 inpatient admissions, 12,000 surgical procedures, 70,000 emergency visits, and 300,000 outpatient visits annually. The hospital is a Level 1 trauma unit and performs the full spectrum of pediatric surgical care including transplant and cardiac procedures. The hospital and physician staffs are affiliated with the University of Toronto. The hospital has 16 theatre operating rooms, with 11 perioperative divisions and departments.
The departmental and divisional structure of the hospital, which emulates the university organizational structure, does not represent the size and level of clinical activity of the groups. For example, the department of otolaryngology, head and neck surgery has 5 surgeons whereas the division of orthopedics (as one of 6 divisions in the department of surgery) has 9 orthopedic surgeons. Furthermore, a divisional and departmental structure arguably does not match the institutional operational aims related to patient care delivery. Thus, in 2007 the 3 departments of surgery, the departments of critical care, anaesthesia and pain medicine, and dentistry were clustered together as “perioperative services,” reporting to a chief of perioperative services who in turn reported directly to the CEO. The chief of perioperative services, responsible for all operational issues, was concurrently the surgeon-in-chief.
Physicians at Sickkids are not paid fee-for-service. Each division/department receives compensation according to their specific speciality on a full-time equivalent (FTE) basis. While clinical and academic productivity is measured, physicians do not receive activity-based compensation. The perioperative service chiefs have primary responsibility for the clinical operations and academic activity. A perioperative care unit (POCU) executive has primarily responsibility for policy and financial oversight of the operating rooms.
As this was primarily a quality improvement initiative, we obtained institutional approval through that process.
Defining the Target for Quality improvement
To determine shared objectives for quality improvement, the surgeon-in-chief organized a daylong retreat in 2005 of all physicians (of the 11 divisions and departments that was later called perioperative services), nurses, and other disciplines involved in delivering surgical care. All scheduled clinics and OR activity were cancelled. The start and end of the retreat day matched the nursing day shift with a voluntary social event at the end. In the morning after meeting together, the 3 disciplines of nursing, surgery and anaesthesia met to discuss speciality-specific issues. In the afternoon, the 3 disciplines reconvened in small multidisciplinary groups of 8 to 10 individuals to discuss the objectives for improvement using the Institute of Medicine framework [1]. Outcomes of the small group discussions were presented to, and discussed by, the entire group, and those initiatives that achieved general endorsement were approved. A report summarising all recommendations arising from the day was widely circulated for comment. Recommendations were grouped, where appropriate, and assigned to task forces. Task forces were multidisciplinary groups co-led by 2 disciplines, with specific objectives arising from the retreat recommendations with measurable goals and a timeline of 12 to 18 months for completion of the recommendations.
The retreat of the perioperative services group recognized that many aspects of high quality care were hampered by variable diagnoses, comorbidities, and multiple and complex interventions with a critical lack of easily measured and cogent outcomes. The 4 areas that were relevant to all disciplines, most amenable to evaluation, and where significant quality gains were perceived to be necessary and possible were safety, perioperative pain, access to surgery, and surgical site infection (SSI). This paper reports on the SSI QI program.
Initial Task Force Work
An SSI task force initially addressed surgical preparation solution, hair clipping, oxygenation and normothermia. All razors were physically removed from the ORs and replaced by electric clippers. Multi-use proviodine preparation solution was replaced by single-use 70% isopropyl alcohol with 2% chlorhexidene (except for open wounds and neonates). Pilot studies of patients arriving in the POCU revealed that hypoxia was not an issue and normothermia was seldom an issue. Thereafter the prime focus shifted to the use of prophylactic antibiotics to reduce SSI.
Compliance with Antibiotic Prophylaxis Guideline
Guideline Update Process
A guideline for the use of prophylactic antibiotics to prevent SSI had been in place at Sickkids for many years. However, a chart review revealed only 40% of patients were receiving the correct drug, dose, duration, and time of administration relative to the incision, and few patients were receiving appropriate intraoperative top-ups [3]. In addition, the existing guideline was incomplete for all specialities and procedures, did not consider the issue of beta-lactam antibiotic allergy, and had no specific dosing for neonates. Therefore, the guideline needed to be updated and be more comprehensive before any attempts to increase compliance with the guideline was initiated. The infection control specialist and pharmacist reviewed evidence-based guidelines from the literature on adults to create a guideline comprehensive for speciality and procedure with specific dosing for neonates and alternative antibiotics for patients allergic to penicillin [3]. Updating the guidelines took almost a year.
The next step was to seek endorsement of all the surgical subspecialities. The guidelines were circulated to all specialities for comments. While a few specialists provided minor comments, as discussed further below, this step did not result in substantive feedback and again took almost a year.
The final guidelines were discussed at multiple meetings of the members of perioperative services and approved by the hospital drug and therapeutics committee. A date was set to introduce the new guideline and announced at departmental meetings, in emails, and on banners in the OR.
The revised guidelines replaced the old guidelines on the e-formulary. Hard copies were attached to the anaesthetic machine in each OR and the need for antibiotics was made part of the “time-out” before commencement of the procedure.
Early Monitoring of Guideline Use
To monitor the use of the guidelines, the use of an antibiotic and the timing related to the surgical incision became part of charting by nurses. Nurses charted many aspects of the surgical procedure through a surgical information management system (SIS, Alpharetta, GA). While documentation of the specific drug and dose was considered important information, the additional charting burden for nurses was considered to be too great. Thus the compromise was to chart if a drug was given and the time of administration to allow determination if the drug was given within an hour of the surgical incision.
Early results from monitoring of antibiotic administration revealed that drugs often were given well in advance of the 1-hour target. To address this issue, first, antibiotics given “on call to OR” was eliminated (because the duration from the call to go to the OR and until the surgical incision was never less than 1 hour) and thereafter all antibiotics were given in the OR. Second, due to prolonged anesthetic times prior to surgical start for complex cases, anesthetists changed their practise to give antibiotics as one of the final steps prior to start of surgery.
The next step was to monitor the use and timing of antibiotics by surgical division/department automatically using data from SIS. Concurrent with the efforts to improve the use of prophylactic antibiotic, a score card had been created to monitor quality and efficiency activities within perioperative services. The use and timing of prophylactic antibiotics became part of that monthly report. While the appropriate use of antibiotics improved over 6 months, a repeat audit revealed that compliance with the guideline for patients to receive, or not receive, antibiotics was only moderately improved [5]. Furthermore, whereas the guideline stated that antibiotics were needed only intra-operatively for the majority of procedures, antibiotics were extended postoperatively for periods ranging from 24 to 72 hours.
Addressing Compliance Issues
First, semi-annual mandatory lectures were presented to residents and fellows delineating the importance of the guidelines, with a specific focus on correct duration of antibiotics. Furthermore a “stop warning” was added to the computerized physician order entry system (orders are completed almost exclusively by house staff). In addition, we introduced an individual audit and feedback mechanism (see below).
Automated Audit and Feedback Process and Results
Each surgeon and anesthetist received an automated email the morning after the procedure detailing whether antibiotics had been indicated and whether they had been given or held appropriately. To accomplish this required that all surgical procedures (entered on SIS by the nurses) were matched to the guidelines. With the assistance of each division and department, each SIS procedural code was matched to the guideline as to whether antibiotics were indicated or not. In the case of multiple procedures, if any of the procedures warranted antibiotics then antibiotics were indicated for that patient. The automatic email sent to the staff acknowledged potential errors due to incorrect matching of the surgical procedure to guideline, incorrect charting by nurses, and incorrect indication of the guideline to receive (or not receive) antibiotics.
The response to this email had several impacts. First, the response identified many errors related to matching of SIS procedure to guidelines. Second, the email served as impetus to improve nurse charting. Third, through the automated emails we determined that some patients were on antibiotics for a pre-existing infection. Thus a separate notation in the SIS charting by the nursing staff was added to indicate a pre-existing infection (to prevent an automated email). Fourth, while circulation of the guidelines to all divisions and departments had provided little feedback to the final draft of guideline, responses to the emails resulted in refinement of ambiguities in guideline related to procedure description, and in some cases changes to the guideline based on the use of antibiotics. Fifth, the emails improved compliance with the guideline [3].
While audit and feedback resulted in a substantial rise in the appropriate use and timing of antibiotics, the nurses were often harassed about their charting, placing them in the uncomfortable position of seen to be enforcing the guideline. Also, some surgeons vehemently disliked the emails, pointing to occasional inaccuracies of the emails. Finally, the audit and feedback provided feedback after the surgical event, and while increasing attention on the guideline, did nothing for the individual patient. An alternative proposed strategy was that at the time of SIS charting of the procedure that SIS could serve as a decision tool and indicate whether antibiotics were indicated, and indicate the correct antibiotic. However SIS is proprietary software and we were unable to make the necessary programming changes.
Measuring SSI Rate
Concurrently with focusing on the process measures of the appropriate use of antibiotics, we also developed a mechanism to measure SSI [4]. Prior to this quality improvement initiative, the existing mechanism to measure institutional SSI was based on daily visits to surgical wards by infection control practitioners (ICPs) supplemented by identification of patients by positive wound cultures in microbiology. Due to the expense of active monitoring across all surgical disciplines, this program had been restricted to neurosurgery, cardiac surgery, and spine surgery (areas of high risk for SSI identified in the past). Because the hospital did not have the resources to expand ICP monitoring to all surgical areas, an alternative strategy of using health record coders was explored as a means to provide comprehensive rates of SSI for all disciplines.
The first step in using health records as a means to identify SSI was to perform a review of all SSIs identified by health records in the 3 priority areas monitored by the ICPs. All health records identified “SSI” were reviewed by a surgeon to determine which were and were not SSI, according to the Centers for Disease Control criteria [5]. The review identified that the International Classification of Disease (ICD−10) coding for SSI included, in addition to SSI, multiple types of infections such as sepsis and central line infections. The review also identified that the health record coders had no specific criteria and therefore were variable in how they coded “SSI.” The review identified that the ICPs missed some true infections that were identified by health record coders.
To address the ambiguity of ICD coding, extension codes to the ICD codes were added to code specifically for SSI. To address the lack of criteria for SSI, the health record coders were trained by ICPs to use Centers for Disease Control criteria for SSI [5]. While both of these steps improved the identification of SSI by health record coders, a subsequent chart audit identified false positive and false negative recording of SSI by both ICPs and health record coders. The task force accepted that no method was completely accurate and that health record coding for SSI was financially feasible and provided SSI rates for all surgical disciplines. The task force concluded that health record coding would serve the purpose of monitoring trends in SSIs.
Impact of Guideline Compliance
The final step in the quality improvement initiative of reducing SSI was to evaluate trends in use of prophylactic antibiotics and the relationship with SSI. Through the multiple iterative strategies described above, the administration of an antibiotic within an hour of the incision increased to over 80% of patients. To evaluate the impact of guideline compliance, approximately 9000 procedures were reviewed over a 21-month period [4]. In the approximately 4500 patients who had a guideline-based indication to receive antibiotics, the 80% who received correct administration of an antibiotic within 1 hour of the incision had a reduction in the rate of SSI by one third compared with the 20% who didn’t receive antibiotics. Of the approximately 4500 patients who did not have an indication for antibiotics, 80% did not receive antibiotics (20% did receive despite no indication) and had a (statistically insignificant) lower rate of SSI compared to the 20% who received antibiotics inappropriately. In summary, only 50% of children having surgery had an indication for antibiotics, and not receiving antibiotics saved money, reduced antibiotic exposure, and did not increase the rate of SSI. In the 50% of patients who received antibiotics according to the guidelines the rate of SSI was reduced by 30% [6].
Discussion
Duration of Project
The total duration of the Sickkids effort to measure and reduce the rate of SSI and thereby improve the quality of surgical care took almost 8 years. The duration, which ideally should have been about one quarter of that time, was due to multiple issues. First, there were many simultaneous competing demands to improve quality in other IOM domains such as safety and efficiency. Second, no one on the task force had protected time and thus meetings could be no more than monthly because people could not complete tasks in a shorter time frame. Third, many of the steps relied on wider physician involvement such as reviewing the revised guidelines. The physicians were slow to respond and only after all 9 surgical disciplines had signed off on the guidelines could implementation proceed. Finally, many of the important issues came up only after implementation of a specific step. For example, the recognition of the need for an individual audit and feedback mechanism created the need of mapping the procedures to guidelines to SIS procedures, a process that took more than a year to complete. Also the responses to the emails created the need for revisions to the guideline with subsequent delays for re-approval with hospital and IT support for eformulary changes.
Success Factors and Impediments
The factors that in retrospect seem critical to effecting positive change started with a general endorsement of the perioperative services group for improving quality and specifically SSI. The retreat and an open forum involving multiple disciplines was critical in creating a mandate for change. Second, the task force not only had multiple and key discipline representation for each aspect of the change management strategy, but the task force members were passionate about the importance of reducing SSI. Third, the multiple strategies used for change needed to be adaptive and iterative to new findings as they arose. While the task force attempted to anticipate barriers to change, only once the quality initiative started did the task force truly understand the barriers and respond in turn. Finally, the need for relentless energy by the leaders and task force was critical to seeing the project to completion.
While the appropriate use of antibiotics increased with a reduction in SSI, several aspects of this initiative were not successful. First, despite the surgeon-in-chief’s semi-annual lectures, this initiative did not successfully engage the majority of the house staff manifested by their continued habit of prescribing postoperative antibiotics for hours to days despite the guideline advice. Second, because nurses were tasked with asking about and recording the use of antibiotics, an unintended consequence was that they took the brunt of disgruntled physicians. Despite all our attempts, many nurses felt this initiative brought negative responses of physicians toward their charting duties. Third, while audit and feedback was an important strategy to improve guideline compliance, many physicians saw the daily emails in response to noncompliance with the guidelines as intrusive and irritating. Also we could not program SIS to make it a decision support in real time rather than documenting an event after the fact and, thereby, not enhancing care for that individual patient. Finally, we adopted a strategy of health record coding for SSI due to the prohibitive expenses of a comprehensive active monitoring strategies by ICPs.
Exportability
The strategies used in this quality improvement project to reduce SSI may be exportable to other hospitals with similar results. However, the emphasis on which element of change management strategy is most important would likely vary by context [2,6]. The elements most essential for success were a mechanism to develop group buy-in, a dedicated multidisciplinary task force with leader(s) with relentless commitment to achieving meaningful change, and a mechanism to evaluate both the process measures and the final outcome. The elements of change would vary by site and including consideration of the mechanism for physician compensation, commitment of physicians to institutional initiatives to enhance quality, and institutional resources to support quality initiatives.
None of the observed changes in this quality improvement initiative can be confidently attributed to any of the specific interventions. The interventions were completed in stages, but most importantly were constantly changed, emphasized and de-emphasized according to the responses. This is the fuzzy nature of change whereby leaders take reasonable steps to effect change but have to constantly adapt to barriers to change. While a specific change strategy generalizable to all contexts would be ideal, in the end at an institutional level, positive change is the ultimate aim rather than determining which interventions are effective. This response to events as they arise as illustrated in our quality improvement journey, is the fuzzy side of change management.
Conclusion
In conclusion, through a long period with a multitude of strategies, use of a guideline for prophylactic antibiotics increased and was associated with a reduction in SSI. Future directions need to consider cost-effective strategies to actively monitor SSI and testing of other strategies to reduce SSI. Institutions embarking on change need to consider that initiatives will likely need to adapt to specific contextual responses.
Corresponding author: James G. Wright, MD, PMH, FRCS, Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford Botnar Research Centre, Windmill Road, Oxford, OX3 7LD, UK, james.wright@ndorms.ox.ac.uk.
Funding/support: RB Salter Chair in Paediatric Surgical Research.
From the Hospital for Sick Children, Toronto, ON.
Abstract
- Objective: To describe the iterative and adaptive process used in implementing strategies to reduce surgical site infections (SSI) in a pediatric academic health science center.
- Methods: A multidisciplinary group was tasked with implementing strategies to reduce SSI with a focus on evaluating the use of a guideline for the use of prophylactic antibiotics and determining the rate of SSI.
- Results: The task force initially addressed surgical preparation solution, hair removal, oxygenation, and normothermia. The task force subsequently revised a guideline for the use of prophylactic antibiotics and implemented the guideline iteratively with multiple strategies including audit and feedback, communication and dissemination, and computerised order entry. The appropriate use of the guideline was associated with a 30% reduction in the rate of SSI.
- Conclusion: Using iterative and adaptive strategies over many years, the SSI rate was reduced by 30%.
Improving quality of care is a prime concern for clinicians, patients, families, and health systems [1]. Quality improvement methods are used widely in medicine for studying and addressing problems with care and have successfully addressed gaps in quality. The challenges include defining quality, obtaining complete and accurate data about quality, developing meaningful and cost-effective interventions to improve quality, and to successfully change clinician’s behaviour with commensurate improvement in quality of care.
Quality improvement in health care involves effecting and assessing change in a setting of complexity and uncertainty. Whereas the randomized trial may be used to measure the effectiveness of a particular treatment, quality improvement implementation involves an iterative and adaptive process in response to local events as the implementation proceeds [2]. These context-specific iterative changes to the implementation process are the fuzzy elements of change. This article describes a quality improvement initative to to reduce surgical site infections at an academic health science center with a focus on the fuzziness inherent in the process and our iterative responses to local events.
Setting
The Hospital for Sick Children (Sickkids) is a childrens’ academic health science center in Toronto, Ontario, Canada. The largest children’s hospital in Canada, with 8000 health care professionals, scientists, trainees, administrative and support staff, it has approximately 300 beds, 15,000 inpatient admissions, 12,000 surgical procedures, 70,000 emergency visits, and 300,000 outpatient visits annually. The hospital is a Level 1 trauma unit and performs the full spectrum of pediatric surgical care including transplant and cardiac procedures. The hospital and physician staffs are affiliated with the University of Toronto. The hospital has 16 theatre operating rooms, with 11 perioperative divisions and departments.
The departmental and divisional structure of the hospital, which emulates the university organizational structure, does not represent the size and level of clinical activity of the groups. For example, the department of otolaryngology, head and neck surgery has 5 surgeons whereas the division of orthopedics (as one of 6 divisions in the department of surgery) has 9 orthopedic surgeons. Furthermore, a divisional and departmental structure arguably does not match the institutional operational aims related to patient care delivery. Thus, in 2007 the 3 departments of surgery, the departments of critical care, anaesthesia and pain medicine, and dentistry were clustered together as “perioperative services,” reporting to a chief of perioperative services who in turn reported directly to the CEO. The chief of perioperative services, responsible for all operational issues, was concurrently the surgeon-in-chief.
Physicians at Sickkids are not paid fee-for-service. Each division/department receives compensation according to their specific speciality on a full-time equivalent (FTE) basis. While clinical and academic productivity is measured, physicians do not receive activity-based compensation. The perioperative service chiefs have primary responsibility for the clinical operations and academic activity. A perioperative care unit (POCU) executive has primarily responsibility for policy and financial oversight of the operating rooms.
As this was primarily a quality improvement initiative, we obtained institutional approval through that process.
Defining the Target for Quality improvement
To determine shared objectives for quality improvement, the surgeon-in-chief organized a daylong retreat in 2005 of all physicians (of the 11 divisions and departments that was later called perioperative services), nurses, and other disciplines involved in delivering surgical care. All scheduled clinics and OR activity were cancelled. The start and end of the retreat day matched the nursing day shift with a voluntary social event at the end. In the morning after meeting together, the 3 disciplines of nursing, surgery and anaesthesia met to discuss speciality-specific issues. In the afternoon, the 3 disciplines reconvened in small multidisciplinary groups of 8 to 10 individuals to discuss the objectives for improvement using the Institute of Medicine framework [1]. Outcomes of the small group discussions were presented to, and discussed by, the entire group, and those initiatives that achieved general endorsement were approved. A report summarising all recommendations arising from the day was widely circulated for comment. Recommendations were grouped, where appropriate, and assigned to task forces. Task forces were multidisciplinary groups co-led by 2 disciplines, with specific objectives arising from the retreat recommendations with measurable goals and a timeline of 12 to 18 months for completion of the recommendations.
The retreat of the perioperative services group recognized that many aspects of high quality care were hampered by variable diagnoses, comorbidities, and multiple and complex interventions with a critical lack of easily measured and cogent outcomes. The 4 areas that were relevant to all disciplines, most amenable to evaluation, and where significant quality gains were perceived to be necessary and possible were safety, perioperative pain, access to surgery, and surgical site infection (SSI). This paper reports on the SSI QI program.
Initial Task Force Work
An SSI task force initially addressed surgical preparation solution, hair clipping, oxygenation and normothermia. All razors were physically removed from the ORs and replaced by electric clippers. Multi-use proviodine preparation solution was replaced by single-use 70% isopropyl alcohol with 2% chlorhexidene (except for open wounds and neonates). Pilot studies of patients arriving in the POCU revealed that hypoxia was not an issue and normothermia was seldom an issue. Thereafter the prime focus shifted to the use of prophylactic antibiotics to reduce SSI.
Compliance with Antibiotic Prophylaxis Guideline
Guideline Update Process
A guideline for the use of prophylactic antibiotics to prevent SSI had been in place at Sickkids for many years. However, a chart review revealed only 40% of patients were receiving the correct drug, dose, duration, and time of administration relative to the incision, and few patients were receiving appropriate intraoperative top-ups [3]. In addition, the existing guideline was incomplete for all specialities and procedures, did not consider the issue of beta-lactam antibiotic allergy, and had no specific dosing for neonates. Therefore, the guideline needed to be updated and be more comprehensive before any attempts to increase compliance with the guideline was initiated. The infection control specialist and pharmacist reviewed evidence-based guidelines from the literature on adults to create a guideline comprehensive for speciality and procedure with specific dosing for neonates and alternative antibiotics for patients allergic to penicillin [3]. Updating the guidelines took almost a year.
The next step was to seek endorsement of all the surgical subspecialities. The guidelines were circulated to all specialities for comments. While a few specialists provided minor comments, as discussed further below, this step did not result in substantive feedback and again took almost a year.
The final guidelines were discussed at multiple meetings of the members of perioperative services and approved by the hospital drug and therapeutics committee. A date was set to introduce the new guideline and announced at departmental meetings, in emails, and on banners in the OR.
The revised guidelines replaced the old guidelines on the e-formulary. Hard copies were attached to the anaesthetic machine in each OR and the need for antibiotics was made part of the “time-out” before commencement of the procedure.
Early Monitoring of Guideline Use
To monitor the use of the guidelines, the use of an antibiotic and the timing related to the surgical incision became part of charting by nurses. Nurses charted many aspects of the surgical procedure through a surgical information management system (SIS, Alpharetta, GA). While documentation of the specific drug and dose was considered important information, the additional charting burden for nurses was considered to be too great. Thus the compromise was to chart if a drug was given and the time of administration to allow determination if the drug was given within an hour of the surgical incision.
Early results from monitoring of antibiotic administration revealed that drugs often were given well in advance of the 1-hour target. To address this issue, first, antibiotics given “on call to OR” was eliminated (because the duration from the call to go to the OR and until the surgical incision was never less than 1 hour) and thereafter all antibiotics were given in the OR. Second, due to prolonged anesthetic times prior to surgical start for complex cases, anesthetists changed their practise to give antibiotics as one of the final steps prior to start of surgery.
The next step was to monitor the use and timing of antibiotics by surgical division/department automatically using data from SIS. Concurrent with the efforts to improve the use of prophylactic antibiotic, a score card had been created to monitor quality and efficiency activities within perioperative services. The use and timing of prophylactic antibiotics became part of that monthly report. While the appropriate use of antibiotics improved over 6 months, a repeat audit revealed that compliance with the guideline for patients to receive, or not receive, antibiotics was only moderately improved [5]. Furthermore, whereas the guideline stated that antibiotics were needed only intra-operatively for the majority of procedures, antibiotics were extended postoperatively for periods ranging from 24 to 72 hours.
Addressing Compliance Issues
First, semi-annual mandatory lectures were presented to residents and fellows delineating the importance of the guidelines, with a specific focus on correct duration of antibiotics. Furthermore a “stop warning” was added to the computerized physician order entry system (orders are completed almost exclusively by house staff). In addition, we introduced an individual audit and feedback mechanism (see below).
Automated Audit and Feedback Process and Results
Each surgeon and anesthetist received an automated email the morning after the procedure detailing whether antibiotics had been indicated and whether they had been given or held appropriately. To accomplish this required that all surgical procedures (entered on SIS by the nurses) were matched to the guidelines. With the assistance of each division and department, each SIS procedural code was matched to the guideline as to whether antibiotics were indicated or not. In the case of multiple procedures, if any of the procedures warranted antibiotics then antibiotics were indicated for that patient. The automatic email sent to the staff acknowledged potential errors due to incorrect matching of the surgical procedure to guideline, incorrect charting by nurses, and incorrect indication of the guideline to receive (or not receive) antibiotics.
The response to this email had several impacts. First, the response identified many errors related to matching of SIS procedure to guidelines. Second, the email served as impetus to improve nurse charting. Third, through the automated emails we determined that some patients were on antibiotics for a pre-existing infection. Thus a separate notation in the SIS charting by the nursing staff was added to indicate a pre-existing infection (to prevent an automated email). Fourth, while circulation of the guidelines to all divisions and departments had provided little feedback to the final draft of guideline, responses to the emails resulted in refinement of ambiguities in guideline related to procedure description, and in some cases changes to the guideline based on the use of antibiotics. Fifth, the emails improved compliance with the guideline [3].
While audit and feedback resulted in a substantial rise in the appropriate use and timing of antibiotics, the nurses were often harassed about their charting, placing them in the uncomfortable position of seen to be enforcing the guideline. Also, some surgeons vehemently disliked the emails, pointing to occasional inaccuracies of the emails. Finally, the audit and feedback provided feedback after the surgical event, and while increasing attention on the guideline, did nothing for the individual patient. An alternative proposed strategy was that at the time of SIS charting of the procedure that SIS could serve as a decision tool and indicate whether antibiotics were indicated, and indicate the correct antibiotic. However SIS is proprietary software and we were unable to make the necessary programming changes.
Measuring SSI Rate
Concurrently with focusing on the process measures of the appropriate use of antibiotics, we also developed a mechanism to measure SSI [4]. Prior to this quality improvement initiative, the existing mechanism to measure institutional SSI was based on daily visits to surgical wards by infection control practitioners (ICPs) supplemented by identification of patients by positive wound cultures in microbiology. Due to the expense of active monitoring across all surgical disciplines, this program had been restricted to neurosurgery, cardiac surgery, and spine surgery (areas of high risk for SSI identified in the past). Because the hospital did not have the resources to expand ICP monitoring to all surgical areas, an alternative strategy of using health record coders was explored as a means to provide comprehensive rates of SSI for all disciplines.
The first step in using health records as a means to identify SSI was to perform a review of all SSIs identified by health records in the 3 priority areas monitored by the ICPs. All health records identified “SSI” were reviewed by a surgeon to determine which were and were not SSI, according to the Centers for Disease Control criteria [5]. The review identified that the International Classification of Disease (ICD−10) coding for SSI included, in addition to SSI, multiple types of infections such as sepsis and central line infections. The review also identified that the health record coders had no specific criteria and therefore were variable in how they coded “SSI.” The review identified that the ICPs missed some true infections that were identified by health record coders.
To address the ambiguity of ICD coding, extension codes to the ICD codes were added to code specifically for SSI. To address the lack of criteria for SSI, the health record coders were trained by ICPs to use Centers for Disease Control criteria for SSI [5]. While both of these steps improved the identification of SSI by health record coders, a subsequent chart audit identified false positive and false negative recording of SSI by both ICPs and health record coders. The task force accepted that no method was completely accurate and that health record coding for SSI was financially feasible and provided SSI rates for all surgical disciplines. The task force concluded that health record coding would serve the purpose of monitoring trends in SSIs.
Impact of Guideline Compliance
The final step in the quality improvement initiative of reducing SSI was to evaluate trends in use of prophylactic antibiotics and the relationship with SSI. Through the multiple iterative strategies described above, the administration of an antibiotic within an hour of the incision increased to over 80% of patients. To evaluate the impact of guideline compliance, approximately 9000 procedures were reviewed over a 21-month period [4]. In the approximately 4500 patients who had a guideline-based indication to receive antibiotics, the 80% who received correct administration of an antibiotic within 1 hour of the incision had a reduction in the rate of SSI by one third compared with the 20% who didn’t receive antibiotics. Of the approximately 4500 patients who did not have an indication for antibiotics, 80% did not receive antibiotics (20% did receive despite no indication) and had a (statistically insignificant) lower rate of SSI compared to the 20% who received antibiotics inappropriately. In summary, only 50% of children having surgery had an indication for antibiotics, and not receiving antibiotics saved money, reduced antibiotic exposure, and did not increase the rate of SSI. In the 50% of patients who received antibiotics according to the guidelines the rate of SSI was reduced by 30% [6].
Discussion
Duration of Project
The total duration of the Sickkids effort to measure and reduce the rate of SSI and thereby improve the quality of surgical care took almost 8 years. The duration, which ideally should have been about one quarter of that time, was due to multiple issues. First, there were many simultaneous competing demands to improve quality in other IOM domains such as safety and efficiency. Second, no one on the task force had protected time and thus meetings could be no more than monthly because people could not complete tasks in a shorter time frame. Third, many of the steps relied on wider physician involvement such as reviewing the revised guidelines. The physicians were slow to respond and only after all 9 surgical disciplines had signed off on the guidelines could implementation proceed. Finally, many of the important issues came up only after implementation of a specific step. For example, the recognition of the need for an individual audit and feedback mechanism created the need of mapping the procedures to guidelines to SIS procedures, a process that took more than a year to complete. Also the responses to the emails created the need for revisions to the guideline with subsequent delays for re-approval with hospital and IT support for eformulary changes.
Success Factors and Impediments
The factors that in retrospect seem critical to effecting positive change started with a general endorsement of the perioperative services group for improving quality and specifically SSI. The retreat and an open forum involving multiple disciplines was critical in creating a mandate for change. Second, the task force not only had multiple and key discipline representation for each aspect of the change management strategy, but the task force members were passionate about the importance of reducing SSI. Third, the multiple strategies used for change needed to be adaptive and iterative to new findings as they arose. While the task force attempted to anticipate barriers to change, only once the quality initiative started did the task force truly understand the barriers and respond in turn. Finally, the need for relentless energy by the leaders and task force was critical to seeing the project to completion.
While the appropriate use of antibiotics increased with a reduction in SSI, several aspects of this initiative were not successful. First, despite the surgeon-in-chief’s semi-annual lectures, this initiative did not successfully engage the majority of the house staff manifested by their continued habit of prescribing postoperative antibiotics for hours to days despite the guideline advice. Second, because nurses were tasked with asking about and recording the use of antibiotics, an unintended consequence was that they took the brunt of disgruntled physicians. Despite all our attempts, many nurses felt this initiative brought negative responses of physicians toward their charting duties. Third, while audit and feedback was an important strategy to improve guideline compliance, many physicians saw the daily emails in response to noncompliance with the guidelines as intrusive and irritating. Also we could not program SIS to make it a decision support in real time rather than documenting an event after the fact and, thereby, not enhancing care for that individual patient. Finally, we adopted a strategy of health record coding for SSI due to the prohibitive expenses of a comprehensive active monitoring strategies by ICPs.
Exportability
The strategies used in this quality improvement project to reduce SSI may be exportable to other hospitals with similar results. However, the emphasis on which element of change management strategy is most important would likely vary by context [2,6]. The elements most essential for success were a mechanism to develop group buy-in, a dedicated multidisciplinary task force with leader(s) with relentless commitment to achieving meaningful change, and a mechanism to evaluate both the process measures and the final outcome. The elements of change would vary by site and including consideration of the mechanism for physician compensation, commitment of physicians to institutional initiatives to enhance quality, and institutional resources to support quality initiatives.
None of the observed changes in this quality improvement initiative can be confidently attributed to any of the specific interventions. The interventions were completed in stages, but most importantly were constantly changed, emphasized and de-emphasized according to the responses. This is the fuzzy nature of change whereby leaders take reasonable steps to effect change but have to constantly adapt to barriers to change. While a specific change strategy generalizable to all contexts would be ideal, in the end at an institutional level, positive change is the ultimate aim rather than determining which interventions are effective. This response to events as they arise as illustrated in our quality improvement journey, is the fuzzy side of change management.
Conclusion
In conclusion, through a long period with a multitude of strategies, use of a guideline for prophylactic antibiotics increased and was associated with a reduction in SSI. Future directions need to consider cost-effective strategies to actively monitor SSI and testing of other strategies to reduce SSI. Institutions embarking on change need to consider that initiatives will likely need to adapt to specific contextual responses.
Corresponding author: James G. Wright, MD, PMH, FRCS, Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford Botnar Research Centre, Windmill Road, Oxford, OX3 7LD, UK, james.wright@ndorms.ox.ac.uk.
Funding/support: RB Salter Chair in Paediatric Surgical Research.
1. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press; 2001.
2. Grol R, Wensing M, Eccles M, Davis D, editors. Improving patient care: the implementation of change in health care. 2nd ed. Wiley Blackwell; 2013.
3. So JP, Aleem IS, Tsang DS, et al. Increasing compliance with an antibiotic prophylaxis guideline to prevent pediatric surgical site infection: before and after study. Ann Surg 2015;262:403–8.
4. Khoshbin A, So JP, Aleem IS, et al. Antibiotic prophylaxis to prevent surgical site infections in children: a prospective cohort study. Ann Surg 2015;262:397–402.
5. Mangram AJ, Horan TC, Pearson ML, et al. Guideline for prevention of surgical site infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. Am J Infect Control 1999;27:97–132.
6. Curran JA, Grimshaw JM, Hayden JA, Campbell B. Knowledge translation research: the science of moving research into policy and practice. J Contin Educ Health Prof 2011;31:174–80.
1. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press; 2001.
2. Grol R, Wensing M, Eccles M, Davis D, editors. Improving patient care: the implementation of change in health care. 2nd ed. Wiley Blackwell; 2013.
3. So JP, Aleem IS, Tsang DS, et al. Increasing compliance with an antibiotic prophylaxis guideline to prevent pediatric surgical site infection: before and after study. Ann Surg 2015;262:403–8.
4. Khoshbin A, So JP, Aleem IS, et al. Antibiotic prophylaxis to prevent surgical site infections in children: a prospective cohort study. Ann Surg 2015;262:397–402.
5. Mangram AJ, Horan TC, Pearson ML, et al. Guideline for prevention of surgical site infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. Am J Infect Control 1999;27:97–132.
6. Curran JA, Grimshaw JM, Hayden JA, Campbell B. Knowledge translation research: the science of moving research into policy and practice. J Contin Educ Health Prof 2011;31:174–80.