Surgical site infections (SSIs) cost an estimated $27,288 per case. An analysis of the National Surgical Quality Improvement Program data at the University of Rochester Medical Center suggested that rates of SSIs could be lowered in comparison with both peers and baseline. The aim of this study was to reduce the number of SSIs to zero through the implementation of a "bundle" or a combination of practices. Meetings were held with the multidisciplinary care team that includes surgeons and staff from pediatric pharmacy, pediatric infectious diseases, anesthesia, and nursing to create a care bundle for all pediatric orthopaedic surgery patients. Bundle elements included use of chlorhexidine gluconate wipes the night before surgery and the day of surgery, use of preoperative nutrition screens, development and use of a prophylactic antibiotic dosing chart, use of methicillin-resistant Staphylococcus aureus screening, maintenance of normal patient temperature, and use of nasal swabs in the operating room. The SSI rate dropped from a baseline figure of 4% in 2013 (n = 154) and 3.2% in 2014 (n = 189) to 0.0% (n = 198) in 2015 after the bundles were implemented. Both compliance with the bundle and SSI rates must be monitored monthly. Staff and providers should be offered monthly feedback on SSI rates and care bundle compliance. If an SSI does occur, a root-cause analysis is performed with the multidisciplinary care team using a standardized review form.
Background
Quality improvement efforts in pediatric surgery can positively impact both outcomes and cost.
Purpose
The use of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP)–Pediatrics was essential in determining where to focus our efforts.
Methods
Utilizing risk-adjusted outcomes data is the key driver behind our successes as a multidisciplinary team. This team, which now includes a parent representative, meets at least monthly to review data, identify trends and problems, propose new change ideas, identify barriers to change, and celebrate success. Detailed agendas and minutes are circulated to all team members to ensure a shared mental model.
Results
Since initiation in 2011, our efforts have resulted in a decrease in multiple morbidities, including surgical site infections, blood transfusions, preoperative Computerized Tomography use for patients undergoing appendectomy, unplanned reintubations, shorter lengths of stay, and fewer readmissions. Our improvement efforts resulted in an estimated cost savings of $1.5 million over a 2-year period (2015–2016).
Conclusions
Our team used NSQIP data to direct and guide quality improvements in patient care.
Implications
The business case for surgical quality comes from getting a return on investment in NSQIP with multidisciplinary teams led by surgeons and nurses.
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