As hospitals face increasing pressure to prevent surgical site infections, the American College of Surgeons National Surgical Quality Improvement Program offers one way to rapidly identify potential problems and track improvement efforts.

That was the experience at Huntington Memorial Hospital in Pasadena, Calif., where surgeons were able to significantly reduce the number of vascular surgical site infections by using the NSQIP to guide their quality improvement efforts. The NSQIP, which is operated by the American College of Surgeons (ACS), is a risk-adjusted data collection tool that captures and analyzes clinical outcomes data. The program sends periodic and real-time data to participating hospitals.

Between January 2009 and December 2010, the rate of vascular surgical site infections at the 650-bed community hospital dropped from 4.16% to 0.85% among 478 vascular surgeries performed during the 2-year period. In 2009, 10 vascular surgical site infections were diagnosed. Seven were categorized as "superficial" and three were considered "deep." But in 2010, only two superficial vascular surgical site infections were diagnosed. There were no deep infections identified at the hospital that year. Surgeons from Huntington Memorial Hospital shared their data at the Western Surgical Association annual meeting in Tucson, Ariz.

Huntington Memorial Hospital, which has an independent general surgery residency program, joined the NSQIP in 2007. Hospital officials reviewed their data in 2008, and found that that the number of vascular surgical site infections was unacceptably high, Dr. Steven Katz, professor of surgery at the University of Southern California in Los Angeles and the director of surgical education at Huntington, said in an interview. The early NSQIP data showed that the observed to expected (O/E) ratio for vascular surgical site infections was 1.97 in 2008. The O/E ratio is a risk-adjusted outcome for a specific surgical site. An O/E ratio of less than 1 means that the site is performing better than expected, but a ratio of greater than 1 means there are an excess of adverse events, according to the ACS.

The hospital convened a multidisciplinary committee with representatives from vascular surgery, anesthesiology, infection control, quality improvement, and nursing. The group then got to work looking for places where their practices fell short of best practices.

As a result, the hospital made a series of changes in perioperative patient management, including changing the surgical preparation solution and handwashing brushes from povidone-iodine to chlorhexidine, increasing the preoperative dose of cefazolin from 1 g to 2 g for patients not on dialysis, and intraoperative redosing of antibiotics in cases where the operative time was 4 hours or more. They also discontinued prophylactic antibiotics within 24 hours of surgery, used supplemental oxygen at an FiO₂ (fraction of inspired oxygen) of 80% intraoperatively and immediately after surgery, and routinely used patient warming devices to maintain a core temperature of 37° C. The changes were phased in starting in August 2009, and were fully implemented by the beginning of 2010.

The new protocols appeared to pay dividends in terms of reducing infections. Between January 2008 and December 2010, the O/E ratio for vascular surgical site infections fell from 1.97 to 0.93.

The NSQIP was important to the hospital’s success, said Dr. Katz, who is the surgical champion for the NSQIP at Huntington. The real-time benchmarking reports provided by the program helped to initially identify the problem of high infection rates and later helped to track the success of the interventions, he said. Although the NSQIP doesn’t instruct hospitals on how to make quality improvements, the systems-based data it provides is especially helpful in developing a multidisciplinary approach to tackling the problems, Dr. Katz said.

The NSQIP database is quickly becoming the standard for measuring surgical quality, and the data from Huntington Memorial Hospital lends the program even more credibility, Dr. Richard Keen, chair of surgery at Cook County Hospital in Chicago, said in an interview.

The experience at Huntington is "exactly how it’s supposed to work," Dr. Keen said. The NSQIP should help hospitals identify problems they otherwise might not have known about, and help them track whether their interventions have been effective, he said.

But despite recognition by the Joint Commission and others, the NSQIP still isn’t in use in a majority of hospitals around the country. For example, Dr. Keen’s hospital doesn’t participate in the NSQIP, though he’s been pushing the administration to do so for years, he said. The major stumbling block, he said, is the issue of return on investment. The annual fee for the program is between $10,000 and $24,000, depending on the size of the hospital, but the larger costs come with the full-time employee that’s needed to work with the data. "People don’t necessarily see the return," he said.

But Dr. Keen said he expects to see an "explosion" in participation in the NSQIP in the next few years, driven in part by pressures from payers. The recent moves by Medicare to link payments to quality will make the NSQIP an important tool for hospitals to show that they are making progress in meeting quality goals, he said.

Hospital Reduces Surgical Site Infections Using NSQIP