Abstract
ObjectivePeaceHealth Sacred Heart Medical Center at RiverBend is a 379 bed hospital; 15,060 surgical procedures were performed in 2014 with 254 being colorectal surgical cases. Using the ACS NSQIP program the hospital was identified as a high outlier for surgical site infection (SSI) in all cases and in colorectal procedures in our July 2012 semiannual report (SAR). MethodsA best practice bundle to reduce SSI's and a colorectal enhanced recovery pathway were concurrently initiated ResultsAfter implementation of these best practice elements, our ACS NSQIP results showed a reduction in our colorectal SSI rate from 17.58% for 2011 to 5.11% (1st decile/low outlier) in the January 2015 SAR. Our SSI rate for all cases were reduced from 4.87% to 1.71% (1st decile/low outlier) during the same time period. A reduction in length of stay for our colorectal surgical patients was also noted. ConclusionsThe ACS NSQIP program was essential to identify colorectal SSI as an area of concern and for providing data to drive quality improvement measures.
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