Colon Surgical Site Infection Research Articles

Closing the gap on infection prevention staffing recommendations: Results from the beta version of the APIC staffing calculator.

Published literature suggests "one-size-fits-all" infection prevention and control (IPC) staffing recommendations do not sufficiently account for program complexity needs. This project's objective was to create and validate a calculator utilizing risk and complexity factors to generate individualized IPC staffing ratios. An online survey-based calculator was created that incorporated factors intended to predict staffing needs and multiple investigative questions to allow for optimization of factors in the algorithm. Hospital characteristics, staffing ratios, staffing perception, and outcomes were analyzed to determine the optimal questions and benchmarks for future releases. The median infection preventionist full-time equivalent to bed ratio was 121.0 beds for 390 participating hospitals. The calculator deemed 79.2% of respondent staffing as below expected. Significant association existed between higher standard infection ratio ranges and staffing status for central line-associated bloodstream infection (P=.02), catheter-associated urinary tract infections (P=.001), Clostridioides difficile infections (P=.003), and colon surgical site infections (P=.0001). This novel approach allows facilities to staff their IPC program based on individual factors. Future versions of the calculator will be optimized based on the findings. Future research will clarify the impact of staffing on patient outcomes and staff retention.

QAPI 123 - Comprehensive Multidisciplinary Performance Improvement Teams Effectively Reduce Colon Surgical Site Infections

QAPI 123 - Comprehensive Multidisciplinary Performance Improvement Teams Effectively Reduce Colon Surgical Site Infections

Do risk adjustment calculations used by governmental agencies adequately assess risk for infection after colon surgery?

Surgical site infections (SSIs) following colon surgery are associated with clinical and financial consequences. The Centers for Medicare and Medicaid Services (CMS) and the New York State Department of Health (NYSDOH) use risk adjustment variables to determine quality measure scores. Among patients in a large public system, surgical risk variables were compared between patients with and without SSIs. Propensity score matching, using CMS and NYSDOH risk variables, created control groups. Receiver Operating Characteristics (ROC) curves were created using current and augmented risk adjustment variables. When matched using CMS risk variables, more patients with SSIs had contaminated/dirty wounds, longer duration of surgery, and emergency surgery. The addition of these variables significantly improved the CMS ROC curve. When matching NYSDOH variables, more SSI patients were male, had contaminated/dirty wounds, and tended to be younger. The addition of these variables to the current NYSDOH adjustment criteria did not significantly improve the ROC curve. The CMS adjustment criteria for colon SSIs do not adequately account for complicated surgeries. The inclusion of additional variables significantly improved the performance of CMS risk adjustment. Until more robust risk adjustment criteria are developed, the reporting of SSIs following colon surgery as a quality measure should be suspended.

The impact of surgical volume on hospital ranking using the standardized infection ratio

The Centers for Medicare and Medicaid Services require hospitals to report on quality metrics which are used to financially penalize those that perform in the lowest quartile. Surgical site infections (SSIs) are a critical component of the quality metrics that target healthcare-associated infections. However, the accuracy of such hospital profiling is highly affected by small surgical volumes which lead to a large amount of uncertainty in estimating standardized hospital-specific infection rates. Currently, hospitals with less than one expected SSI are excluded from rankings, but the effectiveness of this exclusion criterion is unknown. Tools that can quantify the classification accuracy and can determine the minimal surgical volume required for a desired level of accuracy are lacking. We investigate the effect of surgical volume on the accuracy of identifying poorly performing hospitals based on the standardized infection ratio and develop simulation-based algorithms for quantifying the classification accuracy. We apply our proposed method to data from HCA Healthcare (2014–2016) on SSIs in colon surgery patients. We estimate that for a procedure like colon surgery with an overall SSI rate of 3%, to rank hospitals in the HCA colon SSI dataset, hospitals that perform less than 200 procedures have a greater than 10% chance of being incorrectly assigned to the worst performing quartile. Minimum surgical volumes and predicted events criteria are required to make evaluating hospitals reliable, and these criteria vary by overall prevalence and between-hospital variability.

Development of machine learning models for the surveillance of colon surgical site infections

Conventional surgical site infection (SSI) surveillance is labour-intensive. We aimed to develop machine learning (ML) models for the surveillance of SSIs for colon surgery and to assess whether the ML could improve surveillance process efficiency. This study included cases who underwent colon surgery at a tertiary center between 2013 and 2014. Logistic regression and four ML algorithms including random forest (RF), gradient boosting (GB), and neural networks (NNs) with or without recursive feature elimination (RFE) were first trained on the entire cohort, and then re-trained on cases selected based on a previous rule-based algorithm. We assessed model performance based on the area under the curve (AUC), sensitivity, and positive predictive value (PPV). The estimated proportion of reduction in workload for chart review based on the ML models was evaluated and compared with the conventional method. At a sensitivity of 95%, the NN with RFE using 29 variables had the best performance with an AUC of 0.963 and PPV of 21.1%. When combining both the rule-based algorithm and ML algorithms, the NN with RFE using 19 variables had a higher PPV (28.9%) than with the ML algorithm alone, which could decrease the number of cases requiring chart review by 83.9% compared with the conventional method. We demonstrated that ML can improve the efficiency of SSI surveillance for colon surgery by decreasing the burden of chart review while providing high sensitivity. In particular, the hybrid approach of ML with a rule-based algorithm showed the best performance in terms of PPV.

Colon surgical-site infections and the impact of "present at the time of surgery (PATOS)" in a large network of community hospitals.

To describe the epidemiology of complex colon surgical procedures (COLO), stratified by present at time of surgery (PATOS) surgical-site infections (SSIs) and non-PATOS SSIs and their impact on the epidemiology of colon-surgery SSIs. Retrospective cohort study. SSI data were prospectively collected from patients undergoing colon surgical procedures (COLOs) as defined by the National Healthcare Safety Network (NHSN) at 34 community hospitals in the southeastern United States from January 2015 to June 2019. Logistic regression models identified specific characteristics of complex COLO SSIs, complex non-PATOS COLO SSIs, and complex PATOS COLO SSIs. Over the 4.5-year study period, we identified 720 complex COLO SSIs following 28,188 COLO surgeries (prevalence rate, 2.55 per 100 procedures). Overall, 544 complex COLO SSIs (76%) were complex non-PATOS COLO SSIs (prevalence rate [PR], 1.93 per 100 procedures) and 176 (24%) complex PATOS COLO SSIs (PR, 0.62 per 100 procedures). Age >75 years and operation duration in the >75th percentile were independently associated with non-PATOS SSIs but not PATOS SSIs. Conversely, emergency surgery and hospital volume for COLO procedures were independently associated with PATOS SSIs but not non-PATOS SSIs. The proportion of polymicrobial SSIs was significantly higher for non-PATOS SSIs compared with PATOS SSIs. Complex PATOS COLO SSIs have distinct features from complex non-PATOS COLO SSIs. Removal of PATOS COLO SSIs from public reporting allows more accurate comparisons among hospitals that perform different case mixes of colon surgeries.

Combined laparoscopic and open colon surgery rankings fail to accurately rank hospitals by surgical-site infection rate.

To compare strategies for hospital ranking based on colon surgical-site infection (SSI) rate by combining all colon procedures versus stratifying by surgical approach (ie, laparoscopic vs open). Retrospective cohort study. We identified SSIs among Medicare beneficiaries undergoing colon surgery from 2009 through 2013 using previously validated methods. We created a risk prediction model for SSI using age, sex, race, comorbidities, surgical approach (laparoscopy vs open), and concomitant colon and noncolon procedures. Adjusted SSI rates were used to rank hospitals. Subanalyses were performed for common colon procedures and procedure types for which there were both open and laparoscopic procedures. We generated ranks using only open and only laparoscopic procedures, overall and for each subanalysis. Rankings were compared using a Spearman correlation coefficient. In total, 694,813 colon procedures were identified among 508,135 Medicare beneficiaries. The overall SSI rate was 7.6%. The laparoscopic approach was associated with lower SSI risk (OR, 0.5; 95% CI, 0.4-0.5), and higher SSI risk was associated with concomitant abdominal surgeries (OR, 1.4; 95% CI, 1.4-1.5) and higher Elixhauser score (OR, 1.1; 95% CI, 1.0-1.1). Hospital rankings for laparascopic procedures were poorly correlated with rankings for open procedures (r = 0.23). Hospital rankings based on total colon procedures fail to account for differences in SSI risk from laparoscopic vs open procedures. Stratifying rankings by surgical approach yields a more equitable comparison of surgical performance.

Pediatric surgical site infections in 287 hospitals in the United States, 2015-2018.

Among 287 US hospitals reporting data between 2015 and 2018, annual pediatric surgical site infection (SSI) rates ranged from 0% for gallbladder to 10.4% for colon surgeries. Colon, spinal fusion, and small-bowel SSI rates did not decrease with greater surgical volumes in contrast to appendix and ventricular-shunt SSI rates.

Adherence to a standardized infection reduction bundle decreases surgical site infections after colon surgery: a retrospective cohort study on 526 patients

BackgroundColon surgical site infections (SSI) are detrimental to patient safety and wellbeing. To achieve clinical excellence, our hospital set to improve patient safety for those undergoing colon surgery. Our goal was to implement a perioperative SSI prevention bundle for all colon surgeries to reduce colon surgery SSI rates.MethodsThis retrospective cohort study evaluated the impact of implementing a perioperative SSI prevention bundle in patients undergoing colon surgery at Banner University Medical Center - Tucson. We compared SSI rates between the Pre- (1/1/2016 to 12/31/2016) and post-bundle (1/1/2017 to 12/31/2017) cohorts using a chi-square test.ResultsIn total, we included 526 consecutive patients undergoing colon surgery in our study cohort; 277 pre-bundle and 249 post-bundle implementation. The unadjusted SSI rates were 8.7 % and 1.2 %, pre- and post-bundle, respectively. Our CMS reportable standard infection rate decreased by 85.4 % from 3.08 to 0.45 after implementing our SSI prevention bundle.ConclusionsImplementing a standardized colon SSI prevention bundle reduces the overall 30-day colon SSI rates and national standardized infection rates. We recommend implementing colon SSI reduction bundles to optimize patient safety and minimize colon surgical site infections.

Is Hospital-Onset Bloodstream Infection (HOBSI) a Useful Measure to Evaluate Infection Prevention Progress?

Background: Acute-care hospitals in the United States are required to submit 6 healthcare-associated infection (HAI) metrics to the CMS for reporting and performance purposes prior to payment. We examined the association between HAI rate trends and hospital-onset bloodstream infection (HO-BSI) rate trends across a large, multihospital health system. Methods: HO-BSI events were identified across 52 hospitals attributable to Staphylococcus aureus, Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae, or Candida spp using the NHSN Lab ID event definition of ≥day 4 of admission. We compared the performance from January 2016 to March 2019 for HO-BSI and the 6 NHSN-defined HAIs: central-line–associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), Clostridioides difficile, methicillin-resistant Staphylococcus aureus (MRSA) bacteremia, abdominal hysterectomy surgical site infections (SSIs), and colon SSI. We calculated 2 “infection composite scores” to account for the 6 HAIs based on all observed or predicted events (score 1) and an average of the 6 HAI standardized infection ratios (SIRs; score 2). We normalized both measures to 1 for a 12-months rolling baseline. We evaluated the HO-BSI rate change over time and compared it to the change in the infection score over the same period. We compared the change in the 12-month rolling rates of the 2 HAI scores and the HO-BSI rate. Results: During the 39-month period, 3,288 HO-BSI events occurred over 9,775,118 patient days. The source of HO-BSI events included S. aureus (33.5%), P. aeruginosa (10.2%), E. coli (19.7%), K. pneumoniae (13.8%), and Candida spp (22.8%). HO-BSI event rates decreased by 17.3% from 12-month rolling baseline to last 12 months (3.70 vs 3.06 per 10,000 patient days). Similarly, 7,648 HAI events were observed, with the source of events being Clostridioides difficile (57.0%), CAUTI (15.1%), CLABSI (12.8%), MRSA (7.0%), colon SSI (6.4%), and abdominal hysterectomy SSI (1.7%). The 2 HAI scores and the HO-BSI rate all showed a notable decrease from the 2016 baseline period (Fig. 1). The reductions in the HAI scores were both strongly correlated with the reduction in the HO-BSI rate, with the HAI score 1 having a stronger correlation (r = 0.949; P < .001) than was observed for HAI score 2 (r = 0.867; P < .001). Conclusions: Utilization of a HO-BSI measure may prove useful as a correlated but distinct marker of infection prevention improvement or trends. HO-BSI could be useful as an objective electronically obtainable measure to assist in the evaluation of performance within and across facilities.Funding: NoneDisclosures: None

Decreasing Colon Surgical Site Infections Through Multidisciplinary Engagement Using a Practice Bundle

<h3>Background</h3> Despite an increased recognition of evidence-based interventions, surgical site infections (SSIs) remain a source of patient harm. Our 280 bed acute care hospital had an elevated colon SSI rate (18.6%) and SIR (3.81) which was higher than predicted. The purpose of this quality improvement project was to decrease colorectal surgery SSI through the implementation of a formal, measurable bundle of evidence-based actions. <h3>Methods</h3> Our hospital lacked specific actions for colon SSI prevention. We hypothesized that the SSI rate would be reduced by adherence to an evidence-based bundle. Consensus was developed to implement a 7 element prevention bundle involving all phases of perioperative care and a "stop the line" culture to promote compliance. The 7 element bundle included standardization of: 2 step surgical skin preparation, glucose management, active warming, preoperative antibiotics, wound protector use and bowel isolation technique was fully implemented in December 2018. Compliance was actively measured and reported to frontline stakeholders weekly. Full compliance took close to 4 months. <h3>Results</h3> There was a substantial reduction in colon SSI's between the periods T1 (April – December 2018) and T2 (January – September 2019). An SIR of 4.31 (95% Confidence Interval [2.50, 6.95], p-value: 0.00), with a statistical interpretation of higher than predicted, has been reduced to 0.87 (95% Confidence Interval [0.22, 2.38], p-value: 0.88), or no different than predicted. When comparing periods, an 80% reduction in colon SSI's (T1: 15 infections, T2: 3 infections) was observed. Fisher's Exact Test shows a statistically significant difference between T1 and T2 (p-value: 0.005). <h3>Conclusions</h3> The SSI rate was significantly reduced by the implementation of the 7 element bundle. Improved patient outcomes was sustained over an 8-month timeframe with over 95% compliance to each component. Successful implementation of the bundle required support from all levels of the organization and empowerment of frontline staff in full bundle compliance.

Variability in infection surveillance methods and impact on surgical site infection rates

The impact of variability in infection surveillance methodologies on publicly reported rates of surgical site infection (SSI) is not well defined. We performed a cross-sectional study to assess infection preventionists' surveillance practices across acute care US hospitals. We collected self-reported annual facility standardized infection ratios for colon surgery and abdominal hysterectomy as provided by the National Healthcare Safety Network. Trend analysis using Kendall's rank correlation evaluated the association between surveillance rigor and SSI rates. Among 492 participating hospitals, 63%, 15%, 13%, and 8% were community, university-affiliated, critical access, and ambulatory surgical centers, respectively. Most critical access hospitals (82%) and ambulatory surgical centers (98%) reported less than one full time infection preventionists (P ≤ .001). University-affiliated medical centers spent significantly more time and used more data sources for monthly SSI review compared with other hospitals. Critical access hospitals and ambulatory surgical centers were more likely to rely on manual surveillance only (P < .001). The number of different data sources used for SSI surveillance was positively associated with higher SSI rates: (KT 0.14, P = .028 for colon SSI in 2017; KT 0.20, P = .009 for hysterectomy SSI in 2016; KT 0.25, P = .001 for hysterectomy SSI in 2017). Rigorous SSI surveillance using more data sources for case-finding is more likely to be associated with higher facility SSI rates for colon surgery and abdominal hysterectomy.

Implementation of colon surgical site infection prevention bundle—The successes and challenges

Surgical site infection (SSI) prevention bundles have proven successful in decreasing infections. Surgeon and nurse engagement and endorsement are essential for success. The objective of this quality improvement project was to develop, implement and sustain a colon SSI prevention bundle and determine which bundle components are most strongly associated with prevention of SSI. The bundle was developed and implemented in a 525 bed Level I trauma hospital and included pre-, intra- and postoperative components. Bundle adherence and SSI rate were continually tracked and communicated to surgeons and nursing staff throughout project. Univariate and multivariate analyses were performed to determine the components associated with lowest SSI rates. There were 280 elective and urgent/emergent colon surgeries between October 2015 and March 2018. Over 60% had preoperative components, 76.5% had intraoperative components and 55.6% had postoperative bundle components with a nonsignificant decreasing trend in SSI rate of -0.5 SSI/100 procedures per quarter. The multivariate analysis suggested that use of 2% chlorhexidine gluconate/70% alcohol skin prep, use of wound protector and change of gloves for fascial closure were associated with fewer SSI. The implementation of a colon SSI prevention bundle in a Level I trauma hospital with pre-, intra- and postoperative components was described. Future directions include focusing implementation efforts on bundle components that significantly prevent SSI to improve adherence.

The Limited Utility of Ranking Hospitals Based on Their Colon Surgery Infection Rates.

BackgroundThe Centers for Medicare and Medicaid Services (CMS) use colon surgical site infection (SSI) rates to rank hospitals and apply financial penalties. The CMS’ risk-adjustment model omits potentially impactful variables that might disadvantage hospitals with complex surgical populations.MethodsWe analyzed adult patients who underwent colon surgery within facilities associated with HCA Healthcare from 2014 to 2016. SSIs were identified from National Health Safety Network (NHSN) reporting. We trained and validated 3 SSI prediction models, using (1) current CMS model variables, including hospital-specific random effects (HCA-adapted CMS model); (2) demographics and claims-based comorbidities (expanded-claims model); and (3) demographics, claims-based comorbidities, and NHSN variables (claims-plus–electronic health record [EHR] model). Discrimination, calibration, and resulting rankings were compared among all models and the current CMS model with published coefficient values.ResultsWe identified 39 468 colon surgeries in 149 hospitals, resulting in 1216 (3.1%) SSIs. Compared to the HCA-adapted CMS model, the expanded-claims model had similar performance (c-statistic, 0.65 vs 0.67, respectively), while the claims-plus-EHR model was more accurate (c-statistic, 0.70; 95% confidence interval, .67–.73; P = .004). The sampling variation, due to the low surgical volume and small number of infections, contributed 74% of the total variation in observed SSI rates between hospitals. When CMS model rankings were compared to those from the expanded-claims and claims-plus-EHR models, 18 (15%) and 26 (22%) hospitals changed quartiles, respectively, and 10 (8.3%) and 12 (10%) hospitals changed into or out of the lowest-performing quartile, respectively.ConclusionsAn expanded set of variables improved colon SSI risk predictions and quartile assignments, but low procedure volumes and SSI events remain a barrier to effectively comparing hospitals.

Implementing a multidisciplinary care bundle to reduce colon surgical site infections.

PurposeThe aim of this study was to investigate how rates of surgical site infections (SSI) were changed over 2 years after applying colon SSI bundle in patients who underwent colon surgery.MethodsThe multidisciplinary working group developed a care bundle consisting of 8 components, including several recommendations of Surgical Care Improvement Project and monitoring of medical/surgical hand washing. We implemented the care bundle for each patient who underwent colon surgery from April 2013 to December 2014.ResultsOverall bundle compliance was 87.9% before implementation, 88.2% in 2013, and 90.5% in 2014. In particular, compliance of the following 3 components was substantial improved during the project period; discontinuation of prophylactic antimicrobial agent within 24 hours of surgery (from 88.3% to 100%), surgical hand washing (from 50.0% to 78.9%), and medical hand washing (from 74.7% to 82.8%). The rate of SSI was 8.0% (12/150) during 3 months before implementation, 3.3% (16/480) from April to December in 2013, and 2.3% (14/607) in 2014.ConclusionAfter implementation of multidisciplinary care bundle, the compliance of each component was increased and rates of SSIs were significantly decreased compared to those before the quality improvement project.

1248. 30-Day Colon Surgical Site Infections: Using NSQIP to Cross Check NHSN

BackgroundWhile infection prevention (IP) programs utilize National Health Safety Network (NHSN) definitions, surgical site infection (SSI) case-finding methods may vary between facilities based on resources and availability/type of healthcare-associated infection (HAI) electronic surveillance tracking software. Furthermore, surgeons may receive SSI data from other databases such as National Surgery Quality Improvement Project (NSQIP) which has slightly different definitions and case finding methodologies. Our goal was to compare colon SSIs across our health system found by IP using NHSN definitions to those obtained utilizing NSQIP case finding methodology and definitions.MethodsBetween January 2018 and September 2018 across 8 acute care facilities ranging in size from 100 to 898 beds, HAI electronic surveillance tracking triggered IP and infectious diseases (ID) trained physician review for NHSN SSI criteria if a patient was either readmitted or had a positive culture within 30 days of colon surgery. SSI results were compared with NSQIP SSI data which reviews all charts and conducts post-discharge surveillance during active surveillance periods. All discrepant cases were reviewed by an infection preventionist, an ID physician and surgery physician champion. Cases were classified as discrepant due to different case inclusion criteria, different case finding or clinical misclassification.Results69 cases were reviewed. Both databases called 11 cases (16%) an SSI initially. NSQIP identified 35 cases that were not detected by IP surveillance. Of the 35 NSQIP detected SSI, 17 (49%) were felt to meet NHSN SSI criteria after review (7 organ space, 10 superficial). Majority (76%) were discordant due to case finding issues (diagnosed as outpatient, same hospital course with no cultures to flag for review). Two infections were missed because of human error. Once the SSIs were entered into NHSN, only one facility had an increase in the SIR which impacted interpretation of SSI performance (from 0.949 up to 1.423). NHSN identified 23 cases that were not identified in the NSQIP database. There were 8 organ space infections and 8 superficial site infections.ConclusionWithout 100% surveillance, SSIs may be missed. Not all missed infections were superficial. Opportunities were found for both NHSN and NSQIP.Disclosures All authors: No reported disclosures.

Association of Open Approach vs Laparoscopic Approach With Risk of Surgical Site Infection After Colon Surgery

Colon surgery is associated with a high rate of surgical site infection (SSI), and there is an urgent need for strategies to reduce infection rates. To assess whether laparoscopic colon surgery is associated with a lower surgical site infection rate than open-approach laparoscopy, especially in patients with medically complex conditions. This cohort study used previously validated diagnosis and procedure codes from Medicare beneficiaries who underwent colon surgery from January 1, 2009, to November 30, 2013. Analyses were performed from August 1 to December 31, 2018. Outcome measures were SSI events, medical comorbidities, and laparoscopic or open approach procedures. A total of 229 726 patients (mean [SD] age, 74.3 [9.4] years; 128 499 [55.9%] female) underwent colon procedures. There were 105 144 laparoscopic procedures and 124 582 open procedures. The overall mean SSI rate was 6.2%, varying by surgical procedure from 5.8% to 7.6%. Among the full study population, adjusted model results showed a significant association of laparoscopy with lower odds of SSI (odds ratio, 0.43; 95% CI, 0.41-0.46; P < .001). When stratified by surgical approach, the mean SSI rates were 4.1% (procedure-specific range, 3.9%-5.1%) for the laparoscopic approach and 7.9% (procedure-specific range, 7.4%-10.2%) for the open approach. When stratified by Elixhauser score groups, the mean SSI rates were 6.2% (procedure-specific range, 3.2%-8.7%) for group 1 (0-1 comorbidity), 5.5% (procedure-specific range, 3.6%-11.1%) for group 2 (2 comorbidities), and 6.6% (procedure-specific range, 4.6%-10.6%) for group 3 (3-13 comorbidities). An interaction was also observed between laparoscopic approach and Elixhauser groups, with increased odds of SSI among patients who had 3 to 13 comorbidities present at the time of the procedure (odds ratio, 1.21; 95% CI, 1.11-1.32) compared with patient groups with fewer comorbidities. The population attributable fraction of SSIs for use of the open approach was 34.2%. A total of 2317 of 3882 hospitals (59.7%) performed few (0%-10%) or most (>50%) procedures laparoscopically. Policy changes that promote surgical education and resources for laparoscopy, especially at low-adoption hospitals, may be associated with reduced colon SSI rates. Support of the development of innovative educational policies may help achieve improvement in patient outcomes and decreased health care use in colon surgery.

Reducing Surgical Site Infections in the Enhanced Recovery After Surgery Patient Population

BACKGROUND Enhanced Recovery After Surgery (ERAS) is a multimodal, evidence-based practice (EBP) inter-professional approach to improving care for the surgical patient. ERAS pathways include minimally invasive surgeries, pre-op nutritional support, intraoperative fluid management, and decreased opioid use with early mobilization, introduction of food, and gum chewing. Patient engagement is critical to achieving ERAS objectives. European countries have been implementing the concepts associated with ERAS for nearly 20?years. Benefits of ERAS innovative pathways are decreased length of stay, postop complications, infections, malnutrition, pain management and hospital readmission. METHODS Surgical site infections (SSIs) are associated with an increased length of stay, morbidity, costs of care, and readmissions. An ERAS program was started at a large acute care, level II trauma facility in January 2017 to utilize evidence-based interventions to improve patient outcomes in elective colorectal surgery patients. RESULTS From 1st to 4th Quarter 2017, there was a steady decrease in the surgical site infection rate in ERAS colon procedures from 6% to 2%. While a slight increase was noted in the first two quarters of 2018, the overall Colon SSI Standardized Infection Ration (SIR) dropped from 1.867 in the 1st Quarter of 2017 to 0.656 in the 2nd Quarter of 2018. CONCLUSIONS The ERAS program improved the outcomes of patients requiring a colon procedure by improving pain control and return of gastric motility and reducing SSI and length of hospital stay. Interventions that may have contributed to the reduced colon SSI SIR include changes in practice by colon surgeons (separate closure trays, oral antibiotics, separate staplers e.g.) and implementation of an evidenced-based ERAS program.

Success of a Colorectal Surgical Site Infection Prevention Bundle in a Multihospital System.

Surgical site infections, readmissions, and extended hospital stays are risks for patients undergoing colon surgeries. These procedures are often urgent, and patients may have multiple comorbidities. Preoperative and postoperative steps to reduce the number of complications provide substantial benefits clinically, economically, and psychologically. We used a multidisciplinary, collaborative approach to identify best practices when developing and implementing a standardized approach to the management of patients undergoing elective colon surgery. Interventions included nutrition supplements and preoperative and postoperative protocols. Our management project showed a 74.6% reduction in readmissions, a 22.73% reduction in length of stay, an 85% reduction in colon surgical site infections measured by incidence (84.5% reduction) and standard infection ratio (54.55% reduction), and 95% compliance with the use of both order sets during an 18-month period. Applying standardized order sets for assessing and addressing patient comorbidities before colorectal surgery can result in a substantial and sustainable reduction in complications.

Sustained Reduction in Colon Surgical Site Infections After Bundle Implementation: Experience at 2 Hospitals

BACKGROUND: Surgical site infections (SSIs) are costly complications of colon procedures. Current data from our state reporting system showed that our 2 hospitals have made steady progress in reducing colon SSIs. To further reduce the SSI rate a bundled intervention (bundle) was implemented.