A Comprehensive Multi-disciplinary Approach to Improve Surgical Outcomes Following Elective Colon and Rectal Surgery

Transcription

1 A Comprehensive Multi-disciplinary Approach to Improve Surgical Outcomes Following Elective Colon and Rectal Surgery Tripurari Mishra MD, Deepa Bhat MD, Mina Saeed MD, Jan Kaminski MD, Mihaela Banulescu and Joaquin Estrada MD

2 Disclosure There are no conflicts of interests.

3 Introduction Major surgery in US carries a 2% risk for surgical site infections (SSI) Colorectal SSI are estimated to be as high as 30% Various institutions have started implementing Colorectal Surgery Care Bundles KSMC noted a decrease of SSI from 21% to 6.7% Mayo Clinic noted a decrease of SSI from 10% to 4% Advocate Illinois Medical Center implemented our own Colorectal Surgery Care Bundle in 2013 in order to reduce rates of SSI

4 Methods Retrospective study at AIMMC The ACS NSQIP database used to obtain the data from 2011 to 2015 (Colorectal bundle implemented in 2013) Cases selected based on CPT code Comparisons were made between pre-intervention ( ) and post-intervention ( ) group to evaluate any statistically significant difference in the 2 study groups. Chi-squared test and Students T-test

5 Pre-Admission Pre-admission phone call Family/caretaker included in call and education Education given includes: Hand hygiene Explanation about procedure Handouts/web sites about procedure Post-operative wound care Personal hygiene Mobility to prevent VTE Nutrition "12 warning Signs" Pre-op preparation Bowel prep given, if ordered Total body CHG shower taken on 2 consecutive nights before surgery Instructions given on how to obtain and use prep and CHG

6 Intra-op Antibiotic prophylaxis according to height and weight <1 hr before incision (<2 hrs if vancomycin used) Antibiotic re-dosing as appropriate Surgical skin prep CHG scrub (Chloraprep ) over incision site Iodophor impregnated sponge over stoma, if present 2-step iodophor prep for perineum, if lithotomy Normothermia ( >36 C and <38 C) maintained throughout procedure using Bair Hugger Warm irrigating fluids Warm IV fluids

7 Intra-op Glycemic control maintained Blood transfusion given if Hgb <7 Wound protector applied at incision, if ordered Closing protocol (prior to closing of fascia) Gowns and gloves changed by surgical team prior to closing Surgical site re-blocked with fresh sterile towels New sterile Bovie and suction used New sterile "Closing Tray" used Dressing applied before removing drapes

8 Post-op Normothermia maintained in PACU, on nursing unit Glycemic control maintained Out of bed <24 hrs post-op and ambulate asap to prevent VTE Dressing removed <48 hrs by surgeon Daily total body CHG baths using bath cloths Urinary catheter DC'd <48 hrs or daily documentation of need Antibiotic prophylaxis stopped <48 hrs Patient, family and caretaker re-educated on wound care Meticulous hand hygiene emphasized Home health ordered if needed Post-discharge appointment with surgeon, PCP made

9 Patient Demographics Variables Jan Dec 2012 Jan Dec 2015 Total p-value ASA class, n (%) No disturb 1 (0.7) 7 (2.8) 8 2 Mild disturb 53 (37.06) 76(30.5) Severe disturb 74 (51.75) 144(57.8) Life Threat 14 (9.8) 21(8.4) 35 5 Moribund 1 (0.7) 1 (0.4) 2 Diabetes, yes, n (%) 26 (18.18) 54 (21.7) Smoker, yes, n (%) 35 (24.48) 52 (20.88) Functional status, n, (%) Independent 133 (93.01) 247 (99.2) 380 Partially dependent 7 (4.90) 2 (0.8) 9 Totally dependent 3 (2.10) 0 (0) 3

10 Outcomes Infections, (n) Total Superficial Deep Organ Space Pre-intervention Post-intervention Total P-value 38 (26.5%) 16 (6.4%) (12.6%) 7 (2.8%) (4.9%) 0 (0%) (9.1%) 9 (3.6%) * Combined Deep and Organ Space Infections: 14.0% vs 3.6%

11 Percentage Trend through the years Total SSI Total SSI Year

12 Discussion The colorectal bundle can be implemented in a true community hospital with significant gains. Rates of infection have significantly decreased after implementation of the bundle Most importantly: clinically significant wound infections showed a dramatic reduction (14% vs 3.6%) Directly translates into reduced morbidity for the patient

13 References Itani KM, Wilson SE, Awad SS, et al. Ertapenem versus cefotetan prophylaxis in elective colorectal surgery. N Engl J Med 2006; 355:2640e2651. Tang R, Chen HH, Wang YL, et al. Risk factors for surgical site infection after elective resection of the colon and rectum: a single-center prospective study of 2,809 consecutive patients. Ann Surg 2001; 234:181e189. Anthony T, Murray BW, Sum-Ping JT, et al. Evaluating an evidence-based bundle for preventing surgical site infection: a randomized trial. Arch Surg 2011; 146:263e269. Lutfiyya, W., Parsons, D., & Breen, J. (2012). A Colorectal Care Bundle to Reduce Surgical Site Infections in Colorectal Surgeries: A Single-Center Experience. The Permanente Journal, 16(3), Cima, R., Dankbar, E., Lovely, J., Pendlimari, R., Aronhalt, K., Nehring, S., Hyke, R., Tyndale, D., Rogers, J. and Quast, L. (2013). Colorectal Surgery Surgical Site Infection Reduction Program: A National Surgical Quality Improvement ProgrameDriven Multidisciplinary Single-Institution Experience. Journal of American College of Surgeons, 216(1),

14 Special thanks to Pegi Wasserman Christopher Kabir

15 Thank you!

16 Procedures CPT code Laparoscopy, surgical; colectomy, partial, with anastomosis, with coloproctostomy (low pelvic anastomosis) with colostomy Laparoscopy, surgical; colectomy, total, abdominal, without proctectomy, with ileostomy or ileoproctostomy Laparoscopy, surgical; colectomy, total, abdominal, with proctectomy, with ileoanal anastomosis, creation of ileal reservoir (S or J), with loop ileostomy, includes rectal mucosectomy, when performed Laparoscopy, surgical; colectomy, total, abdominal, with proctectomy, with ileostomy Proctectomy; complete, combined abdominoperineal, with colostomy Proctectomy; partial resection of rectum, transabdominal approach Proctectomy, combined abdominoperineal, pull-through procedure (eg, colo-anal anastomosis) Proctectomy, partial, with rectal mucosectomy, ileoanal anastomosis, creation of ileal reservoir (S or J), with or without loop ileostomy Proctectomy, partial, with anastomosis; abdominal and transsacral approach Proctectomy, partial, with anastomosis; transsacral approach only (Kraske type) Proctectomy, combined abdominoperineal pull-through procedure (eg, colo-anal anastomosis), with creation of colonic reservoir (eg, J-pouch), with diverting enterostomy when performed Proctectomy, complete (for congenital megacolon), abdominal and perineal approach; with pull-through procedure and anastomosis (eg, Swenson, Duhamel, or Soave type operation) Proctectomy, complete (for congenital megacolon), abdominal and perineal approach; with subtotal or total colectomy, with multiple biopsies Proctectomy, partial, without anastomosis, perineal approach Laparoscopy, surgical; proctectomy, complete, combined abdominoperineal, with colostomy Laparoscopy, surgical; proctectomy, combined abdominoperineal pull-through procedure (eg, colo-anal anastomosis), with creation of colonic reservoir (eg, J-pouch), with diverting enterostomy, when performed Unlisted laparoscopy procedure, rectum Proctopexy (eg, for prolapse); with sigmoid resection, abdominal approach