Implementation of Surgical Quality Improvement: Auditing Tool for Surgical Site Infection Prevention Practices

BACKGROUND: Surgical site infections are a potentially preventable patient harm. Emerging evidence suggests that the implementation of evidence-based process measures for infection reduction is highly variable. OBJECTIVE: The purpose of this work was to develop an auditing tool to assess compliance with infection-related process measures and establish a system for identifying and addressing defects in measure implementation. DESIGN: This was a retrospective cohort study using electronic medical records. SETTING: We used the auditing tool to assess compliance with 10 process measures in a sample of colorectal surgery patients with and without postoperative infections at an academic medical center (January 2012 to March 2013). PATIENTS: We investigated 59 patients with surgical site infections and 49 patients without surgical site infections. MAIN OUTCOME MEASURES: First, overall compliance rates for the 10 process measures were compared between patients with infection vs patients without infection to assess if compliance was lower among patients with surgical site infections. Then, because of the burden of data collection, the tool was used exclusively to evaluate quarterly compliance rates among patients with infection. The results were reviewed, and the key factors contributing to noncompliance were identified and addressed. RESULTS: Ninety percent of process measures had lower compliance rates among patients with infection. Detailed review of infection cases identified many defects that improved following the implementation of system-level changes: correct cefotetan redosing (education of anesthesia personnel), temperature at surgical incision >36.0 degrees C (flags used to identify patients for preoperative warming), and the use of preoperative mechanical bowel preparation with oral antibiotics (laxative solutions and antibiotics distributed in clinic before surgery). Quarterly compliance improved for 80% of process measures by the end of the study period. LIMITATIONS: This study was conducted on a small surgical cohort within a select subspecialty. CONCLUSIONS: The infection auditing tool is a useful strategy for identifying defects and guiding quality improvement interventions. This is an iterative process requiring dedicated resources and continuous patient and frontline provider engagement.