Surgical Site Infection Prevention: The Importance of Operative Duration and Blood Transfusion—Results of the First American College of Surgeons–National Surgical Quality Improvement Program Best Practices Initiative

Campbell, Darrell A.; Henderson, William G.; Englesbe, Michael J.; Hall, Bruce L.; O'Reilly, Michael; Bratzler, Dale; Dellinger, E. Patchen; Neumayer, Leigh; Bass, Barbara L.; Hutter, Matthew M.; Schwartz, James; Ko, Clifford; Itani, Kamal; Steinberg, Steven M.; Siperstein, Allan; Sawyer, Robert G.; Turner, Douglas J.; Khuri, Shukri F.

doi:10.1016/j.jamcollsurg.2008.08.018

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Volume 207, Issue 6 , Pages 810-820, December 2008

Surgical Site Infection Prevention: The Importance of Operative Duration and Blood Transfusion—Results of the First American College of Surgeons–National Surgical Quality Improvement Program Best Practices Initiative

Darrell A. Campbell Jr, MD, FACS
- Department of Surgery, University of Michigan, Ann Arbor, MI
William G. Henderson, PhD
- VA – NSQIP, Aurora, CO
Michael J. Englesbe, MD
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Correspondence address: Michael J Englesbe, MD, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI 48109
Bruce L. Hall, MD, FACS
- Departments of Surgery, Washington University, St Louis, MO
Michael O'Reilly, MD, FACS
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI
Dale Bratzler, DO
- Oklahoma Foundation for Medical Quality, Washington University, St Louis, MO
E. Patchen Dellinger, MD, FACS
- University of Washington, Seattle, WA
Leigh Neumayer, MD, FACS
- University of Utah, Salt Lake City, UT
Barbara L. Bass, MD, FACS
- Methodist Hospital, Houston, TX
Matthew M. Hutter, MD, FACS
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
James Schwartz, MD
- Kaiser Sunnyside Medical Center, Sunnyside, CA
Clifford Ko, MD, FACS
- American College of Surgeons, Chicago, IL
Kamal Itani, MD, FACS
- The Brigham and Womens Hospital, Harvard Medical School, Boston, MA
Steven M. Steinberg, MD, FACS
- Ohio State University, Columbus, OH
Allan Siperstein, MD
- The Cleveland Clinic Foundation, Cleveland, OH
Robert G. Sawyer, MD, FACS
- University of Virginia, Charlottesville, VA
Douglas J. Turner, MD, FACS
- University of Maryland, Baltimore, MD
Shukri F. Khuri, MD, FACS
- The Brigham and Womens Hospital, Harvard Medical School, Boston, MA

Received 14 April 2008; received in revised form 15 August 2008; accepted 18 August 2008. published online 10 October 2008.

Background

Surgical site infections (SSI) continue to be a significant problem in surgery. The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) Best Practices Initiative compared process and structural characteristics among 117 private sector hospitals in an effort to define best practices aimed at preventing SSI.

Study Design

Using standard NSQIP methodologies, we identified 20 low outlier and 13 high outlier hospitals for SSI using data from the ACS-NSQIP in 2006. Each hospital was administered a process of care survey, and site visits were conducted to five hospitals. Comparisons between the low and high outlier hospitals were made with regard to patient characteristics, operative variables, structural variables, and processes of care.

Result

Hospitals that were high outliers for SSI had higher trainee-to-bed ratios (0.61 versus 0.25, p < 0.0001), and the operations took significantly longer (128.3±104.3 minutes versus 102.7±83.9 minutes, p < 0.001). Patients operated on at low outlier hospitals were less likely to present to the operating room anemic (4.9% versus 9.7%, p=0.007) or to receive a transfusion (5.1% versus 8.0%, p=0.03). In general, perioperative policies and practices were very similar between the low and high outlier hospitals, although low outlier hospitals were readily identified by site visitors. Overall, low outlier hospitals were smaller, efficient in the delivery of care, and experienced little operative staff turnover.

Conclusions

Our findings suggest that evidence-based SSI prevention practices do not easily distinguish well from poorly performing hospitals. But structural and process of care characteristics of hospitals were found to have a significant association with good results.

Abbreviations and Acronyms: ACS–NSQIP, American College of Surgeons–National Surgical Quality Improvement Program, O/E, observed-to-expected ratio, RVU, relative value unit, SCIP, Surgical Care Improvement Project, SIP, Surgical Infection Prevention Project, SSI, surgical site infection