AHRQ Innovations Exchange | Standardized Processes Improve Adherence to Evidence-Based Protocols, Significantly Reducing Common Surgery-Related Complications

Standardized Processes Improve Adherence to Evidence-Based Protocols, Significantly Reducing Common Surgery-Related Complications

Snapshot
Summary
To reduce common surgery-related problems, Baystate Medical Center standardized and automated evidence-based protocols and processes related to the selection, timely initiation, and discontinuation of antibiotics; administration of beta blockers to surgical patients at high risk of cardiovascular events; and use of preventive therapy (or prophylaxis) to reduce the risk of postoperative deep vein thrombosis. The program has significantly increased compliance with the protocols, leading to major reductions in surgical site infections (by 50 percent), postoperative myocardial infarctions (by 65 percent), and postoperative deep vein thrombosis (by 55 percent).

Please see the Description section for updated information about beta blocker protocols used, the Results section for updated evaluation data, and the Tools section for new resources (updated May 2009).
begin doxml
Developing Organizations
Baystate Medical Center

Springfield, MA end dobegin pp
Patient Population
Geographic Location > City


What They Did
Problem Addressed
A significant percentage of the nearly 30 million operations performed annually in the United States result in preventable complications, some of which can be life-threatening.1

Many preventable complications: Many patients undergoing surgery experience preventable complications. For example, roughly a quarter of patients undergoing major surgery who do not receive appropriate prophylactic treatment develop deep vein thrombosis (DVT), which can lead to a pulmonary embolism, long-term disability from venous insufficiency, and/or death.1
Due largely to lack of adherence to evidence-based protocols: Some surgery-related complications are unavoidable, but surgical care can be vastly improved is clinicians adhere to evidence-based recommendations and design systems of care with built-in safeguards.2 Despite promotion and dissemination of these recommendations and practices, overall national compliance remains less than optimal.1 For example:
Poor compliance with antibiotic protocols: The Joint Commission and the Centers for Medicare & Medicaid Services (CMS) recommend use of appropriate prophylactic antibiotics within 60 minutes of surgery; these organizations have also issued guidelines on choosing the appropriate antibiotic and on discontinuing the drug after surgery. Yet nationwide compliance with the 60-minute window averages only 64 percent, and only 28 percent of hospitals comply with all three evidence-based recommendations.1 Baystate Medical Center experienced compliance problems as well. For example, surgical delays after antibiotic administration in the preoperative nursing unit frequently meant that the drugs were not administered within the recommended 60-minute window.3
Poor compliance with beta-blocker protocols: The consensus among experts is that surgical patients on beta blockers before surgery to continue using them afterwards to reduce the risk of myocardial infarction (MI), which has a mortality rate of between 40 and 70 percent after surgery. Yet frequently confusion exists as to which physician—the prescribing doctor, surgeon, or anesthesiologist—should take responsibility for ensuring the patient remains on beta blockers. As a result, beta-blocker therapy may inadvertently be omitted from postoperative care, posing a serious risk to patients.1

Description of the Innovative Activity
To reduce common surgery-related problems, Baystate Medical Center standardized and automated evidence-based protocols and processes related to the selection, timely initiation, and discontinuation of antibiotics; administration of beta blockers to surgical patients at high risk of cardiovascular events; and use of preventive therapy (or prophylaxis) to reduce the risk of postoperative DVT. Key elements of the program include the following:

Antibiotics protocols: Baystate Medical Center uses a standardized process for the selection and timely administration and discontinuation of antibiotics for surgical patients:
Selection: Surgeons prescribe the antibiotic based on Centers for Disease Control and Prevention (CDC) 2003 guidelines, which are incorporated into the computerized physician order entry system.
Administration: Instead of administering antibiotics in the pre-operative suite, nurses prepare the antibiotic and send it to the operating room for administration by the anesthesiologist during the appropriate time window. During a “time-out” period before surgery (designed to identify and mitigate any potential problems), the circulating nurse verifies that the anesthesiologist has given the antibiotic.
Discontinuation: After surgery, the surgeon writes an order to discontinue antibiotics within 24 hours, and nurses monitor patient charts to verify that they have been stopped.
DVT protocols: Baystate uses a standardized, automated process to ensure that at-risk patients receive appropriate DVT prophylaxis before surgery.
Screening: Surgical patients are screened for risk of DVT before admission, with recommended prophylaxis made a routine part of admission orders. Many high-risk patients get DVT prophylaxis preoperatively, while all patients with surgeries scheduled to last longer than 30 minutes receive mechanical prophylaxis. Baystate uses guidelines developed by the American College of Chest Physicians to determine appropriate DVT prophylaxis.
Automatic alerts and real-time review: Baystate created a standardized order set in the computerized physician order entry system that sends alerts to physicians in cases where mechanical or chemical prophylaxis is appropriate but has not been ordered. In these instances, physicians must document the rationale for opting out of DVT prophylaxis. In addition, a clinical-effectiveness nurse conducts a real-time review of orders to ensure that all patients receive appropriate prophylaxis based on their level of risk.
Beta-blocker protocols: Patients are screened for potential risk of postoperative MI during preadmission appointments. Early in the program, hospital staff contacted high-risk patients' primary care physician to suggest initiation of beta-blocker therapy for 2 weeks prior to surgery. However, in October 2007, the program's focus changed to reflect recent research updates. Recent clinical trials (such as the POISE trial) as well the American Heart Association’s 2007 Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation/Treatment for Noncardiac Surgery recommended beta blockers not be started but strongly encouraged they be continued in patients who were already taking them. Currently, when the anesthesiologist conducts rounds the morning before surgery, he or she verifies the beta blocker has been taken, if prescribed and if the patient has not taken the beta blocker will administer one.
Automatic ordering as the default: To ensure that staff administer and discontinue medications and other interventions on time, Baystate Medical Center makes the correct processes the “default” order—in other words, evidence-based protocols are followed unless the physician orders a particular step not to occur, thus making it very easy for physicians to follow the protocols.
Quick followup with noncompliers, adverse events: Hospital administrators contact physicians who do not follow standardized protocols or provide proper documentation as to why a protocol was not followed within 24 hours of the event. Staff also research all postoperative adverse events to identify the root cause(s), and discuss with staff what can be done to prevent similar problems in the future.
Periodic workgroup meetings: Clinical leaders initially met weekly during the design, testing, and evaluation of the new protocols and processes. Once evidence of sustained improvement became clear, meeting frequency changed to every 2 weeks. As of May 2009, the team still meets monthly to review process and performance to ensure that care remains contemporary.

References/Related Articles
Fitzgerald J, Kanter G, Benjamin EM. Case study: preventing surgical complications at Baystate Medical Center. Jt Comm J Qual Patient Saf. 2007 Nov;33(11):666-71. [PubMed]

Kanter G, Connelly N, Fitzgerald J. A system and process redesign to improve perioperative antibiotic administration. Anesth Analg. 2006 Dec;103(6):1517-21. [PubMed]

Fitzgerald J, Benjamin E, Trelease R, et al. Reducing surgical complications. Nurs Manage. 2007 Nov;38(11):35-9. [PubMed]

Griffin FA. Reducing surgical complications. Jt Comm J Qual Patient Saf. 2007 Nov;33(11):666-71. [PubMed]

Fitzgerald J. Resisting surgical infections. Case in Point. 2009 Feb/Mar:50-4.
Contact the Innovator
Janice Fitzgerald, MS, RN, CPHQ
Baystate Medical Center
759 Chestnut St.
Springfield, MA 01199
Phone: (413) 794-0000
Fax: (413) 794-0300
E-mail: Janice.fitzgerald@bhs.org

Did It Work?
Results
The program has significantly improved compliance with evidence-based recommendations, resulting in meaningful reductions in surgical-site infections and postoperative MIs and DVT.

Better adherence to evidence-based recommendations: Selection of the appropriate antibiotic increased from 88 percent before the process redesign to 98 percent as of December 2008. Administration of antibiotics within 60 minutes of surgery increased from 11 percent to 99 percent, well above the national average of 89 percent. Discontinuation of antibiotic therapy within 24 hours after surgery increased from 10 percent to 97 percent.
Fewer surgical-site infections: Surgical-site infections (as measured by the National Nosocomial Infections Surveillance System criteria) fell from 3.8 percent before program implementation to as low as 0.8 percent afterwards, a 75 percent reduction.
Fewer postoperative MIs and DVT: Postoperative MIs decreased by 72 percent, while the incidence of postoperative DVT declined by 65 percent.
Lower cost per case: The program has led to a lower cost per case as a result of avoidance of post operative complications (no data available).
Evidence Rating (What is this?)
Moderate: The evidence consists of pre- and post-implementation comparisons of adherence to evidence-based protocols, surgical-site infections, and postoperative MIs and DVT.

How They Did It
Context of the Innovation
Baystate Medical Center, located in Springfield, MA, is a 653-bed academic, tertiary care, regional referral center that provides a full range of services, including more than 21,000 surgical procedures annually. In 2002, MassPRO, the State quality improvement organization, selected Baystate Medical Center to represent the State in a new pilot program sponsored by the CDC and CMS known as the Surgical Infection Prevention Collaborative. After representatives from the collaborative provided an overview of the goals and rationale for the project and presented evidence to support the value of the process changes, Baystate Medical Center leaders decided to participate. When CMS expanded the effort to include the prevention of postoperative MI, DVT, and pneumonia as part of the Surgical Care Improvement Project, Baystate Medical Center became an early adopter of these processes as well.
Planning and Development Process
Baystate Medical Center's planning and development process included the following steps:

Forming process redesign team: The team initially met weekly; team members included an attending cardiac surgeon, an anesthesiologist, pre-operative nurses, operating room nurses, and nurses from the floor units. The team was led by a senior quality improvement specialist. Once the team started to process changes, daily check-ins occurred. After 6 months, the team met every 2 weeks. After the first year and a half the team moved to monthly meetings, which have continued through today.
Conducting pilot study: The team selected interested surgeons and anesthesiologists to start the process change in a high volume population so that changes could be piloted and tested in a brief time period. Pilot participants were interested in optimizing care for their patients and had worked on improvement projects in the past. Additionally, when they saw the baseline data the were engaged immediately. The pilot study started with six patients; outcomes were measured and the process was tweaked.
Educating staff and identifying clinician champion: Physicians, nurses, and other clinical staff reviewed data documenting the potential of the new protocols and processes to improve the quality of care. After reviewing the evidence, one anesthesiologist became so convinced that outcomes would improve that he took on the role of staunch advocate and champion for the approach, and successfully persuaded his colleagues to cooperate as well.
Creating visual cues and tools to make compliance easy: Baystate Medical Center staff created checklists and other tools to ensure that surgeons, anesthesiologists, and nurses could easily comply with the new processes, including the following:
Anesthesia sheets for anesthesiologists to record the administration of antibiotics
Surveys and checklists to map the correct flow of work
Visual prompts and reminders to administer antibiotics, placed in the perioperative nursing record and anesthesia record
Resources Used and Skills Needed
Staffing: An additional 1.5 full-time equivalent staff were added to manage data and work with surgical teams as change agents.
Costs: Costs to support the program were embedded into the quality improvement structure, so there were no additional costs associated with support of the program.
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Funding Sources
Baystate Medical Center

The program was funded internally by Baystate Medical Center. end fs
Tools and Other Resources
The guidelines for the American College of Chest Physicians' DVT prophylaxis are available at the National Guidelines Clearinghouse: http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=12956&string.

The CDC's Antimicrobial Resistance Interagency Task Force 2003 Annual Report is available at:
http://www.cdc.gov/DRUGRESISTANCE/actionplan/2003report/index.htm.

More information on the CDC's National Nosocomial Infections Surveillance System is available at:
http://www.cdc.gov/ncidod/dhqp/nnis_pubs.html.

Adoption Considerations
Getting Started with This Innovation
Collect baseline data: Collect baseline data on the timing of antibiotic administration and discontinuation, the administration of beta blockers, and the use of DVT prophylaxis. This analysis will reveal the greatest opportunities for improvement.
Engage senior leadership: Redesigning processes requires a leader who is interested, involved, and will push the message throughout the organization.
Identify a champion: Identify someone, ideally a respected clinician, as a champion for process redesign.
Gain staff support: Share data on the program’s potential effectiveness to win support among physicians, administrators, nurses, and other staff.
Clearly define roles and responsibilities: With clearly defined expectations, everyone knows what to do and why they are doing it. For example, the surgeon can be made responsible for prescribing antibiotics, the anesthesiologist for delivering them, and the surgeon for ensuring discontinuation. Each process step should link back to the person designated as responsible.
Start small: This program began by training a small group of anesthesiologists and surgeons whose patients were about to undergo cardiac and vascular surgery.
Involve staff: Include appropriate staff on the process redesign team, including front-line staff, anethesiologists, and others who will be using the protocols.
Sustaining This Innovation
Monitor progress: Routinely monitor patient charts to identify and strengthen any weak links in the process.
Educate staff: Hold frequent, regular meetings to create staff awareness of the process changes and discuss how best to put these changes into practice.
Encourage growth: Expand the program by having those involved bring the processes to new departments. At Baystate, the initial group of anesthesiologists and surgeons brought the new processes with them as they rotated to work with patients in other areas. As a result, the model spread throughout the hospital in 12 months.
Use By Other Organizations
Baystate Medical Center has partnered with several hospitals on the local and national level to share its experiences, including Berkshire Medical Center, Franklin Medical Center, Mary Lane Hospital, South Shore Hospital, and others.

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.
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1 Griffin FA. Reducing surgical complications. Jt Comm J Qual Patient Saf. 2007 Nov;33(11):660-5. [PubMed]

2 Colorado Foundation for Medical Care. Surgical Care Improvement Project [Web site]. 2007. Available at: http://www.cfmc.org/hospital/hospital_scip.htm.

3 Fitzgerald J, Kanter G, Benjamin E. Case study: preventing surgical complications at Baystate Medical Center. Jt Comm J Qual Patient Saf. 2007 Nov;33(11):666-71. [PubMed]

Innovation Profile Classification Disease/Clinical Category: Deep vein thrombosis; Nosocomial infection; Postoperative myocardial infarction; Surgical complications
Patient Population: Geographic Location > City
Stage of Care: Preventive care; Acute care
Setting of Care: Hospital Inpatient - Hospital Type > Teaching hospital, Hospital Inpatient - Services/Departments > Operating room/Surgical suite
Patient Care Process: Preventive Care Processes > Primary prevention; Active Care Processes: Diagnosis and Treatment > Infection control; Medication: ordering, transcription, administration, dispensing; Patient safety; Surgery; After Care Processes > Monitoring; Care Management Processes > Coordination of care; Procedure and policy compliance; Provider-provider communication
IOM Domains of Quality: Effectiveness; Safety
Organizational Processes: Policies and procedures; Process improvement; Technology - Other; Training, knowledge management
Developer: Baystate Medical Center
Funding Sources: Baystate Medical Center

Original publication: April 14, 2008.
Last updated: August 05, 2009.
Date verified by innovator: June 02, 2009.


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AHRQ Innovations Exchange | Standardized Processes Improve Adherence to Evidence-Based Protocols, Significantly Reducing Common Surgery-Related Complications