Department of Surgery, Johns Hopkins University, Baltimore, MD 21287, USA.
J Am Coll Surg. 2012 Aug;215(2):193-200. doi: 10.1016/j.jamcollsurg.2012.03.017. Epub 2012 May 24.
Surgical site infections (SSI) are a common and costly problem, prolonging hospitalization and increasing readmission. Adherence to well-known infection control process measures has not been associated with substantial reductions in SSI. To date, the global burden of preventable SSI continues to result in patient harm and increased health care costs on a broad scale.
We designed a study to evaluate the association between implementation of a surgery-based comprehensive unit-based safety program (CUSP) and postoperative SSI rates. One year of pre- and post-CUSP intervention SSI rates were collected using the high-risk pilot module of the American College of Surgeons National Surgical Quality Improvement Program (July 2009 to July 2011). The CUSP group met monthly and consisted of a multidisciplinary team of front-line providers (eg, surgeons, nurses, operating room technicians, and anesthesiologists) who were directly involved in the care of colorectal surgery patients. Surgical Care Improvement Project process measure compliance was monitored using standard methods from the Centers for Medicare and Medicaid Services.
In the 12 months before implementation of the CUSP and interventions, the mean SSI rate was 27.3% (76 of 278 patients). After commencement of interventions, the rate was 18.2% (59 of 324 patients) for the subsequent 12 months--a 33.3% decrease (95% CI, 9-58%; p < 0.05). The interventions included standardization of skin preparation; administration of preoperative chlorhexidine showers; selective elimination of mechanical bowel preparation; warming of patients in the preanesthesia area; adoption of enhanced sterile techniques for skin and fascial closure; addressing previously unrecognized lapses in antibiotic prophylaxis. There was no difference in surgical process measure compliance as measured by the Surgical Care Improvement Project during the same time period.
Formation of small groups of front-line providers to address patient harm using local wisdom and existing evidence can improve patient safety. We demonstrate a surgery-based CUSP intervention that might have markedly decreased SSI in a high-risk population.
手术部位感染（SSI）是一个常见且代价高昂的问题，会延长住院时间并增加再入院率。尽管人们一直坚持采用众所周知的感染控制流程措施，但 SSI 的发生率并未显著降低。迄今为止，全球范围内可预防的 SSI 负担仍然导致患者受到伤害，并在广泛范围内增加了医疗保健成本。
我们设计了一项研究，以评估实施基于手术的综合单位基础安全计划（CUSP）与术后 SSI 率之间的关联。使用美国外科医师学院国家外科质量改进计划（ACS NSQIP）高风险试点模块收集了 CUSP 干预前后一年的 SSI 发生率数据（2009 年 7 月至 2011 年 7 月）。CUSP 组每月开会，由一线提供者（如外科医生、护士、手术室技术人员和麻醉师）组成的多学科团队组成，他们直接参与结直肠手术患者的护理。使用医疗保险和医疗补助服务中心（CMS）的标准方法监测外科护理改进项目（Surgical Care Improvement Project，SCP）流程措施的合规性。
在实施 CUSP 和干预措施之前的 12 个月中，SSI 的平均发生率为 27.3%（278 例患者中有 76 例）。在开始干预措施之后的 12 个月中，后续的 SSI 发生率为 18.2%（324 例患者中有 59 例），下降了 33.3%（95%CI，9-58%；p<0.05）。干预措施包括标准化皮肤准备；术前氯己定沐浴；选择性消除机械性肠道准备；在麻醉前区域对患者进行加热；采用增强的皮肤和筋膜闭合的无菌技术；解决以前未被发现的抗生素预防措施的疏忽。在同一时期，SCP 测量的手术流程措施的合规性没有差异。
形成由一线提供者组成的小团体，利用当地智慧和现有证据来解决患者伤害问题，可以提高患者安全性。我们展示了一种基于手术的 CUSP 干预措施，该措施可能会显著降低高危人群的 SSI 发生率。
