Focus: Prevent surgical site infections
“The benefits to the patient of reducing SSIs can mean decreased risk of readmission, reduced need for antibiotics, and a lower rate of emergency room admissions and further procedures,” says Shaina Eckhouse, MD, a Washington University weight-loss surgeon who led the safety effort.
SSIs are a common complication following bariatric surgery, with a national incidence ranging from 1.7 percent to 15 percent. In addition to increased length of hospital stays, readmissions and costs, they are associated with higher mortality rates.
Declines in SSIs were the result of a quality-improvement project undertaken by the Washington University Weight Loss Surgery Program as a part of the Metabolic and Bariatric Surgery Accreditation and Quality-Improvement Program (MBSAQIP). Bariatric surgery outcomes are better at MBSAQIP-accredited centers.*
In 2015, when the SSI rate for weight loss surgery patients was 5.9 percent, the program adopted an infection prevention protocol that included the use of chlorhexidine antiseptic showers the night before, and the morning of, surgery. It also included chlorhexidine wipes immediately before the operation and routine cultures of potential SSIs.
In 2016, the SSI rate dropped to 2.1 percent. A follow-up protocol was then implemented that included additional antibiotic coverage for penicillin-allergic patients and more selective use of surgical drain placement. Drains previously were routinely used to identify leaks, a serious but low-incidence complication to bariatric surgery that is associated with high rates of surgical site infections. Now, if a leak test performed in the operating room is negative, a drain is not placed.
In 2017, SSI rates dropped another 1.3 percent to 0.8 percent, demonstrating a highly successful initiative.
*Azagury D, Morton J. Bariatric Surgery Outcomes in US Accredited vs Nonaccredited Centers: A Systematic Review. Journal of the American College of Surgeons. 2016,223(3):469-477.
Hospital readmissions dropped from 11.9 percent in 2016 to 6.8 percent in 2017 after Washington University weight loss surgeons began using an improved readmissions bundle. The bundle expanded peri-operative education; increased use of an infusion clinic; created a 23-hour post-operative observation for nausea, vomiting and dehydration; developed a patient magnet with important information and phone numbers; and offered daily bariatric clinics for patients needing same-day appointments. The bariatric program retrospectively reviewed data on all 30-day readmissions from January 2015 to October 2017 as part of the study. The team included bariatric surgeons Shaina Eckhouse, MD, Arghavan Salles, MD, PhD, J. Christopher Eagon, MD, and Dawn Freeman, RN, MSHI, CNOR.
Minimally Invasive Surgery Chief L. Michael Brunt, MD, and others in the section studied the effects of reclassifying the opioid hydrocodone from Schedule III to II, preventing patients from being able to call in for refills. Analyzing opioid prescriptions for common surgeries at Barnes-Jewish Hospital from 2013 to 2016, the researchers noted that prescriptions for oxycodone (stronger but also a Schedule II drug) and tramadol (for moderate to moderately severe pain) increased, but the schedule change did not affect mean milligram morphine equivalents, or cumulative intake of opioid drugs, prescribed for most procedures. They concluded more research is needed to develop appropriate opioid prescription guidelines. The study was published in the August 2018 issue of Surgery.
To help create better opioid guidelines and a patient education program on opioid use after surgery, the sections of minimally invasive, colon and rectal, and endocrine and oncologic surgery received a $60,000 grant from The Foundation for Barnes-Jewish Hospital.