SUSP Program Launched to Cut Surgical Site Infections

A new program being spearheaded by surgeons at Johns Hopkins University, Baltimore, and patient safety experts aims to dramatically reduce surgical site infections, which occur in almost a third of colorectal procedures and are a major reason for readmissions.

According to a fact sheet on the Surgical Unit-Based Safety Program (SUSP), each year about 50 million people undergo surgery in the United States. Of those, 1 million develop serious complications and more than 150,000 die within 30 days.

The goals of SUSP are to reduce surgical site infections (SSIs), to document use of checklistlike methods to improve safety, and to document the culture of safety through use of the Hospital Survey of Patient Safety Culture.

SUSP is designed to build on the success of the Comprehensive Unit-Based Safety Program (CUSP), which was developed by the Johns Hopkins Armstrong Institute for Patient Safety and Quality. Results of the CUSP program were recently reported in the Journal of the American College of Surgeons.

The CUSP Study

After CUSP was adopted in 2009 by colorectal surgeons at Johns Hopkins, colorectal surgical site infections were reduced by a third in the first year and saved the hospital $168,000-$280,000, according to the study (J. Am. Coll. Surg. 2012;215:193-200).

Surgical site infections occur in 15%-30% of colorectal procedures and lead to as much as $1 billion in costs for longer admissions, readmissions, and treatment.

"Until now, there’s been little evidence on how to effectively address SSIs among this group of patients," said Dr. Elizabeth Wick of the department of surgery at Johns Hopkins, who was the lead investigator.

Dr. Wick and her associates analyzed outcomes after implementation of CUSP, which was developed by Dr. Peter Pronovost, director of the Armstrong Institute at Hopkins

The Hopkins colorectal CUSP team of 36 people included a representative from surgery, nursing, and anesthesia; a team coach; and a hospital executive who was committed to helping the project, according to the researchers.

After attending a lecture on patient safety, all members of the team completed an anonymous two-question assessment that asked how an SSI might develop in the next patient and what could be done to prevent it.

The team identified 95 areas of concern and picked six interventions to focus on to improve care: standardization of skin preparation and prescription of chlorhexidine showers; restricted use of oral bowel-cleansing solution before a procedure; warming of patients in the preanesthesia area; adoption of enhanced sterile techniques for bowel and skin; and addressing lapses in preoperative prophylactic antibiotics.

The team met monthly, using checklists and monitoring progress to address problems quickly. "The benefits of a bottom-up vs. a top-down approach to patient safety were immediately obvious," said Dr. Wick in a statement.

The study consisted of all consecutive colorectal surgery patients who were included in the American College of Surgeons’ NSQIP (National Surgical Quality Improvement Program) from July 2009 to July 2011. Procedures included open and laparoscopic colectomies and proctectomies, but not abdominal perineal resections. SSI rates that were collected using NSQIP were compared from the first year (2009-2010) to the second year (2010-2011); there were 278 patients in the first cohort and 324 in the second.

During that first year, the 27% (76) of patients had an SSI. By the second year, only 18% (59) of patients had an infection, for a decrease of 33%.

The authors said that CUSP seems to be effective, in part because it bridges the divide between frontline staff and senior leaders. The NSQIP outcome measures also helped the team to effectively monitor SSI rates, said the authors.

CUSP/SUSP in Practice

The CUSP model has been applied successfully to decrease central line–associated bloodstream infections in the intensive care unit, as well as to cut mortality and length of stay in a statewide program, the MHA (Michigan Health and Hospital Association) Keystone Intensive Care Unit project.

The elements of CUSP are not well validated in the operating room, however, and there’s little data on how the program could potentially impact other types of infections or complications – even though the program is in use at 1,200 ICUs in 47 states, said Dr. Sean M. Berenholtz, physician director of inpatient quality and safety at the Armstrong Institute. The aim of the SUSP is to adapt the CUSP practices to the OR, Dr. Berenholtz said in an interview.

Project teams consisting of experts from the Agency for Healthcare Research and Quality (AHRQ), the Armstrong Institute, the American College of Surgeons, the University of Pennsylvania in Philadelphia, and the World Health Organization’s Patient Safety Programme will assist SUSP participants.

The CUSP model combines knowledge from both clinical science and social science. The first step is to educate staff on the science of patient safety – most importantly, communicating the idea that "the vast majority of preventable complications don’t belong to an individual surgeon or an individual nurse," but occur within the organization of the health care system, Dr. Berenholtz said.

The project leaders then ask the staff to complete an anonymous, two-question assessment that gauges their experience of how complications develop and what might be done to prevent them. Next, a unit-based improvement team is assigned an executive partner from the Armstrong Institute who meets with the team at least monthly to help prioritize improvement efforts and lead them through any bureaucratic hurdles they may face at their hospitals. Goals are set and agreed upon.

The team then tries to learn from "defects" within the process, and identifies ways to prevent mistakes, especially among the surgeons, nurses, anesthesiologists, and technicians who work in the OR. Finally, tools such as checklists are used to foster teamwork and improvement. SUSP leaders will ask improvement teams to use "briefings" and "debriefings" to learn from mistakes and move forward.

There’s plenty of motivation for hospitals to want to reduce SSIs. The Centers for Medicare and Medicaid Services, as part of the Surgical Care Improvement Project (SCIP), requires public reporting of surgical quality measures, including SSIs.

For instance, hospitals are supposed to report whether patients are given the right antibiotic at the right time. But the measure doesn’t tell anyone whether the patient’s outcome actually improved, noted Dr. Berenholtz. The SUSP goes beyond those SCIP measures to determine which factors at the local level might lead to SSIs at that particular facility, and to identify what intervention works at that particular location.

"It’s clear that there is no single fix for surgical site infections in colorectal surgery," said Dr. Wick, who has worked on content for the SUSP and has helped to present it to interested facilities.

"There are best practices, but not a clear-cut bundle; so for each hospital, whatever they implement will be a little different," she said, adding that the SUSP allows each facility to tailor interventions and improvements to its particular environment.

The AHRQ is funding the 4-year SUSP initiative. Initially, the focus will be on colorectal surgery, but the program will expand to other surgical specialties with the aim of preventing harm from complications such as pneumonia, pulmonary embolisms, and deep vein thrombosis, said Dr. Berenholtz, who is also with the department of surgery and the department of anesthesia and critical care medicine at Johns Hopkins.

The first cohort of hospitals to participate in the SUSP will be in Tennessee, Colorado, and Florida, with a second cohort slated to begin in September. It is not clear exactly how many hospitals will be involved; SUSP organizers are waiting to receive all final letters of commitment, Dr. Berenholtz said. The aim is to reach as many hospitals as possible; there is no upper limit on participants.

An electronic health record is not required for participation, but hospitals need to be able to collect data on the incidence of SSIs.

The organizers are primarily going through the CMS-funded Hospital Engagement Networks (HENs). These are state, local, and regional networks that began forming in December 2011 and will work to develop learning collaboratives for hospitals, as well as provide patient safety initiatives such as the SUSP.

At the end of the 4 years, it is hoped that the HENs will continue to find ways to reduce complications and improve patient safety, Dr. Berenholtz said.

"We hope it ends up that hundreds – if not thousands – of lives will be saved," he said.

Dr. Berenholtz disclosed that he receives grant funding from the Agency for Healthcare Research and Quality, the National Institutes of Health, and the Robert Wood Johnson Foundation, and that he has received speaking honoraria from various hospitals related to patient safety and quality. Dr. Wick and her coauthors reported no conflicts.

A new program being spearheaded by surgeons at Johns Hopkins University, Baltimore, and patient safety experts aims to dramatically reduce surgical site infections, which occur in almost a third of colorectal procedures and are a major reason for readmissions.

According to a fact sheet on the Surgical Unit-Based Safety Program (SUSP), each year about 50 million people undergo surgery in the United States. Of those, 1 million develop serious complications and more than 150,000 die within 30 days.

The goals of SUSP are to reduce surgical site infections (SSIs), to document use of checklistlike methods to improve safety, and to document the culture of safety through use of the Hospital Survey of Patient Safety Culture.

SUSP is designed to build on the success of the Comprehensive Unit-Based Safety Program (CUSP), which was developed by the Johns Hopkins Armstrong Institute for Patient Safety and Quality. Results of the CUSP program were recently reported in the Journal of the American College of Surgeons.

The CUSP Study

After CUSP was adopted in 2009 by colorectal surgeons at Johns Hopkins, colorectal surgical site infections were reduced by a third in the first year and saved the hospital $168,000-$280,000, according to the study (J. Am. Coll. Surg. 2012;215:193-200).

Surgical site infections occur in 15%-30% of colorectal procedures and lead to as much as $1 billion in costs for longer admissions, readmissions, and treatment.

"Until now, there’s been little evidence on how to effectively address SSIs among this group of patients," said Dr. Elizabeth Wick of the department of surgery at Johns Hopkins, who was the lead investigator.

Dr. Wick and her associates analyzed outcomes after implementation of CUSP, which was developed by Dr. Peter Pronovost, director of the Armstrong Institute at Hopkins

The Hopkins colorectal CUSP team of 36 people included a representative from surgery, nursing, and anesthesia; a team coach; and a hospital executive who was committed to helping the project, according to the researchers.

After attending a lecture on patient safety, all members of the team completed an anonymous two-question assessment that asked how an SSI might develop in the next patient and what could be done to prevent it.

The team identified 95 areas of concern and picked six interventions to focus on to improve care: standardization of skin preparation and prescription of chlorhexidine showers; restricted use of oral bowel-cleansing solution before a procedure; warming of patients in the preanesthesia area; adoption of enhanced sterile techniques for bowel and skin; and addressing lapses in preoperative prophylactic antibiotics.

The team met monthly, using checklists and monitoring progress to address problems quickly. "The benefits of a bottom-up vs. a top-down approach to patient safety were immediately obvious," said Dr. Wick in a statement.

The study consisted of all consecutive colorectal surgery patients who were included in the American College of Surgeons’ NSQIP (National Surgical Quality Improvement Program) from July 2009 to July 2011. Procedures included open and laparoscopic colectomies and proctectomies, but not abdominal perineal resections. SSI rates that were collected using NSQIP were compared from the first year (2009-2010) to the second year (2010-2011); there were 278 patients in the first cohort and 324 in the second.

During that first year, the 27% (76) of patients had an SSI. By the second year, only 18% (59) of patients had an infection, for a decrease of 33%.

The authors said that CUSP seems to be effective, in part because it bridges the divide between frontline staff and senior leaders. The NSQIP outcome measures also helped the team to effectively monitor SSI rates, said the authors.

CUSP/SUSP in Practice

The CUSP model has been applied successfully to decrease central line–associated bloodstream infections in the intensive care unit, as well as to cut mortality and length of stay in a statewide program, the MHA (Michigan Health and Hospital Association) Keystone Intensive Care Unit project.

The elements of CUSP are not well validated in the operating room, however, and there’s little data on how the program could potentially impact other types of infections or complications – even though the program is in use at 1,200 ICUs in 47 states, said Dr. Sean M. Berenholtz, physician director of inpatient quality and safety at the Armstrong Institute. The aim of the SUSP is to adapt the CUSP practices to the OR, Dr. Berenholtz said in an interview.

Project teams consisting of experts from the Agency for Healthcare Research and Quality (AHRQ), the Armstrong Institute, the American College of Surgeons, the University of Pennsylvania in Philadelphia, and the World Health Organization’s Patient Safety Programme will assist SUSP participants.

The CUSP model combines knowledge from both clinical science and social science. The first step is to educate staff on the science of patient safety – most importantly, communicating the idea that "the vast majority of preventable complications don’t belong to an individual surgeon or an individual nurse," but occur within the organization of the health care system, Dr. Berenholtz said.

The project leaders then ask the staff to complete an anonymous, two-question assessment that gauges their experience of how complications develop and what might be done to prevent them. Next, a unit-based improvement team is assigned an executive partner from the Armstrong Institute who meets with the team at least monthly to help prioritize improvement efforts and lead them through any bureaucratic hurdles they may face at their hospitals. Goals are set and agreed upon.

The team then tries to learn from "defects" within the process, and identifies ways to prevent mistakes, especially among the surgeons, nurses, anesthesiologists, and technicians who work in the OR. Finally, tools such as checklists are used to foster teamwork and improvement. SUSP leaders will ask improvement teams to use "briefings" and "debriefings" to learn from mistakes and move forward.

There’s plenty of motivation for hospitals to want to reduce SSIs. The Centers for Medicare and Medicaid Services, as part of the Surgical Care Improvement Project (SCIP), requires public reporting of surgical quality measures, including SSIs.

For instance, hospitals are supposed to report whether patients are given the right antibiotic at the right time. But the measure doesn’t tell anyone whether the patient’s outcome actually improved, noted Dr. Berenholtz. The SUSP goes beyond those SCIP measures to determine which factors at the local level might lead to SSIs at that particular facility, and to identify what intervention works at that particular location.

"It’s clear that there is no single fix for surgical site infections in colorectal surgery," said Dr. Wick, who has worked on content for the SUSP and has helped to present it to interested facilities.

"There are best practices, but not a clear-cut bundle; so for each hospital, whatever they implement will be a little different," she said, adding that the SUSP allows each facility to tailor interventions and improvements to its particular environment.

The AHRQ is funding the 4-year SUSP initiative. Initially, the focus will be on colorectal surgery, but the program will expand to other surgical specialties with the aim of preventing harm from complications such as pneumonia, pulmonary embolisms, and deep vein thrombosis, said Dr. Berenholtz, who is also with the department of surgery and the department of anesthesia and critical care medicine at Johns Hopkins.

The first cohort of hospitals to participate in the SUSP will be in Tennessee, Colorado, and Florida, with a second cohort slated to begin in September. It is not clear exactly how many hospitals will be involved; SUSP organizers are waiting to receive all final letters of commitment, Dr. Berenholtz said. The aim is to reach as many hospitals as possible; there is no upper limit on participants.

An electronic health record is not required for participation, but hospitals need to be able to collect data on the incidence of SSIs.

The organizers are primarily going through the CMS-funded Hospital Engagement Networks (HENs). These are state, local, and regional networks that began forming in December 2011 and will work to develop learning collaboratives for hospitals, as well as provide patient safety initiatives such as the SUSP.

At the end of the 4 years, it is hoped that the HENs will continue to find ways to reduce complications and improve patient safety, Dr. Berenholtz said.

"We hope it ends up that hundreds – if not thousands – of lives will be saved," he said.

Dr. Berenholtz disclosed that he receives grant funding from the Agency for Healthcare Research and Quality, the National Institutes of Health, and the Robert Wood Johnson Foundation, and that he has received speaking honoraria from various hospitals related to patient safety and quality. Dr. Wick and her coauthors reported no conflicts.

A new program being spearheaded by surgeons at Johns Hopkins University, Baltimore, and patient safety experts aims to dramatically reduce surgical site infections, which occur in almost a third of colorectal procedures and are a major reason for readmissions.

According to a fact sheet on the Surgical Unit-Based Safety Program (SUSP), each year about 50 million people undergo surgery in the United States. Of those, 1 million develop serious complications and more than 150,000 die within 30 days.

The goals of SUSP are to reduce surgical site infections (SSIs), to document use of checklistlike methods to improve safety, and to document the culture of safety through use of the Hospital Survey of Patient Safety Culture.

SUSP is designed to build on the success of the Comprehensive Unit-Based Safety Program (CUSP), which was developed by the Johns Hopkins Armstrong Institute for Patient Safety and Quality. Results of the CUSP program were recently reported in the Journal of the American College of Surgeons.

The CUSP Study

After CUSP was adopted in 2009 by colorectal surgeons at Johns Hopkins, colorectal surgical site infections were reduced by a third in the first year and saved the hospital $168,000-$280,000, according to the study (J. Am. Coll. Surg. 2012;215:193-200).

Surgical site infections occur in 15%-30% of colorectal procedures and lead to as much as $1 billion in costs for longer admissions, readmissions, and treatment.

"Until now, there’s been little evidence on how to effectively address SSIs among this group of patients," said Dr. Elizabeth Wick of the department of surgery at Johns Hopkins, who was the lead investigator.

Dr. Wick and her associates analyzed outcomes after implementation of CUSP, which was developed by Dr. Peter Pronovost, director of the Armstrong Institute at Hopkins

The Hopkins colorectal CUSP team of 36 people included a representative from surgery, nursing, and anesthesia; a team coach; and a hospital executive who was committed to helping the project, according to the researchers.

After attending a lecture on patient safety, all members of the team completed an anonymous two-question assessment that asked how an SSI might develop in the next patient and what could be done to prevent it.

The team identified 95 areas of concern and picked six interventions to focus on to improve care: standardization of skin preparation and prescription of chlorhexidine showers; restricted use of oral bowel-cleansing solution before a procedure; warming of patients in the preanesthesia area; adoption of enhanced sterile techniques for bowel and skin; and addressing lapses in preoperative prophylactic antibiotics.

The team met monthly, using checklists and monitoring progress to address problems quickly. "The benefits of a bottom-up vs. a top-down approach to patient safety were immediately obvious," said Dr. Wick in a statement.

The study consisted of all consecutive colorectal surgery patients who were included in the American College of Surgeons’ NSQIP (National Surgical Quality Improvement Program) from July 2009 to July 2011. Procedures included open and laparoscopic colectomies and proctectomies, but not abdominal perineal resections. SSI rates that were collected using NSQIP were compared from the first year (2009-2010) to the second year (2010-2011); there were 278 patients in the first cohort and 324 in the second.

During that first year, the 27% (76) of patients had an SSI. By the second year, only 18% (59) of patients had an infection, for a decrease of 33%.

The authors said that CUSP seems to be effective, in part because it bridges the divide between frontline staff and senior leaders. The NSQIP outcome measures also helped the team to effectively monitor SSI rates, said the authors.

CUSP/SUSP in Practice

The CUSP model has been applied successfully to decrease central line–associated bloodstream infections in the intensive care unit, as well as to cut mortality and length of stay in a statewide program, the MHA (Michigan Health and Hospital Association) Keystone Intensive Care Unit project.

The elements of CUSP are not well validated in the operating room, however, and there’s little data on how the program could potentially impact other types of infections or complications – even though the program is in use at 1,200 ICUs in 47 states, said Dr. Sean M. Berenholtz, physician director of inpatient quality and safety at the Armstrong Institute. The aim of the SUSP is to adapt the CUSP practices to the OR, Dr. Berenholtz said in an interview.

Project teams consisting of experts from the Agency for Healthcare Research and Quality (AHRQ), the Armstrong Institute, the American College of Surgeons, the University of Pennsylvania in Philadelphia, and the World Health Organization’s Patient Safety Programme will assist SUSP participants.

The CUSP model combines knowledge from both clinical science and social science. The first step is to educate staff on the science of patient safety – most importantly, communicating the idea that "the vast majority of preventable complications don’t belong to an individual surgeon or an individual nurse," but occur within the organization of the health care system, Dr. Berenholtz said.

The project leaders then ask the staff to complete an anonymous, two-question assessment that gauges their experience of how complications develop and what might be done to prevent them. Next, a unit-based improvement team is assigned an executive partner from the Armstrong Institute who meets with the team at least monthly to help prioritize improvement efforts and lead them through any bureaucratic hurdles they may face at their hospitals. Goals are set and agreed upon.

The team then tries to learn from "defects" within the process, and identifies ways to prevent mistakes, especially among the surgeons, nurses, anesthesiologists, and technicians who work in the OR. Finally, tools such as checklists are used to foster teamwork and improvement. SUSP leaders will ask improvement teams to use "briefings" and "debriefings" to learn from mistakes and move forward.

There’s plenty of motivation for hospitals to want to reduce SSIs. The Centers for Medicare and Medicaid Services, as part of the Surgical Care Improvement Project (SCIP), requires public reporting of surgical quality measures, including SSIs.

For instance, hospitals are supposed to report whether patients are given the right antibiotic at the right time. But the measure doesn’t tell anyone whether the patient’s outcome actually improved, noted Dr. Berenholtz. The SUSP goes beyond those SCIP measures to determine which factors at the local level might lead to SSIs at that particular facility, and to identify what intervention works at that particular location.

"It’s clear that there is no single fix for surgical site infections in colorectal surgery," said Dr. Wick, who has worked on content for the SUSP and has helped to present it to interested facilities.

"There are best practices, but not a clear-cut bundle; so for each hospital, whatever they implement will be a little different," she said, adding that the SUSP allows each facility to tailor interventions and improvements to its particular environment.

The AHRQ is funding the 4-year SUSP initiative. Initially, the focus will be on colorectal surgery, but the program will expand to other surgical specialties with the aim of preventing harm from complications such as pneumonia, pulmonary embolisms, and deep vein thrombosis, said Dr. Berenholtz, who is also with the department of surgery and the department of anesthesia and critical care medicine at Johns Hopkins.

The first cohort of hospitals to participate in the SUSP will be in Tennessee, Colorado, and Florida, with a second cohort slated to begin in September. It is not clear exactly how many hospitals will be involved; SUSP organizers are waiting to receive all final letters of commitment, Dr. Berenholtz said. The aim is to reach as many hospitals as possible; there is no upper limit on participants.

An electronic health record is not required for participation, but hospitals need to be able to collect data on the incidence of SSIs.

The organizers are primarily going through the CMS-funded Hospital Engagement Networks (HENs). These are state, local, and regional networks that began forming in December 2011 and will work to develop learning collaboratives for hospitals, as well as provide patient safety initiatives such as the SUSP.

At the end of the 4 years, it is hoped that the HENs will continue to find ways to reduce complications and improve patient safety, Dr. Berenholtz said.

"We hope it ends up that hundreds – if not thousands – of lives will be saved," he said.

Dr. Berenholtz disclosed that he receives grant funding from the Agency for Healthcare Research and Quality, the National Institutes of Health, and the Robert Wood Johnson Foundation, and that he has received speaking honoraria from various hospitals related to patient safety and quality. Dr. Wick and her coauthors reported no conflicts.