SVMC Improves Post-Op Colectomy Care

When the SVMC general surgeons learned that they were having a string of poor outcomes with their colectomy cases, they requested a comprehensive review of these cases in an effort to learn what might be going wrong. 

The patient safety improvement initiative that resulted is now completed; however, not enough outcome data has been tabulated to highlight all of the promising changes.  The narrative below lays out the problem, the improvement strategies, and some early conclusions.

The springboard for this effort was a dramatic rise in the infection rate following colectomy procedures.  The 2003 rate was 9.43%, the 2004 rate was 5.08%, and the rate for 2005 was 20.69%.  Upon further investigation, we learned that in one 3-month period, the infection rate jumped to 40%!  Although there were several types of infections, the most prevalent of those was the infection that results from an anastamotic leak.  Our Medical Director for the Physician-Hospital Organization reported that the LOS for colectomy cases was in the top 10 for our hospital, with many of the infection cases racking up very long LOS. 

We established an interdisciplinary group to address this matter.  Our members included professionals from Infection Control, Perioperative Services, and Quality.  Following a review of the literature, we identified the recommended management strategies following a colectomy procedure, including such things as:  patient body temperature, antibiotic administration, adhesions, blood loss, steroid use, and oxygen administration.  We learned that we had some variation in the timing of our antibiotic administration, in the use of post-op oxygen, and the maintenance of a stable body temperature.  We also learned that there were some differences in model and sizing of the stapling device.  In keeping with patient safety philosophies, we wanted to establish a highly reliable system of post-op colectomy care.

The two key improvements were:

1. Develop standardized pre- and post-op colectomy orders that include the specific "best practice" management strategies found to be sometimes deficient in the previous cases and
2. Decide on the use of one model of stapler device and through in-service training, improve surgeon's technique in using the stapler device.

The surgical orders took quite a bit of time to develop.  First the individual surgeons needed to agree on each practice element.  Several times there were differences of opinion that necessitated one of the surgeons going to the literature to learn the practices that produce the best outcomes.  Next, the draft orders needed to be reviewed by the people that receive orders:  nurses, laboratory technicians, unit coordinators, and pharmacists.  Each representative offered their own interpretation of the order language and so considerable negotiation was undertaken to get the document to reflect what all parties would consistently understand. 

The orders went live just two months ago, so it is too early to tell if the clinical outcomes have improved.  Preliminary feedback from the PHO indicates that colectomy cases are no longer on the top 10 LOS for the hospital.  The Infection Control office reports a decline in the number of infections following colectomy procedures.  The surgeons report satisfaction using the new order forms.  And nurses are happy to have clearly written, reliable order sets to work from.  In another 6 months we should have a large enough sample size to publish more specific data.