What Was Done?
Global Problem Addressed
While technology has continued to advance the surgical field toward more minimally invasive, cost-conscious, patient satisfaction driven procedures, the battle to prevent surgical complications has also taken center stage as a means to improve patient outcomes and reduce overall health care costs for both patients and hospitals. Complications and their associated costs after surgical intervention vary widely in both complexity and cost. Wound infections alone can vary from estimated costs of $400 to $30,000 dependent on complexity.1 Major surgeries with significant complications, including those requiring re-operation, can surge cost by five times, approximating an increase of $159,345 per case.2 Many guidelines and initiatives have been developed to reduce surgical complications. Initiatives like Enhanced Recovery After Surgery (ERAS) have greatly reduced complications, re-operations, and readmissions all while improving costs and satisfaction.3 Ideally, developing an overall plan that incorporates a multi-initiative approach to reduce complications and minimize returns to the operating room while decreasing length of stay and improving patient satisfaction is key.
Identification of Local Problem
In 2017, an initiative was started within our facility to increase efficiency, quality of care, and safety within the operating room at Holston Valley Medical Center. During a retrospective review of cases, concern arose regarding patient returns to the operating room. These issues were brought to light when multiple returns labeled as “planned,” consisting often of acute care surgical patients left in discontinuity with wound vacs, were called out as a concern for quality of care. As an example, a single patient experienced more than 30 returns to the operating room by multiple surgeons. While a reasonable number of returns to the operating room are expected, we began our journey reviewing all returns in attempt to identify specific areas of improvement. Review of the nearly 11,000 cases performed yearly in the main operating room at our facility demonstrated that one out of every six patients experienced a return to the operating room, most of which were unplanned. These returns led to decreased patient satisfaction and increased health care cost not only for the hospital, but more importantly the patient. The return cases were clustered between acute care surgery and orthopaedic surgery, many which were emergent/urgent in nature.
Our goal was to focus on improving quality of care by working through a team effort to identify and reduce returns to the operating room while improving overall outcomes. We identified that critical to the success of this project was the cooperative involvement of our quality team, surgeons, and operating room team, combined with overall support of our hospital’s administrative team. Of upmost importance was obtaining surgeon buy-in while maintaining a non-punitive approach in both case review and communication.
How Was the Quality Improvement (QI) Activity Put in Place?
Context of the QI Activity
Holston Valley Medical Center is a not-for-profit, tertiary center located in Kingsport, TN. During the time this initiative was started, Holston Valley served as one of two Level I trauma centers in our region. Since that time, Holston Valley has undergone a merger into a larger system, Ballad Health. In order to minimize duplication and better serve our communities, Holston Valley became a Level III trauma center while remaining a large tertiary care center in our region.
Since 2016, Holston Valley has participated in the American College of Surgeons National Surgical Quality Improvement Project. We are an active member in the Tennessee Surgical Quality Collaborative. Our involvement in both these areas dramatically increased from 2016 forward. As a result, our focus turned to improving areas demonstrated on our ACS NSQIP risk-adjusted score card.
While focusing on overall improvements in surgical site infections, length of stay, and moving forward with starting our ERAS program, reducing returns to the operating room became a priority.
Planning and Development Process
Once our return to the operating room rates were determined to be 16.67 percent, we knew as a facility that we must act swiftly. The process for improvement started by designating that all cases that returned to the operating room within thirty days of the original operation would be reviewed weekly then presented to an overseeing committee, the Incident Review Committee (IRC). Additional review can be provided if necessary at monthly Peer Review or existing Quality Committee meetings. These committees report to the Medical Executive Committee which in turn reports to the Community Board for Holston Valley.
In order to obtain buy-in from the surgeons, establishing their involvement early was critical. The Medical Director of the Operating Room, a surgeon, reviewed all return to the operating room cases. Once presented to the IRC, the attending surgeon was sent a letter either stating that there were no concerns of care identified or asking for further explanation. This letter serves to keep the surgeon in the loop for which cases are being reviewed and allows them active participation in the quality review process. With consensus reached amongst surgeons that reducing returns and therefore improving patient care, our project moved forward rapidly.
Description of the Quality Improvement Activity
Having garnered the support of both surgeons and administration, we began outlining a clear process that incorporated both the involvement of our quality team and our medical staff to facilitate change. The overall process was two-pronged.
First, we established a process to review each return to the operating room. Second, we focused on changes that can be made in the operating room to reduce potential causes for unplanned returns.
In regard to the review process for returns to the operating room, we developed the policy to review all returns to the operating room on a case-by-case basis, regardless of whether the return was planned or unplanned. In addition, any case, for which a concern is identified, whether it involves a return to the operating room or not, can be reported through the incident report system by any staff member. This has allowed all staff members to feel empowered to report quality of care concerns in real-time for evaluation. Each return to the operating room or reported concern is reviewed in detail by the Medical Director of the Operating Room, a fellow surgeon.
Once the case is reviewed, the Medical Director reports the details of the case along with a recommendation to either validate, invalidate, or request further review to the IRC. The IRC consists of the Chief Medical Officer (CMO), Medical Staff Executive committee (President, President-Elect, Past President, and Secretary/Treasurer), Quality Physician Chair, Quality Manager, Risk Management, Chief Nursing Officer (CNO), and Pharmacy Director. At this point, the reviewed case can be deemed invalid with no concerns, valid with concerns, recommended to Peer Review for that specialty for further evaluation, or request explanation from the surgeon. Peer Review recommendations are made to the Quality Committee which forwards information to the Medical Executive Committee. Validated concerns are placed on the surgeons Ongoing Professional Practice Evaluation (OPPE) Scorecard for two years. The surgeon is contacted throughout the course of the review by letter for full transparency and allowed to contribute in dialog throughout.
The second arm of our approach to quality improvement focused on reducing potential risks contributing to returns in the operating room. A considerable portion of the focus in the area utilized a team of Infection Prevention, Quality, and Operating Room Management who drove an initiative of re-education. Emphasis was placed on reinforcing sterilization techniques, re-educating to ensure proper hand scrubbing, and patient optimization as the patient moved through all phases of the operating room. Traffic in and out of the individual operating suites was minimized. Vendors were monitored to ensure scrubs were changed, movement in and out of the operating suite was reduced, and re-education performed to reiterate not violating sterile field.
In conjunction with the implementation of our return to the operating room reduction initiative in late 2018, other initiatives contributed to reduction in returns. In November 2016 a colorectal bundle aimed to reduce colon surgical site infections was started. ERAS protocols were implemented in April 2017. Both these initiatives, as a result of reduction in surgical complications in colorectal patients, assisted with returns to the operating room and improved quality of care.
The orthopedists assisted during the initiative by helping to develop appropriate guidelines governing elective orthopaedic cases. These guidelines established body mass index (BMI) and glucose (A1C) parameters that determine if a patient qualifies for elective orthopaedic surgeries, or if weight loss/improved glucose control is required before a case can be scheduled. Appropriate antibiotic use was also closely monitored. In order to further contribute, Orthopaedics Peer Review specifically requested to review all joint infections that occur on a monthly basis.
Resources Used and Skills Needed
Staff
The staffing required for this quality improvement project was filled with existing staff members. Those staff members included: perioperative and surgical nursing staff, Operating Room Manager, Quality nurse, and Risk Management Staff member. Leadership included: CMO, CNO, Medical Director of the Operating Room, Medical Executive Committee Staff, Quality Chair. No additional staffing positions were created for this initiative. All surgeons actively participated on an as needed basis depending on cases reviewed.
Costs
No additional costs were created beyond existing costs.
Funding Sources, If Any
Funding in the form of an annual stipend from the Tennessee Surgical Quality Collaborative was utilized in the colorectal bundle and ERAS patient information and signs that contributed to this initiative.
What Were the Results?
Overall Results
When the percentage of returns to the operating room were calculated for 2017 and 2018 prior to our initiative, the data resulted with rates of return at 16.1 percent and 15 percent respectively. The raw numbers were 1,736 of 10,769 cases in 2017 experienced a return to the Operating Room. For 2018, 1,611 of 10,763 cases experienced a return. Clearly these numbers were unacceptable and demonstrate why our initiative became a priority.
After the call to action was made and a plan for a quality initiative focusing on reducing unnecessary set in motion, dramatic results followed. We calculated.
our monthly returns to the operating for all cases, planned and unplanned, from January through August of 2019. It is important to note that starting in September of 2019, Holston Valley Medical Center made the transition from a Level I to Level III trauma center. In order to preserve the integrity of the data, we stopped our data collection for this case study at that transition time. We continue to collect our return to the operating room data, but beyond that time it is not included. The results demonstrated that Holston Valley saw a reduction in returns to the operating room for all cases to 8.2 percent (Table 1).
