Impact of surgeon-specific feedback on surgical site infection rates in Thailand

Effect of surgeon-specific feedback on surgical outcomes: a systematic review of the literature

BACKGROUND

Surgeon-specific outcome reporting provides an opportunity for quality assurance and improved surgical results. It is becoming increasingly prevalent and remains contentious amongst surgeons. The purpose of this systematic review was to evaluate the extent to which published literature supports the concept that feedback of surgeon-level outcomes reduces morbidity and/or mortality. No systematic reviews have previously been completed on this subject.

METHODS

Medline and Embase were systematically searched for studies published prior to the 1st of January 2022. Feedback was defined as a summary of clinical performance over a specified period of time provided in written, electronic or verbal format. Studies were required to provide surgeon-specific feedback to multiple individual consultant surgeons with the primary purpose being to determine if feedback improved outcomes. Primary outcome(s) needed to relate to surgical outcomes as opposed to process measures only. All surgical specialties and procedures were eligible for inclusion.

RESULTS

Seventeen studies were included in the review, traversing a wide range of specialties and procedures. Sixteen were non-randominsed and one randomized. Fifteen were before and after studies. The balance of the non-randomized studies support the concept that provision of surgeon-specific feedback can improve surgical outcomes, while the single randomized study suggests feedback may not be effective.

CONCLUSIONS

This systematic review supports the use of surgeon-level feedback to improve outcomes. The strength of this finding is limited by reliance on before and after studies, further randomized studies on this subject would be insightful.

The Effect of Feedback on Surgeon Performance: A Narrative Review

Surgeons play a critical role in the healthcare community and provide a service that can tremendously impact patients' livelihood. However, there are relatively few means for monitoring surgeons' performance quality and seeking improvement. Surgeon-level data provide an important metric for quality improvement and future training. A narrative review was conducted to analyze the utility of providing surgeons direct feedback on their individual performance. The articles selected identified means of collecting surgeon-specific data, suggested ways to report this information, identified pertinent gaps in the field, and concluded the results of giving feedback to surgeons. There is a relative sparsity of data pertaining to the effect of providing surgeons with information regarding their individual performance. However, the literature available does suggest that providing surgeons with individualized feedback can help make meaningful improvements in the quality of practice and can be done in a way that is safe for the surgeons' reputation.

Safety in the operating theatre--a transition to systems-based care

All surgeons want the best, safest care for their patients, but providing this requires the complex coordination of multiple disciplines to ensure that all elements of care are timely, appropriate, and well organized. Quality-improvement initiatives are beginning to lead to improvements in the quality of care and coordination amongst teams in the operating room. As the population ages and patients present with more complex disease pathology, the demands for efficient systematization will increase. Although evidence suggests that postoperative mortality rates are declining, there is substantial room for improvement. Multiple quality metrics are used as surrogates for safe care, but surgical teams--including surgeons, anaesthetists, and nurses--must think beyond these simple interventions if they are to effectively communicate and coordinate in the face of increasing demands.

Impact of surveillance of hospital-acquired infections on the incidence of ventilator-associated pneumonia in intensive care units: a quasi-experimental study

INTRODUCTION

The preventive impact of hospital-acquired infection (HAI) surveillance is difficult to assess. Our objective was to investigate the effect of HAI surveillance disruption on ventilator-associated pneumonia (VAP) incidence.

METHODS

A quasi-experimental study with an intervention group and a control group was conducted between 1 January 2004 and 31 December 2010 in two intensive care units (ICUs) of a university hospital that participated in a national HAI surveillance network. Surveillance was interrupted during the year 2007 in unit A (intervention group) and was continuous in unit B (control group). Period 1 (pre-test period) comprised patients hospitalized during 2004 to 2006, and period 2 (post-test period) involved patients hospitalized during 2008 to 2010. Patients hospitalized ≥ 48 hours and intubated during their stay were included. Multivariate Poisson regression was fitted to ascertain the influence of surveillance disruption.

RESULTS

A total of 2,771 patients, accounting for 19,848 intubation-days at risk, were studied; 307 had VAP. The VAP attack rate increased in unit A from 7.8% during period 1 to 17.1% during period 2 (P <0.001); in unit B, it was 7.2% and 11.2% for the two periods respectively (P = 0.17). Adjusted VAP incidence rose in unit A after surveillance disruption (incidence rate ratio = 2.17, 95% confidence interval 1.05 to 4.47, P = 0.036), independently of VAP trend; no change was observed in unit B. All-cause mortality and length of stay increased (P = 0.028 and P = 0.038, respectively) in unit A between periods 1 and 2. In unit B, no change in mortality was observed (P = 0.22), while length of stay decreased between periods 1 and 2 (P = 0.002).

CONCLUSIONS

VAP incidence, length of stay and all-cause mortality rose after HAI surveillance disruption in ICU, which suggests a specific effect of HAI surveillance on VAP prevention and reinforces the role of data feedback and counselling as a mechanism to facilitate performance improvement.

Implementation of the World Health Organization surgical safety checklist at a university hospital in Thailand

BACKGROUND

Compliance with the World Health Organization (WHO) surgical safety checklist may reduce preventable adverse events. However, compliance may be difficult to implement in Thailand. This study was conducted to examine compliance with the WHO checklist at a Thai university hospital.

METHODS

A descriptive study was conducted among 4,340 patients undergoing surgery in nine departments from March to August 2009. The compliance rates were computed.

RESULTS

The highest compliance rate (91.4%) during the sign-in period was with patients' confirmation of their identity, operative site, procedure, and consent. However, only 19.4% of the surgical sites were marked. In the time-out period, surgical teams had introduced themselves by name and role in 79% of the operations; and in 95.7% of the cases, the patient's name, the incision site, and the procedure had been confirmed. Antibiotic prophylaxis had been given within 60 min before the incision in 71% of the cases. For 83% of the operations, the surgeons reviewed crucial events whereas only 78.4% were reviewed by the anesthetists. Sterility had been confirmed by the operating room nurses for every patient, but the essential imaging was displayed at a rate of only 64.4%. In the sign-out period, nurses correctly confirmed the name of the procedure orally in 99.5% of the cases. Instrument, sponge, and needle counts were completed and the specimen was labeled in most cases, 96.8% and 97.6%, respectively. Equipment-related problems were identified in 4.4% of the cases, and 100% of them were addressed. The surgeon, anesthetist, and nurse reviewed the key concerns for recovery and management of the patient at the rate of 85.1%.

CONCLUSIONS

The WHO checklist can be implemented in a developing country. However, compliance with some items was extremely low, reflecting different work patterns and cultural norms. Additional education and enforcement of checklist use is needed to improve compliance.

Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis

BACKGROUND

Health-care-associated infection is the most frequent result of unsafe patient care worldwide, but few data are available from the developing world. We aimed to assess the epidemiology of endemic health-care-associated infection in developing countries.

METHODS

We searched electronic databases and reference lists of relevant papers for articles published 1995-2008. Studies containing full or partial data from developing countries related to infection prevalence or incidence-including overall health-care-associated infection and major infection sites, and their microbiological cause-were selected. We classified studies as low-quality or high-quality according to predefined criteria. Data were pooled for analysis.

FINDINGS

Of 271 selected articles, 220 were included in the final analysis. Limited data were retrieved from some regions and many countries were not represented. 118 (54%) studies were low quality. In general, infection frequencies reported in high-quality studies were greater than those from low-quality studies. Prevalence of health-care-associated infection (pooled prevalence in high-quality studies, 15·5 per 100 patients [95% CI 12·6-18·9]) was much higher than proportions reported from Europe and the USA. Pooled overall health-care-associated infection density in adult intensive-care units was 47·9 per 1000 patient-days (95% CI 36·7-59·1), at least three times as high as densities reported from the USA. Surgical-site infection was the leading infection in hospitals (pooled cumulative incidence 5·6 per 100 surgical procedures), strikingly higher than proportions recorded in developed countries. Gram-negative bacilli represented the most common nosocomial isolates. Apart from meticillin resistance, noted in 158 of 290 (54%) Staphylococcus aureus isolates (in eight studies), very few articles reported antimicrobial resistance.

INTERPRETATION

The burden of health-care-associated infection in developing countries is high. Our findings indicate a need to improve surveillance and infection-control practices.

FUNDING

World Health Organization.

Improving surveillance system and surgical site infection rates through a network: A pilot study from Thailand

Background:

Surveillance of surgical site infections (SSI) provides data upon which interventions to improve patient safety can be based. In Thailand, however, SSI surveillance has not yet been standardized.

Objectives:

To develop a standardized SSI surveillance system and to monitor SSI rates after introduction of such a system.

Methods:

We conducted a prospective study among 17,752 patients who underwent surgery in ten hospitals in Thailand from April 2004 to May 2005. The SSI rates were computed and benchmarked with the US rates, reported in terms of standardized infection ratio (SIR). We estimated the incidence rate ratio of surgical site infections by comparing the incidence in the last study period with the incidence in the first study period.

Results:

The study included 17,869 operations and identified 248 SSIs, yielding an SSI rate of 1.4 infections/100 operations and a corresponding SIR of 0.6 (95% confidence interval [CI] = 0.5–0.7). During the study period the overall SSI rate decreased from 1.8 infections/100 operations to 1.2 infections/100 operations, yielding an incidence rate ratio of 0.65 (95% CI = 0.47–0.89).

Conclusion:

Our study highlighted that a standardized SSI surveillance in a developing country can be initiated through a network and may be followed by a decrease in SSI rates.

The "six sigma approach" to the operating room environment and infection

The patient's external environment plays a significant, and in some cases dominant, role in his or her infection risk. The use of ultraclean air for certain procedures, as well as avoidance of hypothermia have been proven to reduce the risk of infection. There is no data to support the routine use of surgical masks (by surgeons or staff), ventilating helmets, or routine cleaning of all environmental surfaces in between cases. More research needs to be done in order to determine whether OR design changes, in addition to increasing OR efficiency and thus reducing case times, can also reduce infection rates. Further research is also needed to determine whether or not double gloves and/or the use of antiseptic scrubbing in addition to painting are efficacious.