Don’t Just Do Something, Stand There
Sometimes inaction may be the best action. Recently the hospital where I do much of my elective surgery noted an increased incidence of infections following colon surgery. This was part of a project undertaken in order to comply with a Joint Commission and CMS requirement to demonstrate ongoing quality improvement activity. That’s bureaucratic doublespeak for looking at what you do anyway, and making up some BS about how you’ll do it better. Unfortunately, this time there may really be a problem. The infection rate that the QA department reported was twice as high as other hospitals in the area. Not a good indicator of quality surgical care if true, and not a good way to advertise your hospital.
A meeting of all surgeons who perform colon surgery was quickly called in order to ‘drill down’ on the infection report and find out what was going wrong. Full panic mode ensued in the Admin Office – ‘Oh my God, the sky is falling! We have to DO SOMETHING!’
There may indeed be a problem, but the initial report is very vague and the raw data isn’t necessarily indicative of something amiss. That’s not to imply that post-operative infections are no big deal. They can be and if indeed patient are twice as likely to get an infection at my hospital, I sure want to know why.
The problem isn’t simple. First, no matter what we do, the colon is not a clean place. Antibiotics and cleansing bowel preparations don’t make it even as clean as the small intestine There’s even good evidence that vigorous mechanical cleansing (enemas, bowel washouts, etc.) preoperatively may actually increase the risk of infection. No matter how careful we are, there will be a certain baseline incidence of infection that is inherent in the procedure.
Second, other factors influence infection risk in any surgery, but particularly in contaminated operations such as those on the colon. These include: the presence of infection before the surgery even starts, such as diverticulitis; obesity, which increases the risk of both wound and deep space (inside the abdomen) infections; diabetes which increases infection risk in any procedure; low body temperature – getting cold in the OR; and smoking. If these comorbidities are not accounted for, any apparent increase in infections may be due to patient diseases and conditions rather than anything the surgeon or OR staff does.
Finally, the criteria for reporting an infection may play a role. By Center for Disease Control guideline, any infection within 90 days of surgery is a surgical site infection, but if it’s been more than seven days since surgery, it’s unlikely that anything done in the OR or in the first few hours after surgery played anything other than a permissive role. Altering our preop and postop routines probably won’t change anything.
All of the surgeons understood the problem. We all were motivated to find out what was really going on. Was this just a run of bad luck? The data only represented six calendar months and may have been an aberration. Were our patients just sicker to begin with? There was no information at all about the other hospital to which we were being compared other than their overall infection rate. Was everybody reporting their infections in the same way? Did individual surgeon differences represent differences in patient selection or were some of us just that much better than others?
The Infection Control Nurse had actually done a very good job of analyzing the information. She presented a three page spread sheet detailing the surgeon’s name, the patient’s name and age, the patients BMI (Body Mass Index, an indicator of obesity), the location of the infection, type of infection, organism responsible and about ten other parameters that could have a bearing on why the infection occurred. Unfortunately, in all that data, neither she nor we could find any common factor, break in technique or best practice guideline to explain the spike in infections. We looked at the data we were given, talked about the possibilities and then shrugged our collective shoulders and told the administration there was little we could conclude from the information we had. The infections both individually and collectively appeared to be a mix of patient and surgeon factors and not a systemic issue.
‘Not good enough’, came the reply from the hospital CEO and the Chief Medical Officer (neither of them surgeons). ‘Don’t you all understand? We’ve got to take action to correct this. We’ve got to DO SOMETHING’. And if we as a department didn’t, then they would.
Nobody said anything after that for a few minutes. I looked to our current department Chairman to speak up and explain the issue, maybe advocate that we try to get more information from other hospitals that would allow us to really evaluate whether there was a problem at our institution. He stared at the table. He’s a hospital employee, one of four hired surgeons the hospital brought in to undercut the independent surgeons like me. Finally, I had the temerity to ask, ‘What would you suggest we do?’
Silence. We waited, and when no one else spoke, everyone stood up and left the room.
I fully expect some new regulations out of the front office in the next few days, likely some requirement that we observe ‘best practice’ guidelines, which we do anyway, coupled with a new batch of spies and overseers to grade us on how well we follow the script. It will be a colossal waste of time and energy and will satisfy no one except the administrators. Meanwhile, a couple of the colon rectal surgeons and I have persuaded the QA nurse manager to let us do a focused review of all the colon cases for the next six months. If there is a real problem, we may be able to find it. Or we may only find that sick old people who have major surgery don’t do as well as healthy young ones. Imagine that. If that is the case, then standing still may be the best action to take.