Banner Health Initiative Reduces Surgical Site Infections

The performance improvement effort was implemented at every one of the health system's hospitals.

A surgical antimicrobial prophylaxis bundle at Banner Health has reduced surgical site infections, mortality, length of stay, and hospital readmissions.

A surgical site infection occurs at the site of a surgical incision on the skin or in deep tissue. Surgical site infections occur in as many as 4% of inpatient surgical procedures, and they are a significant cause of morbidity and mortality after surgery, according to the Agency for Healthcare Research and Quality.

Banner Health reported on the impact of its surgical antimicrobial prophylaxis bundle at this week's APIC Annual Conference. The data reported features more than 57,000 surgical cases from January 2019 to December 2023. Four types of surgery were included in the data: hip arthroplasty, knee arthroplasty, colorectal surgery, and abdominal hysterectomy.

Antiobiotic management is the core element of the bundle, says William Holland, MD, MHA, senior vice president of care management and chief medical informatics officer at Banner Health. Holland functions as a health system CMO, with responsibilities in areas including quality, safety, infection prevention, regulatory affairs, clinical performance improvement, and clinical supply chain. The CMOs of Banner Health's largest hospitals report to him.

"We want to make sure that patients get the correct antibiotic before surgery, which varies based on the procedure," Holland says. "We want to make sure that patients get the right dose of antibiotic, which is mainly dependent on the patient's weight. We make sure we time administration of an antibiotic before surgery appropriately—most medications are administered an hour before surgery. If a surgery takes a lot of time, we re-dose the antibiotic during surgery."

Implementation of the bundle generated several positive results:

• Surgical site infection rates for knee arthroplasty procedures decreased 15.2%
   
• The bundle was associated with a four-day reduction in hospital length of stay
   
• Overall mortality rates decreased 4.4%
   
• Average 30-day hospital readmission rates fell by 3.9%

"By reducing surgical site infections, we reduced the time that patients needed to be in the hospital on antibiotics, so we reduced length of stay," Holland says. "Anytime a patient is going to be in the hospital for a prolonged period of time or a patient has an infection that becomes septic, you increase the risk of mortality. So, by reducing surgical site infections, we reduced mortality. The healthier and more functional we could send patients home, we reduced the risk of readmissions."

Developing and implementing the bundle

Development and implementation of the surgical antimicrobial prophylaxis bundle followed Banner Health's model for performance improvement, Holland says.

"It is a stepwise process that starts with clinical leaders identifying an opportunity in medical literature or internal data," he says. "Several years ago, guidelines were released around antibiotic utilization to decrease surgical site infections. The idea was to get the right dose of antibiotic into the blood or tissue to decrease the potential colonization of bacteria."

After the opportunity was identified, Banner Health started looking at internal data with a structure called clinical consensus groups, which are typically led by a physician and a nurse, Holland says.

"These groups have peers from across the health system and the different hospitals have representation," he says. "In this case, a clinical consensus group looked at the literature and internal data to try to understand whether we had consistent performance across the health system and to identify facilities that were doing really well and others that were not doing well. They focused on driving a level of consistency across the organization."

The surgical antimicrobial prophylaxis bundle was endorsed by the members of the clinical consensus group. Then the initiative went up to the clinical leadership team, which is the most senior leadership team in the organization, and those leaders endorsed the bundle as an expected practice. Then Banner Health developed resources to implement the bundle such as process engineers, informatics, and program managers.

Finally, the health system put together an "implementation bundle" that was deployed at Banner Health's hospitals. "Typically, the leads for the implementation bundle are CMOs and CNOs, who identify delegates at their facility to drive the change," Holland says. "Then there were monthly meetings with those folks to measure improvement."

The most challenging aspect of the implementation process was re-dosing of antibiotics during surgery, he says. "With the re-dosing of antibiotics during surgery, we had to do some additional measures to educate surgical teams, to provide reminders, and to help them understand that element of the bundle."

Performance improvement best practices

Involving physicians and nurses in the design and implementation of the surgical antimicrobial prophylaxis bundle was crucial in the initiative's success, Holland says.

"When you are looking to drive a change like this that is going to have a broad impact and involve large teams of staff members, you must have people who do this type of work involved in the change," he says. "That is why we have a conscious effort to bring physicians and nurses together. That is why we have a structured process to define the problem we are going after."

Implementing the bundle at all of the health system's hospitals was also crucial, Holland says.

"Many times, health systems try to tailor approaches to performance improvement for each hospital in the organization," he says. "However, we look for consistency. We want the experience for our patients to look the same no matter which one of our hospitals they go to. Our expectation is that the level of care that a patient gets should be consistent whether they are at one of our critical access hospitals or one of our large tertiary care centers."