Plastic Surgeon Compliance with National Quality Forum and Surgical Care Improvement Projects in Patients at Risk in an Academic Community Hospital
Robert X. Murphy, Jr., MD, MS, Emily Peterson, MD, Joshua M. Adkinson, MD, James F. Reed, III, PhD.
Lehigh Valley Hospital, Allentown, PA, USA.
BACKGROUND: Since the 1998 publication of the Institute of Medicine’s Statement on Quality of Healthcare, there have been ever increasing initiatives to improve patient care and safety, particularly for patients who are hospitalized or undergoing invasive procedures. Two such initiatives include the Surgical Care Improvement Project, (identification of both venous thromboembolism (VTE) and surgical site infection (SSI) as areas of preventable surgical complications), and the National Quality Forum endorsed Safe Practices 17 (evaluation of patients on admission and thereafter for risk of VTE and utilization of clinically appropriate prophylaxis) and 21 (prevention of SSI). Two measures of prevention of SSI are administration, when indicated, of prophylactic antibiotics within 1 hour prior to surgery and discontinuation within 24 hours of surgery end time. The specific role of these practice initiatives is not well defined for the aesthetic plastic surgery patient. We examined the historic compliance of the clinical faculty in an academic community hospital with the measures of VTE and appropriate antibiotic prophylaxis, as well as the incidence of adverse outcomes, in patients undergoing abdominoplasty or panniculectomy.
METHODS: A retrospective chart review was performed on 243 patients who underwent abdominoplasty or panniculectomy by one of two board-certified plastic surgeons over an 8-year period from 2000-2007. These patients were considered to be at risk because of their generally increased BMI, their need for prolonged general anesthesia, and their relative postoperative immobility. Data extraction included prior VTE, body mass index (BMI), age, length of operative procedure, type of anesthesia, oral contraceptive use, smoking history, diabetes, use of VTE and antibiotic prophylaxis, and adverse outcomes such as deep venous thrombosis (DVT), pulmonary embolism (PE), infection, and hematoma. Analysis was completed using Pearson’s chi-square and Fisher’s exact test as appropriate. Significance was set at α < 0.05.
RESULTS: All patients received at least one form of VTE prophylaxis in the perioperative period. One patient had a DVT (0.4%) and two had a PE (0.8%). 25.5% of patients received appropriate antibiotics. Eleven patients (4.5%) developed a postoperative infection requiring hospital admission and intravenous antibiotic therapy. There was one perioperative mortality from acute congestive heart failure. There were no differences in occurrences of DVT when stratified by patient risk factors. Both patients with a PE were obese (BMI > 30) and 10 (66.7%) of the readmissions were obese. There was no association between adverse outcome and whether the patient had DM or tobacco use.
CONCLUSIONS: Despite good compliance with quality and safety outcome measures in this plastic surgery population at risk, several adverse outcomes occurred. This study highlights both the potential need for increased compliance with these quality measures and documents the fact that adverse outcomes may result even with adherence to best surgical practices.