QI in AWR

Welcome back to another episode of Behind the Knife. This is your hernia team from Carolina's Medical Center coming at you with our final episode in this series. We very much appreciate behind the Knife, willing us to have us and hopefully share some ideas with the listeners of behind the Knife.

So the topic that we're gonna discuss today is quality improvement in abdominal wall reconstruction. This is a journal review episode, and we're going to be touching on two papers, but can hopefully paint a a larger picture in terms of what quality improvement has meant to our group. So the, this episode is gonna emphasize why is important to track your outcomes for patients and then use those outcomes to better clinical care over time.

The two papers that we're gonna be discussing are open pre peritoneal ventral hernia repair prospective observational outcomes of quality improvement over 18 years in 1,842 patients. And then implementation of penicillin allergy protocol and open abdominal wall reconstruction, a preoperative optimization

program.

Both of those papers have been published within the last four years in surgery, I think will be good in terms of having additional talking points for what quality improvement means. So the first article will give a kind of a global overview. View about quality improvement and look at our outcomes over time.

And then the second, we will give a more granular example and talk about we'll talk about the challenges and implementation of penicillin allergy protocol at our institution. But to set the stage, we're gonna talk about what quality improvement means. Dr would you like to start us off with a working definition for the rest of the episode?

Thanks. S and at s Medical Center I will be actually. Going to endeavor Health in Evanston beginning actually my last day has been about a month at the Charles Medical Center. After 26 years, really, it's been a, it's been an amazing place to grow up as a surgeon and then become a teacher and and constant learner.

And the constant learning I've done often has been in this quality improvement. Why would

you want to improve and why would I choose like to do this in abdominal reconstruction? Well, first I'll go to the abdominal reconstruction part of it. These patients are few things that make them really good.

Study group One is that they're complicated. These patients are often obese. They're often very comorbid as far as smoking, diabetes, and and other issues. They've developed infections. You know, these are complicated patients. They're also, they're not easy operations. They can be done minimally invasively.

So you can do quality improvement, minimal invasively, but also a lot of these operations need to be done and will be done open. And there's a lot of them. So they're complicated. They're, they often have had complications previously, and there's a lot of patients. And so when you start marking, you know what you're doing in your outcomes.

In this group, you know, it becomes pretty quick that you can see where your problems are, where your flaws are. You know, we've been doing this now and we've made a living actually doing quality improvement in tracking these outcomes. You know, working

with king Kercher and Vera Stein in the abdominal reconstruction center, the hernia center at the Carolinas Medical Center, we've tracked 22,000 patients that we've operated on.

The other consideration about, you know, doctors and surgeons that make us really good at quality improvement, honestly, is because, you know, we have been pleasers our whole life. We have responded to report cards. I mean, you, you were a pleaser as a kid. You're, you know, you lived and, and died by your report cards, and your outcomes are your report cards.

So if you can just track your outcomes, go back to where you're having a problem, and then you can, you take, let's say like in geriatrics a few years ago we looked at our length of stay and who are the patients that that required the longest length, and there were several, one. Patients with higher body mass index, we knew that.

We've been working on that for a long time. Patients who come in with infections, we, you know, hard to treat an infection preoperatively. You treat 'em with surgery. The others

would include patients the length of length of the operation. Quite honestly, that is a surrogate for how difficult the surgery is.

And then lastly was in for every five years over the age of 60, you increase, statistically increase the length of stay. Well in talking to our team and Cheryl Elhaj at the time, who was the, who, the research fellow was like, well, you can't fix age. Actually what we ended up doing is bringing geriatric geriatrics in our clinic, and we were able to do that just in like a couple of weeks after we had gotten this data and then they've been with us ever since.

We now have documented that we can decrease the unexpected admissions to the ICU decrease length of stay in the hospital and improve our outcomes. And that is just, you know, just one of many things that you say, this is a problem. How do I step back and fix this? Thanks, Sally. Appreciate you introducing the topic, Dr.

Hefford. I think one of the interesting things about quality improvement in abdominal wall reconstruction and all parts of surgery is that you can target different parts of the

surgical pathway. So the geriatrics medicine example is a perfect example about how you can continue to optimize patients in the preoperative period.

And then obviously you want to improve your surgical technique over time which would be indicative. Things that you can do actually in the operating room and then taking care of patients in the postoperative recovery setting, you can target any part of that pathway to potentially improve your outcomes.

Dr. Stein, I know that you have driven many of the things that have improved the outcomes for our patients and a few of which you are particularly passionate about. Do you mind talking about a few of those? Sure. Thanks Sally. Definitely it's been a team effort and I think that's the wonderful thing about our group has been that we really discuss all of these things and then come up with new protocols and then the residents and you guys are extremely helpful.

Since I joined the faculty at Carolinas, there's been a lot of. Quality improvement efforts and even as a fellow. And I started out, I guess I'm gonna talk about two of these. One of them is performing conco concurrent pin

colectomies at the time of abdominal wall reconstruction. In the past we used to have plastic surgeons doing these now, most of the time we're doing them ourselves.

And then also use the. Preoperative Botox in patients who have loss of domain hernias or just hernias that we really don't think we can potentially close. So the cumulative impact of these QI projects will be discussed a little bit later by Monica when she reviews the paper that tracks our outcomes for 18 years.

But as you guys know, for any QI project. That's important to formulate a statement as far as like what you're trying to improve have an intended intervention and then have measurable outcomes. So as you guys know, we have been performing abdominal wall reconstruction and concurrent pin colectomy for probably more than 15 years at this time, and it.

It really allows for improved surgical exposure. Lifting the subcu flaps releases the muscle essentially, so it helps with some of these really large hernias. And then also removal of the

excess skin and subcu tissues also offloads the tension on the repair. However, historically doing these pinco colectomies at the same time has shown to have an increased wound of complication rate.

You have large incisions but we've done a lot as far as preoperative optimization of complications and also use of incisional vacs with the pinco colectomies, which have really decreased wound morbidity in these patients. It's really rare now that we actually see patients develop any wound complications with these large, very large incisions.

As you guys probably know, these incisional wound vacs have a number of mechanisms. There are many of them on the market but they basically decreased accumulation of interstitial fluid. They promote angiogenesis and lymphatic drainage and they reduce lateral wall stress. So they're really.

Quite fabulous. I think most of the just about any large incision non robotic incision or laparoscopic incision I make, I put an incisional back on it because you really wanna try to prevent wound

infections and then prevent hernias. So we did track wound complication rate immediately following the use of, of the incisional vac.

And we saw that these complication, the rate half from the previous and now it's pretty much standard of care for them. Similarly, adopting preoperative Botox is something that Dr. Jennifer Kutcher used even before I was a fellow there especially for the really large ventral hernias and loss of the main patients.

And we've now done multiple studies looking at the patients that we have performed Botox on matched patient populations. And not only does it reduce the amount of bridging, but it also lessens the amount of component separations. Being performed. So, I'll turn it over to Monica. Thank you, Dr.

Stein. I'll move on to an introduction of our first article for this episode, which is entitled, open Pre Peritoneal Ventral Hernia Repair, prospective Observational Outcomes of Quality Improvement over 18 years and 1,842 Patients. This article was published in the journal

surgery in March of 2023 and described the many quality improvement initiatives over time at the Carolinas Medical Center.

Then further compare the outcomes of early and recent patients undergoing open pre peritoneal ventral hernia repair, grouped into repairs performed prior to and post 2013. What you'll see is interesting about this paper is that the general surgical technique remains the same as the authors have utilized a mainly pre peritoneal approach to hernia repair for several decades.

The benefits of this have been discussed in previous episodes, but briefly, preperitoneal repairs allow for extra peritoneal sublay mesh placement with very wide overlap. And the mesh overlap you can achieve is similar to a tar, but without the need to divide any muscle. So anyway, the technique has not really changed, but what has changed over time has been the implementation of several evidence-based changes in the perioperative care of these patients.

And rather than focusing on individual changes, this paper really evaluated the cumulative impact over time of a

continuous quality improvement process and its impact on our ab wall reconstruction patients. There are a number of specific changes that have been made over time as we began to identify modifiable risk factors that negatively impacted hernia outcomes.

For instance, beginning in 2006, we required patients to stop smoking for four weeks prior to surgery. Then four years later, we began focusing on weight loss for obese patients through a ketogenic diet or bariatric referrals were appropriate. In 2012, we began targeting a hemoglobin A1C of 7.2 prior to surgery.

And these are just a few examples and several other efforts over time are described, including the use of tap blocks, preoperative Botox, a penicillin allergy protocol, which we will discuss in more depth a little bit later, and the partnership with our geriatricians to improve outcomes in elderly patients with hernia.

Dr. Hannaford, is there anything else you would specifically like to add here about the quality improvement efforts that have been made at Carolinas? Thanks Monica. And if I may, I,

I'd like to say, you know, the consideration of quality improvement and we've done a lot with pre rehabilitation as Monica has talked about, we've changed a lot, what we do in the operating room.

We have evaluated postoperative pain. We've evaluated patients postoperatively, have talked about as far as wound complications and. One of the things I like to say when we have fellows come in, if you do the, you know, you have on the same patient, you do the same operation, expect the same outcomes, don't expect better.

And then also too, when you do an evaluation of something and you think you, you're actually going to improve care, don't stop there. Go back and continue to evaluate your change that you made. I'll give you an example and you know, most of the things that we write about, you know, we write about our wins.

And, but like I was a big proponent of lightweight polypropylene mesh in the lab. It decreased infection, decreased the number of bacteria it would hold compared to heavyweight polypropylene and at six months it was plenty strong for the human abdomen. But then once we

started putting it in and started using it in adult reconstruction, what we found was is that we started to see the mesh split somewhere around 18 months.

And there was a big divergence between the heavyweight and mid-weight polypropylenes and the lightweight polypropylenes. Then even so, and you know, Kira Huntington presented this at the American College of Assured is almost 900 cases. And you know, what we had to do is just like, not only are we gonna improve ourselves, but we have to just give a warning to people that, you know, this, this was, we thought this was gonna be great.

But then you kind of hat in hand have to go and then say, well guys it wasn't as great as we thought, but it took long-term follow up in those patients early follow up at a year, the outcomes are the same. But but the mesh had more flexibility, better incorporated, et cetera, but it wasn't good for long-term outcomes.

And so I, I just think it's important that even when you think you're right about something and you have some data, the support that you're right, continue to look at your data to prove that indeed what you're doing is correct.

Thank you. So we'll get back to the results of the manuscript, which are going to be relatively unsurprising, given that each intervention had been previously studied and individually backed by data.

But overall, we noted that even though the more recent group consisted of more complex hernias, which were overall larger of higher wound class and more often recurrent. Hernia recurrence still decreased over time from 7.1% to 2.4%. There were fewer instances of wound complications and fewer 30 day readmissions In the later group, in both the early and late group wound complications were associated with hernia recurrence On multivariable analysis, one of the most significant findings in this paper was that diabetes and smoking were significantly associated with wound complications on multi-variable analysis in the early group.

Not in the later group. This initially seemed surprising, but actually suggests that our defined parameters for optimization of these specific variables have been able to successfully mitigate these risk factors and the negative impact on outcomes.

Outstanding, Monica. I think you know, seeing the improvement over time really will continue to drive us to want to answer more questions.

One question seemingly leads to another, which is the exciting part about all of this. We're gonna transition from the overall outcomes that we presented in our group to one particular project, which is the penicillin allergy protocol, back to a. Earlier point that was made by Dr. Hannaford. Penicillin allergy is a relatively common problem that's reported among patients and it's long been known that the use of beta-lactam antibiotics is the most effective way to prophylax a patient prior to surgery.

The penicillin allergy protocol at our institution was actually driven by our own data. Katie Schlosser in 2020 reviewed our patients and found that 11% had a penicillin allergy, a reported penicillin allergy at the time of open ventral hernia repair. However, a lot of these patients didn't have a true allergy.

And that's you know, the case in above 90% of

patients with a reported allergy. But what she found was that patients who ended up getting a beta-lactam at the time of operation had better outcomes. And this was particularly true in complex and contaminated cases, which comprised the majority of the cases that, you know, that are seen at Carolinas and other hernia centers.

So as a result of that study, we worked with infectious disease team to develop a protocol for our patients to risk stratify them prior to surgery. And so what we would do is we developed a questionnaire that nurses and the anesthesia team would administer in the preoperative setting that would look and see, you know, what exactly was the reaction that these patients were having.

Was it something as mild as a rash which was you know, the most common reported reason for an allergy? Or was it something that was actually more severe like an anaphylactic reaction? And only for these high risk patients would. Patients with a reported penicillin allergy, not get a beta-lactam, which is most commonly cefazolin.

So after the initiation of this protocol we reviewed 315 patients in the paper that was published by Alexis Holland in surgery, and we found that 250 in the pre protocol group and 65 in the post protocol group were included and beta-lactam prophylaxis. Increased from pre to pros protocol for patients that had app penicillin allergy from 22% to 83%.

So there's a net 60% improvement in the amount of patients with an allergy who are getting the correct antibiotic or at least the most effective antibiotic. And again, not surprisingly, what we found was that the number of surgical site infections drastically decreased in this amount, in this, period from 24% to 3% and wound breakdown decreased from 16 to 3.3%.

And again, this is something that was created in a multidisciplinary fashion, backed by data, backed by experts, and ultimately had a very positive impact on our

patient population. I think one of the things to note here is that, you know, we have published. Previous literature in particular the Cedar R app that Dr.

Stein published looking at cost savings for complications. And we use that to calculate a cost savings for the penicillin allergy protocol, which is estimated about one point. 0.3 million in the post protocol group. And if you combine that with two of the other projects that have been mentioned, which are the closing tray project where we bring in a, a clean closing tray at the end of the case to perform closure and then the Geriatric Me Medicine partnership, those add up to over $4 million in cost savings just for the minimally invasive surgery division.

Dr. Hanford since you helped to spearhead this, I would love to get your thoughts on some of the challenges with implementation and some of the considerations there when you're bringing all parties to the table. Well, first I think that, you know, as we've kind of discussed as new veteran talked about, the team approach.

And, and you mentioned with this

pen cell allergy, it was Vera's idea to actually do this study. And I was shocked at our outcomes. And immediately you have to do something about this. And so she passed it off to me, allowed me to to kind of take it and run. And I met with infectious disease, as you mentioned, but I also met with pharmacy and I, and also with the people in Epic, because you gotta get put in Epic.

You gotta streamline this. You got, if you don't make it easy, nobody will do it. It's pretty simple. Like being in a big hospital system these, these guys knew what the downstream of this might be, that we could really improve care not only in abdominal reconstruction, but in orthopedics and colorectal and head and neck and cardiac and GYN, et cetera.

And so now with this just working through complex patients, and again, hernia patients are complex patients and they make a great group to do quality improvement. And now this is going through the whole hospital system. Immediately the orthopedic hospital in our, in our system immediately adopted it.

And,

you know, and often you'll see, you know, surgeons are, you know, a bit they don't want to change and all that. And, but this has been really adopted very well. And, and, but one, one of the reasons is because you brought in multiple groups and you made it easy. And if you can do that, then you can really save money and improve outcomes.

That's fantastic. I think that that you know, penicillin allergy protocol is something that is pretty, fairly easy to implement too. And when you have quality improvement efforts that are easy to implement, then they become usable and then they can be compounded throughout larger systems. So, is a very, a very good project that was spearheaded by you guys on the call Dr.

Hannaford, any final words about. Quality improvement efforts and I guess where we're going, what the future holds? In, in hernia specifically. Well, I think we've talked a lot about it, but I do wanna say that, you know, areas where we've improved a bunch is where we can bring others in to work with us.

I believe that hernia centers, yeah, you gotta have somebody who knows how to operate, knows how to take care of hernias, knows how to dissect, knows how to do component separations, perhaps robotics, place mesh, all those things. But we need to lean because of the complexities of these patients, lean on other physician groups and other specialists.

And, you know, we've worked heavily with radiology and talked about talked about using Botox but indeed. The, you know, they also drain our seromas, they also do injections for us. We've worked a lot with infectious disease. We have an infectious disease in our clinic. We have the largest series of mesh infections, you know, transferred into us in the world.

And we haven't for 15 years. We have infectious disease coming to our clinic. I've mentioned bariatrics. Now working with physical therapy, I mean, it the way we've gotten better is identify a problem and if we can't fix it directly. Then we'll just this, just have people join us and it's amazing when you have an enthusiastic team who wants to get better.

How, like our geriatrician, I mean, we work with her and she's fantastic. Know she's within in our clinic every Monday. Jim Horton worked the infectious disease doctor. He came to our clinic every other week for years and it's, it's been quite. And it's and I guess it, it's a self-feeding kind of escalation of care that everybody gets excited about, that the people that we work with, that, that we consult with get excited.

They excite us back. And again, we've made a living academically too about writing about this, saying how we could've, we could have done better. And I'll just conclude my part of this and just say that, you know, for every one of these quality improvement papers. You know, I could like start the introduction by saying I have, you know, know when to thank but myself for not being such a good surgeon to now be able to improve and write about it.

I thought I was a really good surgeon 25 years ago and 20 years ago, and 15 years ago, but there is no question because of quality improvement. I'm a much better surgeon now

than I was at any time in my career. Thank you Dr. Hannaford. I'll just summarize with a few quick hits from our conversation. So, number one, quality improvement involves making a concerted effort to enact an intervention that may measurably impact patient care, and then to measure that impact, which means that surgeons should diligently track their outcomes to know whether or not these interventions are effective optimization of.

Patients with high risk comorbidities for abdominal wall reconstruction, specifically diabetes and active smoking can significantly decrease the rate of wound complications. Cefazolin and beta-lactam antibiotics are most effective in surgical site prophylaxis for intraabdominal operations. And finally, the best quality improvement efforts are the ones that are ongoing rather than stagnant.

Thank you guys so much for joining us today and for the last time. This is the Behind the Knife hernia team based outta the Carolinas Hernia Center, reminding you to dominate the day. Thanks so much.