Local anesthesia: a strategy for reducing surgical site infections?

BACKGROUND: Surgical site infections (SSIs) contribute to increased morbidity, mortality, and hospitalization costs. A previously unidentified factor that may reduce SSIs is the use of local anesthesia. The objective of this study was to determine if the use of local anesthesia is independently associated with a lower incidence of SSIs compared to nonlocal anesthesia. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program database (2005-2007), we identified all patients undergoing surgical procedures that could be performed using local or general anesthesia, depending on the preference of the surgeon. Logistic regression was used to identify factors independently associated with the use of local anesthesia. Propensity matching was then used to match local and nonlocal anesthesia cases while controlling for patient and operative characteristics. SSI rates were compared using a χ(2) test. RESULTS: Of 111,683 patients, 1928 underwent local anesthesia; and in 109,755 cases the patients were given general anesthesia where a local anesthetic potentially could have used. In the unmatched analysis, patients with local anesthesia had a significantly lower incidence of SSIs than patients with nonlocal anesthesia (0.7 vs. 1.4%, P = 0.013). Similarly, after propensity matching, the incidence of SSIs in patients given local anesthesia was significantly lower than for that of patients given nonlocal anesthesia (0.8 vs. 1.4%, P = 0.043). CONCLUSIONS: Use of local anesthesia is independently associated with a lower incidence of SSIs. It may provide a safe, simple approach to reducing the number of SSIs.

Accelerating the pace of surgical quality improvement: the power of hospital collaboration.

HYPOTHESIS: A regional collaborative approach is an efficient platform for surgical quality improvement. DESIGN: Retrospective cohort study. SETTING: Academic research. PATIENTS: Patients undergoing general and vascular surgical procedures in 16 hospitals of the Michigan Surgical Quality Collaborative (MSQC) were evaluated quarterly to discuss surgical quality, to identify best practices, and to assess problems with process implementation. MAIN OUTCOME MEASURES: Results among MSQC patients were compared with those among 126 non-Michigan hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) over the same interval. RESULTS: A total of 315 699 patients were included in the analysis. To assess improvement, patients were stratified into 2 periods (T1 and T2). The 35 422 MSQC patients (10.7% morbidity in T1 vs 9.7% in T2 [9.0% reduction], P = .002) showed improvement, while 280 277 non-Michigan ACS NSQIP patients did not (12.4% morbidity in T1 and T2, P = .49). No improvements in mortality rates were noted in either group. Overall, the odds of experiencing a complication in T2 compared with T1 were significantly less in the MSQC group (odds ratio, 0.898) than in the non-Michigan ACS NSQIP group (odds ratio, 1.000) (P=.004). CONCLUSION: A statewide surgical quality improvement collaborative supported by a third-party payer showed significant improvement in quality and high levels of participant satisfaction.

The Michigan Surgical Quality Collaborative: a legacy of Shukri Khuri.

BACKGROUND: From the legacy of Shukri Khuri, we have successfully implemented a regional quality collaborative in Michigan, the Michigan Surgical Quality Collaborative (MSQC). METHODS: The MSQC represents a partnership between the American College of Surgeons (ACS), 34 Michigan hospitals, and a large private payer. It is based on a "pay for participation" rather than a "pay for performance" model. Although based on the ACS National Surgical Quality Improvement Program (NSQIP) platform, this collaborative has a unique infrastructure for information technology, collaboration, and ad hoc quality improvement (QI) initiatives. RESULTS: Specific initiatives have been implemented with colectomy, myocardial ischemia, and surgical site infection (SSI). Based on these initiatives, best practices have been implemented. Adherence to these best practices is modest, but despite this, there has been significant QI. CONCLUSIONS: The improved quality was likely the result of diverse process measures, many not yet recognized in the literature, which came together effectively in specific hospitals.