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Best Practice in all of Surgery

Robin McLeod and
Emily Pearsall

from left to right Robin McLeod & Emily Pearsall

Robin McLeod has taken on the responsibility of Vice Chair of the Department of Surgery, Quality and Performance. Robin currently leads the Best Practice in General Surgery (BPIGS) program and Jim Rutka has asked her to expand this quality initiative across all the divisions in the department. The Best Practice in General Surgery program was initiated in 2006 with the goal of standardizing care based on best evidence across all of the adult teaching hospitals. The Steering Group has representatives from all of the fully and partially affiliated adult hospitals. With the support of all of the general surgeons, they have developed and implemented guidelines on Surgical Site Infections, Thromboprophylaxis, Mechanical Bowel Preparation and Management of Intra-abdominal Infection. Their current focus is on developing, in conjunction with anaesthesia, nursing and allied healthcare representatives, an “Enhanced Recovery after Surgery” Guideline.

An important aspect of the program is the involvement of both residents and medical students. Prior to developing the guidelines, audits had been performed to assess whether a gap in care exists. A second audit was then conducted after guideline implementation to determine if there had been an improvement in care. Not surprisingly, the group has been able to identify significant gaps in care. For example, in an audit of 350 patients who had intra-abdominal sepsis, 34 different antibiotic combinations were prescribed and 40% of the patients had prolonged courses of antibiotics of more than 7 days.

A unique feature of BPIGS is the collaborations that have been developed across hospitals as well as specialties. For instance, the Intra-abdominal Infection guideline has been developed in collaboration with the Toronto Antimicrobial Stewardship Corridor, and a multidisciplinary listserv is planned to familiarize surgeons, physicians and residents with the recommendations.

The BPIGS group has been able to show that they have been able to improve care. For instance, as shown in Figure 1, the appropriate administration of pre-operative antibiotics increased following the implementation of the Surgical Site Infections Guideline. As a result, there has been good buy - in from the CEOs of all the hospitals. The work of BPIGS helps CEO’s fulfill the institutional requirements of the provincial “Excellent Care for All” mandate.

Jim Rutka hopes to see the Best Practice in General Surgery program expanded across the department to develop protocols, guidelines, and centers of excellence. Already there are examples where services have been consolidated to improve care such as the Vascular Surgery Program. The Trauma Program, which until recently had been comprised of two fairly independent sites, is also in the midst of developing common protocols and sharing fellows. The Bariatric Program is a coordinated university program situated at 4 sites. Developing a department quality improvement initiative will be one of the priorities of the Strategic Planning process. According to Robin “there is a great opportunity for our department but it will take surgeon buy -in as well as champions in each division. Audit will be an important component to show success, which in turn will help to attain government and other external funding to support the initiative.”

Emily Pearsall, a PhD candidate in Knowledge Translation, is the coordinator for the Department’s Quality and Performance program. The members of the Steering Committee include Mary- Anne Aarts, Darlene Fenech, David Lindsay, Avery Nathens, Allan Okrainec, Lorne Rotstein, Peter Stotland, and Alice Wei. More information about Best Practice in General Surgery can be found at www.bpigs.ca.


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