Constant quality improvement
Quality Improvement That Delivers Impact
At the heart of every surgical innovation is a commitment to doing better—for our patients, our teams, and the healthcare systems we serve. Throughout his career, Dr. Heniford made quality improvement (QI) a driving force behind his clinical practice and research.
From reimagining protocols to reduce postoperative complications, to developing prehabilitation programs that enhance outcomes and shorten recovery, his group’s work in QI has consistently led to meaningful change. At his previous institution, three recent quality improvement projects alone prevented avoidable complications and generated more than $4 million in cost savings - a reflection not just of operational efficiency, but of lives made better.
His research in this space has been recognized with regional, national, and international awards, including top honors from the American College of Surgeons, SAGES, American and European Hernia Societies and other surgical professional organizations. Indeed, his research has won the American Hernia Society Research Award 5 of the last 6 years and 17 years in total. More importantly, it has helped redefine what is possible in complex abdominal wall reconstruction, influencing care delivery well beyond his hospital walls.
Dr. Heniford believes that transparency, data-driven decision-making, and the courage to challenge outdated assumptions are what lead to progress. Every initiative his team launches is a step toward a safer, more effective, and more human-centered future in surgery.
Implementation of a penicillin allergy protocol in open abdominal wall reconstruction: Preoperative
Introduction
Beta-lactam prophylaxis is the first-line preoperative antibiotic in open abdominal wall reconstruction. However, of the 11% patients reporting a penicillin allergy (PA), most receive second-line, non–β-lactam prophylaxis. Previously, abdominal wall reconstruction research from our institution demonstrated increased wound complications, readmissions, and reoperations with non–β-lactam prophylaxis. Therefore, a collaborative quality improvement initiative was developed with the infectious disease service, and a penicillin allergy protocol was instituted that stratified patients’ risk of allergic reaction with a goal to increase β-lactam prophylaxis use. The effect of the penicillin allergy protocol on open abdominal wall reconstruction outcomes was prospectively evaluated.
Methods
Patients with penicillin allergy undergoing open abdominal wall reconstruction were identified and grouped according to penicillin allergy protocol implementation. Pre–penicillin allergy protocol underwent open abdominal wall reconstruction before January 1, 2020, predominantly receiving non–β-lactam prophylaxis; post–penicillin allergy protocol underwent open abdominal wall reconstruction between January 1, 2020–November 1, 2023, predominantly receiving β-lactam prophylaxis. Incidence of surgical site infection was the primary outcome. Standard and inferential statistical analyses were performed.
Results
Of 315 patients with penicillin allergy, 250 underwent open abdominal wall reconstruction pre–penicillin allergy protocol and 65 post–penicillin allergy protocol. Pre– and post–penicillin allergy protocol were similar in allergic reaction severity history, sex, race, age, diabetes, American Society of Anesthesiologists score, hernia defect size, and mesh type (P > .05). Post–penicillin allergy protocol had lower body mass index (33.4 ± 7.9 vs 29.8 ± 5.3 kg/m2; P = .002) and fewer active smokers (12.4% vs 1.5%; P = .019). Expectedly, post–penicillin allergy protocol received more β-lactam prophylaxis (22.8% vs 83.1%; P < .001) and no antibiotic-induced allergic reactions. Post–penicillin allergy protocol had significantly fewer surgical site infections (24.4% vs 3.1%; P < .001), wound breakdown (16.0% vs 3.1%; P = .004), reoperations (19.2% vs 0.0%; P < .001), and readmissions (25.3% vs 9.2%; P = .006) but no statistically significant reduction in recurrence (8.4% vs 1.5%; P = .057).
Conclusions
The penicillin allergy protocol safely increased the number of patients with penicillin allergy undergoing open abdominal wall reconstruction receiving β-lactam prophylaxis and decreased the rate of surgical site infections, wound complications, reoperations, and readmissions. These data supported the systemwide implementation of the penicillin allergy protocol for both general and orthopedic surgery, which has been incorporated into the electronic medical record of 13 hospitals within the system.
Read about this study in Surgery
The impact of a closing protocol on wound morbidity in abdominal wall reconstruction with mesh
Introduction
Wound complications (WC) after abdominal wall reconstruction (AWR) are associated with increased cost, recurrence, and mesh infection. Operative closing protocols (CP) have been studied in other surgical disciplines but not in AWR. Our aim was to study the effect of a CP on WC after AWR.
Methods
The CP consists of antibiotic wound irrigation, glove and complete instrument exchange, and re-draping of the sterile field to cover the skin entirely prior to mesh implantation. A prospective institutional database at a tertiary hernia center was queried for patients who underwent open AWR with mesh. Standard descriptive and inferential statistics are reported. A Bayesian structured time-series analysis was performed to evaluate rates of wound infection (WI) and WC before and after implementation of a CP in late 2016.
Results
A total of 2541 AWR patients were examined. Mean age and BMI were 57.9 ± 12.6 years and 32.9 ± 9.8 kg/m2, 56.7% were female, and 24.2% were diabetic. Significantly more CP patients had contaminated wounds. Mean defect size was 203.1 ± 205.8 cm2. Average follow-up was 31.5 ± 41.4 months. WI rate before CP (preCP) was 14.5% compared to 2.6% after CP (P < 0.001). WC rate was higher before CP (29.3% vs 10.3%, P < 0.001). Specifically, wound cellulitis (9.7% vs 2.7%, P < 0.001), wound infection (13.8 vs 1.8%, P < 0.001), and mesh infection (2.1% vs 0.6%, P < 0.004) rates were reduced after CP implementation. For WI, Bayesian Structured time-series analysis showed that the implementation of CP had an effect of 83% (± 2%, 95% CI − 87%, − 78%; P < 0.001) reduction in WI compared to counterfactual. For WC, the Bayesian analysis revealed a reduction compared to counterfactual for WC of − 67% (± 3%, 95% CI − 60%, − 72%; P < 0.001).
Conclusions
Introduction of a CP for open AWR with mesh has reduced overall WI and WC rates. The use of a CP should be strongly considered in AWR.
Read about this study in Surgical Endoscopy
Open preperitoneal ventral hernia repair: Prospective observational study of quality improvement out
Background
This study aimed to describe progressive evidence-based changes in perioperative management of open preperitoneal ventral hernia repair and subsequent surgical outcomes and to analyze factors that affect recurrence and wound complications.
Methods
Prospective, tertiary hernia center data (2004–2021) were examined for patients undergoing midline open preperitoneal ventral hernia repair with mesh. “Early” (2004–2012) and “Recent” (2013–2021) groups were based on surgery date.
Results
Comparison of Early (n = 675) versus Recent (n = 1,167) groups showed that Recent patients were, on average, older (56.9 ± 12.6 vs 58.7 ± 12.1 years; P < .001) with a lower body mass index (33.5 ± 8.3 vs 32.0 ± 6.8 kg/m2; P = .003) and a higher number of comorbidities (3.6 ± 2.2 vs 5.2 ± 2.6; P < .001). Recent patients had higher proportions of prior failed ventral hernia repair (46.5% vs 60.8%; P < .001), larger hernia defects (199.7 ± 232.8 vs 214.4 ± 170.5 cm2; P < .001), more Center for Disease Control class 3 or 4 wounds (11.3% vs 18.6%; P < .001), and more component separations (22.5% vs 45.7%; P < .001). Hernia recurrence decreased over time (7.1% vs 2.4%; P < .001), as did wound complication rates (26.7% vs 13.2%; P < .001). Comparing respective multivariable analyses (Early versus Recent), wound complications were associated with panniculectomy (odds ratio [95% confidence interval]: 2.9 [1.9–4.5], P < .001 vs 2.1 [1.4-3.3], P < .01), contaminated wounds (2.1 [1.1–3.7], P = .02 vs 1.8 [1.1–3.1], P = .02), anterior component separation technique (1.8 [1.1–2.9], P = .02 vs 3.2[1.9–5.3], P < .01), and operative time (per minute: 1.01 [1.008–1.015], P < .01 vs 1.004 [1.001–1.007], P < .01). Diabetes (2.6 [1.7–4.0], P < .01) and tobacco (1.8 [1.1–2.9], P = .02) were only significant in the early group. In both groups, recurrence was associated with wound complication (8.9 [4.1–20.1], P < .01 vs 3.4 [1.3–8.2]. P < .01) and recurrent hernias (4.9 [2.3–11.5], P < .01 vs 2.1 [1.1–4.2], P = .036).
Conclusion
Despite significant increased patient complexity over time, detecting and implementing best practices as determined by recurring data analysis of a center’s outcomes has significantly improved patient care results.
Read about this study in Surgery