EP865 - Implementation of a Standardized Operative Report Template to Improve the Accuracy of Surgical Site Infection Documentation in Colorectal Surgery

ePoster Presenter(s)

• 

  Roni Y. Rosen, MD

  General Surgery Resident
  Hackensack University Medical Center
  Hackensack University Medical Center, NJ
  Tenafly, NJ, United States

  All of the relevant financial relationships listed below have been mitigated.
  This individual has no relevant relationships with ineligible companies.

Author(s)

• CE

  Carly Earle, D.O.

  Resident
  Hackensack University Medical Center
  Hackensack, New Jersey, United States

  Disclosure information not submitted.
• AD

  Angelica R. Del Vecchio, PhD

  Medical Research Associate
  Hackensack University Medical Center
  Hackensack, New Jersey, United States

  Disclosure information not submitted.
• BK

  Brian D. Kopping, MD

  Resident Physician
  Hackensack University Medical Center
  Rutherford, New Jersey, United States

  Disclosure information not submitted.
• JR

  Jonathan E. Rhoton, MD

  Surgery Resident
  Hackensack University Medical Center
  Hackensack, New Jersey, United States

  Disclosure information not submitted.
• ZN

  Zohal Najem, BA

  Medical student
  Hackensack Meridian School of Medicine
  Bordentown, New Jersey, United States

  Disclosure information not submitted.
• GC

  Gregory Charak, MD

  Disclosure information not submitted.
• CC

  Charles Cooper, MD

  Colorectal surgeon
  Summit health
  Ridgewood, New Jersey, United States

  Disclosure information not submitted.
• RM

  Ryan Moore, MD

  Assistant Professor of surgery
  Hackensack Meridian School of Medicine
  Cedar Grove, New Jersey, United States

  Disclosure information not submitted.
• GG

  Gregory J. Gallina, MD, FASCRS

  Senior Attending Surgeon
  Hackensack University Medical Center
  Maywood, New Jersey, United States

  Disclosure information not submitted.
• HR

  Howard M. Ross, MD

  Chair/ Surgeon-in-Chief
  Hackensack University Medical Center
  Hackensack, New Jersey, United States

  Disclosure information not submitted.

Senior Author(s)

• SL

  Steven Lee-Kong, MD

  Professor of Surgery , Division Chief of Colon and Rectal Surgery
  Hackensack University Medical Center
  Hackensack Meridian School of Medicine
  FORT LEE BORO, NJ, United States

  Disclosure information not submitted.

Purpose/Background: The incidence of surgical site infections (SSIs) following colorectal surgery is a highly tracked quality metric used to evaluate institutional performance, making such data critical not only for patient safety, but also for benchmarking hospital outcomes and reputation. A subset of surgical site infections is designated as "present at the time of surgery" (PATOS) and is not attributable to the surgical intervention itself. These must be documented distinctly from postoperative surgical site infections to prevent falsely inflated hospital-associated SSI rates. This study presents the results of a quality initiative to accurately document SSIs after colorectal surgery using a standardized template.

Methods/Interventions: A retrospective analysis was conducted at a single institution that included patients who underwent colorectal surgery and experienced a post-operative surgical site infection within 30 days of surgery between January 2016 and July 2025. A standardized operative report (PATOS template) was developed to clearly state the presence of infection at the time of surgery in a dichotomous fashion and was implemented throughout the department of surgery in January 2023. The study population was divided into two cohorts: pre-PATOS template and post-PATOS template. Patients who experienced a true SSI, and those who were falsely documented as experiencing an SSI when they should have been reported as PATOS (false SSI) were identified via chart review. The incidence of true SSIs, false SSI, and PATOS documentation was calculated in each group and compared using chi-squared testing.

Results/Outcomes: A total of 259 patients with reported SSIs were identified via an institutional database and divided into two cohorts: pre-PATOS template (n=156) and post-PATOS template (n=103) implementation. Thirty-eight patients (24.4%) in the pre-PATOS group were falsely documented as having an SSI versus fifteen patients (13.6%) in the post-PATOS group (p=0.0343). The documentation of infection present at the time of operation was also more accurate in the post-PATOS template group (n=47, 45.6%) than the pre-PATOS template group (n=33, 21.1%; p< 0.0001). The documentation of true-SSIs was more accurate in the post-PATOS (n=42/103; 40.8%) template group than in the pre-PATOS template group (n=85/156, 54.5%), resulting in a relative reduction of reported true-SSIs of 44.3% (p=0.0308).

Conclusion/Discussion: Implementing a standardized documentation process guided by PATOS criteria may enable more accurate classification of SSIs following colorectal surgery, thereby reducing misattributed postoperative SSI rates and supporting unbiased institutional quality reporting.

Figure 1 Effects of PATOS template implementation on rates of true SSI, false SSI, and PATOS documentation.