1. SCIP: Preventing Surgical Site Infections
Gary Kanter, M.D.
Betsy Lehman Center
December 4, 2007

2. I would highlight our website once again
I would highlight our website once again. You can learn a lot more about both projects at the MedQIC website. Information is available and will be updated as it becomes available on each of these websites.
It has certainly been my pleasure to give this presentation today, and I will be happy to answer questions by communicating through the websites, through the links that provide information on how to ask questions about the projects. Thank you.

3. Surgical Care Improvement Project
National Quality Partnership
CMS,CDC
Reduce nationally the incidence of surgical complications by 25% by 2010
(13,027 deaths, 271,055 complications)/yr
Focus on
Surgical infection prevention
Adverse cardiac events
Prevention of DVT
Post operative pneumonia
Using evidence based medicine

4. How often do patients receive “scientifically indicated care” in this country?
Near 100%- we are doing a great job
75%- not too shabby
55%- flip a coin
What does science have to do with medicine?
McGlynn, et al: The quality of health care delivered to adults in the United States. NEJM 2003; 348: (June 26, 2003)

5. How often do patients receive “scientifically indicated care” in this country?
Near 100%- we are doing a great job
75%- not too shabby
55%- flip a coin
What does science have to do with medicine?
McGlynn, et al: The quality of health care delivered to adults in the United States. NEJM 2003; 348: (June 26, 2003)

10. Surgical Infection (SI): Epidemiology & Impact
Account for % of all Hospital Acquired Infections (HAI)
2-5% of operative patients will develop SI
0.8-2 million infections a year
SI increase LOS
Average 7.5 additional days
Excess costs
$130-$845 million per year
Adds $2,734 - $26,019 per pt (average $3,000)
Pain and suffering

11. SI: Epidemiology & Impact
Patients who develop infection are:
60% more likely to spend time in an ICU
5 times as likely to be readmitted
Have a mortality rate twice that of noninfected patients
An estimated 40-60% of these infections are preventable

12. Business Case for SCIP
APU increased to 2%

13. Business Case for SCIP

14. Baystate Medical Center
700 bed tertiary care referral center (population of ~1M)
Flagship of Baystate Health
41 k admissions/year
Annual surgical volume: 29,043
Western Campus of TUFTS
Member CoTH, 9 residency programs, 244 residents
1200 member medical staff, 206 faculty MDs
Level 1 Trauma Center
IHI Mentor Hospital Surgical Infection Prevention

15. Use of antimicrobial prophylaxis for major surgery: baseline results from the National Surgical Infection Prevention Project Arch Surg Feb;140(2):

17. Quality Improvement Process
Benchmarking, measurement, and feedback
Work with key physician champions
Disseminate recommendations to educate
Use physician order entry
Enlist help of case managers as quality safety net
Use PDSA cycles to test and improve

18. Prophylactic Antibiotics
Antibiotics given for the purpose of preventing infection when infection is not present but the risk of post-operative infection is present

19. Prophylactic Antibiotics Questions
Which cases benefit?
When should you start?
Which drug should you use?
How much should you give?
How long should antibiotics be continued?

20. Recently Updated Antibiotic Recommendations
Surgery Type
Antimicrobial recommendations
Hip or knee arthroplasty
Preferred: Cefazolin or cefuroxime
If patient high risk for MRSA: Vancomycin*
Beta-lactam allergy:
Vancomycin or clindamycin
Cardiac or vascular
* For the purposes of national performance measurement a case will pass the antibiotic selection performance measure if vancomycin is used for prophylaxis (in the absence of a documented beta-lactam allergy) if there is physician documentation of the rationale for vancomycin use (effective for July 2006 discharges).

21. Recently Updated Antibiotic Recommendations (continued)
Surgery Type
Antimicrobial recommendations
Hysterectomy
Cefotetan, cefazolin, cefoxitin, cefuroxime, or ampicillin-sulbactam
Beta-lactam allergy:
Clindamycin + gentamicin or fluoroquinolone* or aztreonam
Metronidazole + gentamicin or fluoroquinolone*
Clindamycin monotherapy
Colorectal †
Neomycin + erythromycin base; neomycin + metronidazole
Cefotetan, cefoxitin, cefazolin + metronidazole, or ampicillin-
sulbactam
* Ciprofloxacin, levofloxacin, gatifloxacin, or moxifloxacin (effective for July 2006 discharges).
† For the purposes of national performance measurement, a case will pass the antibiotic selection indicator if the patient receives oral prophylaxis alone, parenteral prophylaxis alone, or oral prophylaxis combined with parenteral prophylaxis.

22. Prophylactic Antibiotics Questions
Which cases benefit?
When should you start?
Which drug should you use?
How much should you give?
How long should antibiotics be continued?

23. Timing of Antibiotic Prophylaxis GI Operations
Stone HH et al. Ann Surg. 1976;184:

24. Perioperative Prophylactic Antibiotics Timing of Administration
14/369
15/441
1/41
1/47
Infections (%)
1/81
2/180
5/699
5/1009
Hours From Incision
Classen. NEJM. 1992;328:281.

25. Antibiotic Timing Related to Incision
Bratzler DW, Houck PM, et al. Arch Surg. 2005;140:

26. Visual Prompt and data collection

27. Never Underestimate the Power of Competition
BMC AB Timing by Anesthesiologist
Never Underestimate the Power of Competition

28. Memorandum DIVISION OF HEALT H CARE QUALITY TO: , MD FROM:
Associate Medical Director
DATE:
, 2006
SUBJECT:
SCIP
(Surgical Care Improvement Program)
As part of the SCIP process,
the medical record of
PATIENT
was reviewed. As eviden
ced by the attached
documentation ,
it appears
that the
patient’s
prophylactic pre -
operative
antibiotic w as :
_____
given greater than 1
hour prior to th e
initial incision
time
not re
dosed.
_____given after the initial surgical incision. _ X
__not g
iven at all ( no time of administration was documented)
Please
remember
that current standard of practice is
operative an
tibiotic administration within
60 minutes p
rior to the incision (Levaq
uin
and Vancomycin are within 120 minutes
pri
or to the
incision ). Re
dosing of antibiotics if the case extends beyond 3 hours
when cefazolins are used
Please contact
me at 4
4326
if you have any questions. Thank
you .

32. Quality Indicators National Surgical Infection Prevention Project
Proportion of patients who receive prophylactic antibiotics consistent with current recommendations
The second performance measure is the proportion of patients who received prophylactic antimicrobials consistent with current recommendation. Basically, the expert panel reviewed all of the published guidelines for antimicrobial prophylaxis for patients having surgery and made the decision that, if the antibiotic was recommended in any of the published guidelines, it would be considered an appropriate antibiotic for prophylaxis.
There are some antimicrobials that do have FDA approval for prophylaxis but are not currently recommended in any published guideline for prophylaxis, therefore, those antimicrobials are considered inappropriate.
At this time, JCAHO and CMS have jointly agreed to suspend public reporting on this measure. Data collection will continue but the results will not be publicly reported.

33. Antibiotic Recommendation Sources
American Society of Health System Pharmacists
Infectious Diseases Society of America
The Hospital Infection Control Practices Advisory Committee
Medical Letter
Surgical Infection Society
Sanford Guide to Antimicrobial Therapy 2003
This is a list of guidelines that have been published for antimicrobial prophylaxis. They include the American Society of Health System Pharmacists, Infectious Disease Society of America, The Centers for Disease Control Hospital Infection Control Practices Advisory Committee, The Medical Letter guidelines (which are updated every other year), The Surgical Infection Society, and The Sanford Guide. In review of all of these guidelines, if any one guideline listed an antibiotic as approved or recommended for prophylaxis, the antimicrobial was considered acceptable for the procedure.

34. Antibiotic Selection - Successful Interventions
Distribution of guidelines to perioperative staff (standardize practice)
Antibiotic selection and ordering (standardize process, opt out for selection)
Decision aids in the system (active prompt )
Use of cephalosporins and vancomycin/gentamicin in penicillin allergic patients
Reviewed and revised AB selections in computer order sets (opt out, forcing function)

35. The Advisory Statement published in 2004 in Clinical Infectious Diseases.
Clin Infect Dis. 2004;38:

39. Expanded pt populations

41. Quality Indicator #3
Proportion of patients whose prophylactic antibiotics were discontinued within 24 hours of surgery end time
The third performance measure is the proportion of patients whose prophylactic antibiotics were discontinued within twenty-four hours after the end of surgery. Most of the national experts believe, based on published data, that giving a single preoperative dose of antibiotic is sufficient to prevent surgical site infections. Giving antibiotics after the incision is closed is of no value in reducing infection rates further. There was a very large opportunity for improvement if most of the country reduced any antimicrobial use to twenty-four hours after surgery, based on the review of many studies.

42. Discontinuation of Antibiotics
Patients were excluded from the denominator of this performance measure if there was any documentation of an infection during surgery or in the first 48 hours after surgery.
Bratzler DW, Houck PM, et al. Arch Surg. 2005;140:

43. Antibiotic Prophylaxis Duration
Most studies have confirmed efficacy of  12 hours
Many studies have shown efficacy of a single dose
Whenever compared, the shorter course has been as effective as the longer course

44. Papers Comparing Duration of Peri-op Antibiotic Prophylaxis
Colorectal 3
Mixed GI 4
Hysterectomy 3
Gyn & GI 1
Head & Neck 3
Orthopedic 4
Vascular 3
Cardiac __7__
Total 28
Papers supporting longer duration 1

45. Duration of prophylactic antibiotic administration should not exceed the 24-hour post-operative period
Prophylactic antibiotics should be discontinued within 24 hours of the end of surgery
Medical literature does not support the continuation of antibiotics until all drains or catheters are removed and provides no evidence of benefit when they are continued past 24 hours

46. Consequences of Prolonged AB Use
Increased antibiotic and drug administration costs
Increased antibiotic-associated complications
Increased patterns of antibiotic resistance
Clostridium difficile Enterocolitis
Colonization with MRSA

52. Barriers – Antibiotic Use
Timing
Consistency
Sustainability (constant monitor)
Selection
Resistance (surgeons and organism)
Availability; national consensus issues
Duration
Knowledge gap
If it’s not broke, don't change it

53. Surgical Infection Rate
1.13 %
NNISS Benchmark = 2-11 %

54. Duration of Antibiotic Prophylaxis: What is Best for Our Patients?
Antibiotic prophylaxis is one of many methods for reducing the incidence of SSI
There is a lack of evidence that antibiotics given after the end of the operation prevent SSIs
There is evidence that increased use of antibiotics promotes antibiotic resistance

55. Glycemic Control

56. Diabetes Complications
Estimated 10 million Americans
Poor glucose control is associated with:
Increased risk of infection
Delayed healing
Increased mortality
Blunts inflammatory response

57. Diabetes, Glucose, Control and SI
Infections (%)
Latham,ICHE 2001; 22:607-12

58. Glucose Control and Deep Sternal Wound Infections
Historically, diabetics got q 4 hr sliding scale sqi to keep bg < 200.; after 1991, diabetics got insulin drip titrated to keep glucose levels between 150 and Here there deep sternal infect rate declines.
Furnary et al. Ann Thorac Surg 1999:67:352

59. Survival increased with intensive insulin therapy ( nondiabetic patients included ) targeting BG mg/dL
Van den Berghe et al. NEJM 2001; 345:

61. Glycemic Control
Established IV insulin protocol for cardiac surgery patients with known diabetes (Pre-op BG > 75 mg/dl) and all others (Pre-op BG >150 mg/dl)
The protocol was developed by surgeons, anesthesiologists, endocrinologists, and nursing
Insulin infusions to be initiated in OR
Insulin infusion to be used for the duration of post-op period while the patient is in cardiac intensive care unit (CICU)
Endocrine referral if insulin infusion is utilized
Conversion protocol (IV infusion to sliding scale)

62. Diabetes, Glucose Control, & SIs ICHE 2001; 22: 607-12
Summary
Peri-operative hyperglycemia and diabetes are associated with increased risk of SIs
Early diagnosis of diabetes among high-risk patients may have short and long-term benefits

64. Hair Removal Pre-operative Shaving
Shaving the surgical site with a razor induces small skin lacerations:
Potential sites for infection
Disturbs hair follicles which are often colonized with S. aureus
Risk greatest when done the night before
Patient education
be sure patients know that they should not do you a favor and shave before they come to the hospital!
Shaving the surgical site with a razor induces small skin lacerations and causes potential sites for infection. When the skin is shaved, particularly the area where the surgery will be performed, the hair follicles are disturbed, and most of the studies have demonstrated that it increases the risk of surgical site infections. This is particularly great when the shaving is done the night before surgery. Patient education needs to be done to make sure patients don’t do the surgical team a “favor” by shaving the surgical site the day before they come into the hospital. It can result in a higher infection rate.

65. Shaving, Clipping & SI Infections (%)
Alexander. Arch Surg 1983; 118:347

66. Hair Removal
Preoperative shaving of the surgical site the night before an operation is associated with a significantly higher SI risk than either the use of depilatory agents or no hair removal
Do not remove hair preoperatively unless the hair at or around the incision site will interfere with the operation (Category IA)
If hair is removed, remove immediately before the operation, preferably with electric clippers (Category IA)

67. Cochrane Database Syst Rev. 2006 Apr 19;(2)
Three trials involving 3193 patients
Compared shaving with clipping
Statistically significantly more SSIs when people were shaved rather than clipped (RR 2.02, 95%CI 1.21 to 3.36)

68. Interventions Razors removed from OR’s
Razors removed from most clinical areas
Patients may use razors for personal hygiene

70. HYPOTHERMIA Increased myocardial ischemia & VT
Bleeding and increased transfusion requirements
Surgical wound infections & prolonged hospitalizations
Lower pain threshold
Drug metabolism decreased

71. Temperature and SSI Following Colectomy
Normo (N=104) Hypo (N=96) P
SSI
Collagen dep
Time to eat 5.6d 6.5d <.006
Kurz. NEJM 1996;334:1209

72. Normothermia Standardization Review by patient populations
Pre warm
Removed “random number generators”
One device and one measure (first PACU temp)
Review by patient populations
Education/communication
Room set point pre-op
Increased temperature upon pt arrival to room until draped
Staff comfort balanced against patient centered care
Products
Forced hot air
Warm fluids
Cooling vests
Temporal thermometers

74. Barriers - Normothermia
Staff comfort
Expense
Knowledge gap
Impact
Importance
Consistent application

75. Apparently Unavoidable
Potentially Preventable This complication may not have occurred with the application of every indicated prevention measure
Apparently Unavoidable
Despite the application of every indicated prevention measure the complication occurred anyway
A mystery………

76. Surveillance
List of patients sent to each surgeon, 30 days post procedure
97% return rate (SASE, interoffice mailing)
Self report: any post operative infection/ comments
Daily admissions with wound infection
Review for surgical date and s/s infection
Daily microbiology reports of all + cultures reviewed for wound, fluid cultures, e.g joint aspirates
Charts reviewed for NNIS criteria, surgical date and s/s infection

77. Investigation NNIS criteria: ASA, Wound Class, Length of Procedure
Presence of interventions
Antibiotic use
Surgical prep and skin condition
Implants
Cluster evaluation
Specific conditions of the patient
Surgical environment
Organism
Surgical team

78. Potentially Preventable Review
All infections reviewed for potential preventability using SCIP guidelines
Reviewed using other criteria as well
Review done by IC dept and fed back to multiple cmts (COI, SCIP, SPIT, SAQI)
System level changes made when applicable
Consistently, 50% of infections have a SCIP miss!!

79. Where Do Things Fall Through the Cracks?
System – information, tests, diagnoses
Communication
Hand offs
Failure to recognize
Failure to activate
Failure to rescue

80. Improvement Tools Systems Populations Cycles of Change
PDSA, Six Sigma, LEAN
Process Analysis
Failure Mode Identification
BH PI Tool Kit

81. Make The Right Thing The Easy Thing
Keys to Success
Persistence and reinforcement/high visibility
Senior leader support
Multidisciplinary cooperation & collaboration
Accurate, timely and relevant data
Right people
Willing to try changes and take a risk
Develop reliable systems (strive for 10-2 > 90%)
Incorporate into workflow
Make changes easy and transparent
Stress importance of impact on patient and practitioner
Make The Right Thing The Easy Thing

82. Lessons Learned Involve all stakeholders
Leave your stripes at the door
Must have physician champions- credible
Be humble
Take more blame and give more credit
BROAD shoulders
Must work as team
Small tests of change with frequent tempo
Small pilot population
Work within your culture
Steal shamelessly
Make the right thing the easy thing

83. Medicine used to be simple, ineffective, and relatively safe…….
Now it is complex, effective, and potentially dangerous.
Sir Cyril Chantler
1999 Hollister Lecture at Northwestern University, Illinois
James, B. 16th IHI Conference

84. Department of Anesthesiology Baystate Medical Center
For More Information:
Gary Kanter, M.D.
Department of Anesthesiology
Baystate Medical Center
Springfield MA 01199