1. Surgical Infection Prevention In Washington State Where we started and where we’re going…
Nancy West, RN, MPH, CPHQ
Qualis Health
With Many Thanks to Dale W. Bratzler, DO, MPH and E. Patchen Dellinger, MD

2. Why focus on surgical quality?
~30 million major operations each year in the US
Despite advances in surgical and anesthesia technique and improvements in perioperative care, variations in outcomes for patients having surgery are well known

3. Consequences of Surgical Complications
Dimick and colleagues demonstrated increased costs:
infectious complications was $1,398
cardiovascular complications $7,789
respiratory complications $52,466
thromboembolic complications $18,310.
Khuri and colleagues demonstrated that, independent of preoperative patient risk, the occurrence of a 30-day complication reduced median patient survival by 69%.
Dimick JB, et al. J Am Coll Surg 2004;199:531-7.
Khuri SF, et al. Ann Surg 2005;242:

4. Who Pays for Surgical Complications?
Hospital
Reimbursement $
Costs of care
Profit
Profit margin %
14266
(uncomplicated)
10978
3288
23.0
21911
(complicated)
21156
755
3.4
Complications were always associated with an increase in costs to healthcare payors: complications were associated with an average increase in payment of $7645 (54%) per patient.
Dimick JB, et al. Who pays for poor surgical quality? Building a business case for quality improvement. J Am Coll Surg. 2006;202:933-7.

5. CMS

6. Medicare Surgical Infection Prevention (SIP) Project Objective
To decrease the morbidity and mortality associated with postoperative infection in the Medicare patient population

7. Selected Surgical Procedures
Cardiac
Coronary Artery Bypass Graft (CABG)
Colon
Hip & Knee Arthroplasty
Abdominal & Vaginal Hysterectomy
Vascular Surgery:
Aneurysm repair
Thromboendarterectomy
Vein Bypass
These procedures are being evaluated in the Medicare project because there is no controversy over the use of antibiotics for these operations. This does not imply that antibiotic prophylaxis should not be used for other procedures.

8. Antibiotic Timing Related to Incision
Where we started in 2001
Bratzler DW, Houck PM, et al. Arch Surg. 2005;140:

9. 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.

10. Infection antibiotic Indicators National Surgical Care Improvement Project
SCIP INF – 1: Proportion of patients with antibiotic initiated within 1 hour before surgical incision
SCIP INF – 2: Proportion of patients who receive prophylactic antibiotics consistent with current recommendations
SCIP INF – 3: Proportion of patients whose prophylactic antibiotics were discontinued within 24 hours of surgery end time

11. Surgical Care Improvement Project Performance measures - Process
Surgical infection prevention
Antibiotics
Administration within one hour before incision
Use of antimicrobial recommended in guideline
Discontinuation within 24 hours of surgery end
Other Process Improvement
Glucose control in cardiac surgery patients
Proper hair removal
Normothermia in colorectal surgery patients

12. INF – 1: the questions
Antibiotic administered within 60 minutes prior to incision time
“On call” to OR?
Give in pre-op?
What about ED surgical admissions?
Who is responsible?
Where is the time documented?

13. INF-1: What works!
Anesthesiology takes responsibility for administration of abx; time is included in anesthesia record
Keep abx in pre-op Pyxis
Utilize a visual/physical cue: push the abx when you hit the button to open the OR door!
Utilize a forcing function: have abx hanging and plugged into the port so that it must be given before the anesthesiologist can run the sedation
Use the preop “pause” to check for administration time for abx.
If over 60 mins, redose!

14. SCIP INF – 2: Selection 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
The Johns Hopkins Guide
Society of Thoracic Surgeons

15. #1 – Currently published guidelines…
….. favor the use of 1st or 2nd generation cephalosporins for prophylaxis because of numerous published randomized trials that have demonstrated their effectiveness for prophylaxis
Safe and inexpensive

16. #2 – Be cautious about wanting to use vancomycin for prophylaxis
Vancomycin resistance remains a public health problem
Vancomycin is not a particularly good antibiotic for prophylaxis
Challenges with administration and slower tissue perfusion
May result in higher infection rates

17. INF - 2: Selection: the questions
What about allergy?
What about formularies?
Who made up the approved list?
What about ertapenem?
What about bowel preps?

18. INF – 2: What works! See www.medqic.org for list of approved abx
Abx selection list comes from a group including major specialty societies, IDSA, CDC, etc.
Ertapenem will be allowed for colon cases x 1 dose starting 10/07
Vancomycin use is still a problem: education for physicians seems to help!
Keep up with what’s new by joining the national SCIP list

19. SCIP INF – 3: Discontinuation of Prophylaxis
Numerous clinical trials have compared short-term to long-term antimicrobial prophylaxis
Infection rates are the same regardless of duration of prophylaxis
Prolonged prophylaxis has been associated with higher rates of infections with resistant organisms (when infection occurs). Prolonged prophylaxis only changes the flora – it does not lower infection rates.
Prolonged prophylaxis is a patient safety issue.

20. SCIP #3: 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:

21. 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 SSI’s
There is evidence that increased use of antibiotics promotes antibiotic resistance (CDAD)

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

23. 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.

24. INF – 3: What works!
We are working on having the first postop dose given in PACU by standardizing the postop orders as much as possible.
Postop orders Q8hrs X3=24 hours?
We have found that when we have outliers, most are because that last dose is given 1-2 hours after the 24 hour cutoff. We have our clinical pharmacists on board with this plan and they helped to draft the postop order sheet and presented it to the surgeons.
Having the pharmacists involved is the best thing we have done as they know how best to administer the antibiotics and what timeframes are acceptable. We are now working on getting the surgeons to buy in to the plan.

25. INF – 3: What works!
Have an automatic stop order for PROPHYLACTIC antibiotics.
Nursing has signage at patients bedside that tells when the last dose must be in.
Send MD's their data along with overall data for their service area. As being competitive by nature no one wants to be lagging behind.
This was approved through our Pharmacy and Therapeutics Committee. Along with this is the process of "stop sign stickers" that nursing places on the front of the chart (this was a MD idea) that state prophylactic antibiotics are automatically stopped with in 24 hours. (the cardiac folks have a different process due to the 48 hours)
Nursing is also helping to facilitate that if the antibiotic is ordered for >24 the MD, NP or PA needs to have documentation in the chart as to why this is occurring.
In the last few months it appears to be showing up in our data as the discontinuing in 24 hours has had huge % in compliance.

26. Protocols, protocols, protocols
Design protocols based on surgery type
Initiate protocol as a standard
– Nursing and/or pharmacy drives protocol
– No reliance on individual physician memory
Include guidance for exceptions
– Beta Lactam allergy
• Use your own formulary to narrow choices
– Makes protocol easier and saves costs

27. Surgical Care Improvement Project Performance measures - Process
Surgical infection prevention
Antibiotics
Administration within one hour before incision
Use of antimicrobial recommended in guideline
Discontinuation within 24 hours of surgery end
INF – 4: Glucose control in cardiac surgery patients
INF – 6: Proper hair removal
INF – 7: Normothermia in colorectal surgery patients

28. Glucose Control Lowers the Risk of Wound Infection in Diabetics After Open Heart Operations Zerr et al Portland, OR 7 6 5 4 3 2 1
1585 Diabetic Patients
Infection
Rate %
Mean DMG Range POD # 1

29. INF – 4: Glucose Control: the questions
What about patients who are not in the ICU? We only run insulin drips in the ICU
What glucose level needs to be maintained?
Why only cardiac surgery patients?
Corollary: we don’t do cardiac surgery but want to pursue glucose control
What is the glucose level that will have the best results for patients?
What about sliding scale insulin?

30. INF – 4: What works!
Implement Insulin Protocol for tighter glycemic control: BG target goal
Baseline measurement of BG Ranges prior to institution of new protocol
Use BG level by fingerstick on DAY OF surgery
Mandatory Staff Education
Weekly Data Collection
Data Reporting/Presentation

31. INF – 6: Hair removal
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!

32. Influence of Shaving on SSI
No Hair Group Removal Depilatory Shaved
Number
Infection rate 0.6% 0.6% 5.6%
Seropian. Am J Surg 1971; 121: 251

33. INF – 6: the questions What about neurosurgery?
What about “delicate” areas?
Why do the razors keep coming back?
Is the literature too old?
Others?

34. INF – 6: What works! Remove all razors from OR and entire hospital!
Provide packs allowing for “wet” hair removal with clipper
Re-educate, re-check for razors: early and often!
Post data and have a competition
Visual reminders (“Shave Free Zone” poster)

35. SCIP INF – 7: Temperature Control
200 colorectal surgery patients
control - routine intraoperative thermal care (mean temp 34.7°C)
treatment - active warming (mean temp on arrival to recovery 36.6°C)
Results
control - 19% SSI (18/96)
treatment - 6% SSI (6/104), P=0.009
Kurz A, et al. N Engl J Med
Also: Melling AC, et al. Lancet (preop warming)

36. INF – 7: Temp control: the questions
Why only colorectal surgery patients?
What kind of thermometer do you use?
What about OR temp/humidity?
Don’t the Bair huggers get in the way?
When should we warm up the patients?
What about core temperature?

37. INF – 7: What works!
Bair huggers for all patients preoperatively/intraoperatively
In winter, educate scheduled patients to stay warm on the way in to the hospital
Use of temporal arterial thermometers
Warmed IV fluids
Increasing OR temperatures
Involving technicians in OR temp maintenance
Caps, booties for patients

39. Surgical Care Improvement Project (SCIP)
Preventable Complication Modules
Surgical infection prevention
Cardiovascular complication prevention
Venous thromboembolism prevention
Respiratory complication prevention

40. Prevention of Cardiac Events Introduction
As many as 7 to 8 million Americans that undergo major noncardiac surgery have multiple cardiac risk factors or established coronary artery disease
More than 1 million cardiac events annually
Myocardial ischemia either clinically occult or overt confers a 9 - fold increase in risk of unstable angina, nonfatal myocardial infarction, and cardiac death
Schmidt M, et al. Arch Intern Med. 2002;162:63-69.
Mangano DT, et al. N Engl J Med. 1996;335:
Selzman CH, et al. Arch Surg. 2001;136:

41. Surgical Care Improvement Project Performance measure - Process
SCIP CARD – 2: Perioperative cardiac events
Perioperative beta blockers in patients who are on beta blockers prior to admission
We’ve only just started to report this indicator. When best practices are known, we’ll share them!
Any examples at your facility?

43. Prevention of Venous Thromboembolism
Recent estimates show that
more than 900,000 Americans suffer VTE each year
about 400,000 of these being DVT
About 500,000 being manifest as PE
In about 300,000 cases, PE proves fatal; it is the third most common cause of hospital-related deaths in the United States.
Heit JA, Cohen AT, Anderson FA on behalf of the VTE Impact Assessment Group. [Abstract] American Society of Hematology Annual Meeting, 2005.

44. Risk Factors for VTE
Previous venous thromboembolism
Increased age
Surgery
Trauma - major, local leg
Immobilization - ? bedrest, stroke, paralysis
Malignancy & its Rx (CTX, RTX, hormonal)
Heart or respiratory failure
Estrogen use, pregnancy, postpartum, SERMs
Central venous lines
Thrombophilic abnormalities
Most hospitalized patients have at least one additional risk factor for VTE

45. Surgical Care Improvement Project Performance measures - Process
Prevention of venous thromboembolism
SCIP VTE 1: Proportion who have recommended VTE prophylaxis ordered
SCIP VTE 2: Proportion who receive appropriate form of VTE prophylaxis (based on ACCP Consensus Recommendations) within 24 hours before or after surgery
These have been endorsed by the NQF and are limited to surgical patients
There are 7 refined measures recommended for endorsement
Prophylaxis within 24 hrs of admission or documented risk assessment indicating that the patient doesn’t need it
Prophylaxis documentation within 24 hours after ICU admission or surgery

47. What’s Next? MRSA VTE assessment and tracking HCAHPS
Outpatient measures 2008
Timing of antibiotics
Antibiotic selection
(pediatric asthma)

48. VBP Design Assumptions
Would build on infrastructure of the Reporting Hospital Quality Data for Annual Payment Update Program (RHQDAPU) – “pay-for-reporting” program
Would not include additional funding
– 2-5% withhold of base DRG funding for all Medicare patients
VBP payments based on the quality of care provided – not the fact that data were reported.
If you don’t report data, you can’t play!

49. What’s New on the SCIP Web Site!
Here are some of the latest additions to the SCIP web site at Feel free to visit the SCIP site often as we post new tools, interventions and more weekly.

50. Nancy West, RN, MPH, CPHQ
ext 2007