1. Developing a surgical site infection bundle to improve patient outcomes Felix W. Tsai MD 1, Kathy Masters RD 2, Douglas Maposa MD 3, Lillian S. Kao MD 4, Charles Monney MS 5, and Galit Holzmann-Pazgal MD 6 1. Department of Pediatric Surgery, 3. Department of Anesthesia, 4. Department of Surgery, 6. Department of Pediatrics, UTHSC; 2. Department of Healthcare Improvement, 5. Department of Infection Control, Memorial Hermann Hospital

2. Background -44,000-98,000 preventable deaths a year -World Health Organization (WHO) Surgical Safety Checklist demonstrated to decrease mortality and morbidity world-wide -National Health Service has since advocated universal usage of the checklist N Engl J Med 2009;360:491

3. Background -Surgical Site Infections -Range between 2-5% for all surgical patients -Can add up to $30,000 additional hospital costs -Patient specific risk factors -Modifiable risk factors -Our infection rate -Between July 2007-December 2008, 7% -Between January 2009-September 2009, 4.8%

4. Goals -Decrease overall infection rates to less than 3% within 12 months -To develop a Surgical Site Infection (SSI) bundle, facilitated by an operative checklist, to decrease morbidity

5. Methods -SSI bundle creation -Preoperative chlorhexidine baths – September 2008 -Routine antibiotic discontinuation within 48 hours – April 2009 -Standardized prophylactic Vancomycin (targeted antibiotics) – January 2010 -Antibiotics given 30-120 minutes before skin incision – March 2010

7. Methods -SSI bundle creation -Preoperative chlorhexidine baths -Standardized prophylactic Vancomycin (targeted antibiotics) -Antibiotics given 30-120 minutes before skin incision -Routine antibiotic discontinuation within 48 hours

8. Methods -SSI bundle creation -Preoperative chlorhexidine baths -Routine antibiotic discontinuation within 48 hours -Standardized prophylactic Vancomycin (targeted antibiotics) -Antibiotics given 30-120 minutes before skin incision 1 1 J Antimicrob Chemother 2006;58(3):645

9. Methods -SSI bundle creation -Preoperative chlorhexidine baths -Routine antibiotic discontinuation within 48 hours -Standardized prophylactic Vancomycin (targeted antibiotics) -Antibiotics given 30-120 minutes before skin incision 1 1 J Antimicrob Chemother 2006;58(3):645

10. Methods -SSI bundle creation -Preoperative chlorhexidine baths -Routine antibiotic discontinuation within 48 hours -Standardized prophylactic Vancomycin (targeted antibiotics) -Antibiotics given 30-120 minutes before skin incision 1 1 J Antimicrob Chemother 2006;58(3):645

11. Methods -SSI bundle creation -Preoperative chlorhexidine baths -Routine antibiotic discontinuation within 48 hours -Standardized prophylactic Vancomycin (targeted antibiotics) -Antibiotics given 30-120 minutes before skin incision 1 1 J Antimicrob Chemother 2006;58(3):645

12. Methods -Risk stratification by Risk Adjusted Congenital Heart Surgery (RACHS) score -Low risk (RACHS 1, 2) -Medium risk (RACHS 3, 4) -High risk (RACHS 5, 6)

13. Methods -Retrospective and prospective data collection between August 2007 to August 2010 -Continuous ongoing data collection -Preoperative baths – September 2008 -Routine antibiotic discontinuation within 48 hours – April 2009 -Standardized antibiotic usage in January 2010 -Implementation of operative checklist began on March 24, 2010 -First cohort (August 2007-March 2010): 349 patients -Second cohort (March 2010-September 2010): 73 patients

14. Methods -Outcomes measured -Time between antibiotic administration and skin incision -SSI rates

15. Results -Random audits of preoperative baths: 100% compliance -Routine discontinuation of antibiotics on order form: 100% -Standardized usage of Vancomycin: >95% -Before the checklist, appropriate timing and dosing was only found in 21.4 - 40% of patients -After the checklist, actual compliance was 97.2% in all cases requiring cardiopulmonary bypass

16. Results Pre-intervention Antibiotic to Skin Incision Time Post-intervention Antibiotic to Skin Incision Time p value Low Risk (RACHS 1,2) 26 ± 34 Median = 24 minutes 60 ± 29 Median = 59 minutes 0.003 Medium Risk (RACHS 3,4) 32 ± 27 Median = 22.5 minutes 55 ± 28 Median = 62.5 minutes 0.000 High Risk (RACHS 5,6) 26 ± 13 Median = 21 minutes 59 ± 23 Median = 57 minutes 0.036 Surgical operations stratified as low risk, medium risk and high risk Pre- and post-bundle antibiotic dosage timing was analyzed by Student’s t-test

17. Antibiotic Dosing Interval

18. Results

21. Conclusions -A SSI bundle appears to improve antibiotic delivery to biologically plausible times -This may help decrease the overall risk of developing a SSI -Quality process improvement requires a baseline commitment and environment

22. Conclusions -Checklists are flexible tools that may be effective in a variety of situations -Checklist utilization serve as reminders and may improve teamwork and intraoperative safety culture

23. Future Directions -Continue SSI surveillance -General pediatric surgery: process compliance -Pediatric neurosurgery & plastic surgery: near- misses (implants) -Laparoscopic surgery: OR efficiency -Further studies are needed to determine factors that help and hinder checklist utilization

24. Acknowledgements Jannette Gutierrez Jose Delgado Raul Guardiola Betsabe Quezada Sarah Eshelman Heather Dunne Bill Douglas Mohammed Rafique Kevin Lally Kathy Masters Eric Thomas This work was supported in part by a training fellowship from the AHRQ Training Program of the W.M. Keck Center for Interdisciplinary Bioscience Training of the Gulf Coast Consortia (AHRQ Grant No. T32 HS017586)