1. Surgical Infection Prevention Project Team: Anesthesia Infectious Disease Pharmacy Surgical Services Labor & Delivery Quality Resource Management Center for Clinical Effectiveness

2. Opportunity Statement Surgical site infections are a major complication after surgery, resulting in considerable morbidity, mortality, and resource utilization. Proper use of antibiotics – giving the right drug and the right time – is effective in preventing infections after surgery.

3. Project Goals To achieve 100% compliance for the following measures: 1.Administer antibiotics within one hour before surgical incision 2.Administer the appropriate antibiotic 3.Stop antibiotics within 24 hours after surgery Defined by the National Surgical Infection Prevention Project (CMS/CDC)

4. Targeted Surgeries Abdominal and Vaginal Hysterectomy Hip and Knee Replacement Cardiac Bypass Other Cardiac Surgery Vascular Surgery Colon Surgery

5. Most Likely Causes Antibiotic not administered within recommended time intervals Variation in physician ordering practices Variation in documentation of antibiotic administration

6. Solutions Implemented Initiated extensive data collection plan Based on CMS and JCAHO specifications Monthly chart review Shared service specific data Reviewed with Physicians and Nurse Practitioners Identified improvement opportunities Revised pre and post operative standard order sets to mirror guidelines

7. Definition: Surgical patients who received prophylactic antibiotics within 60 minutes prior to surgical incision / Patients undergoing CABG, cardiac surgery, hip / knee arthroplasty, colon surgery, hysterectomy, or vascular surgery. Vancomycin and fluoroquinolones timeframe is extended to 120 minutes prior to incision. Data source: LUMC medical records abstracted by RNs. Ninety percent of LUMC patients receive prophylactic antibiotics within 60 minutes prior to surgical incision

8. Definition: Surgical patients receiving prophylactic antibiotics consistent with current guidelines / Patients undergoing CABG, cardiac surgery, hip / knee arthroplasty, colon surgery, hysterectomy, or vascular surgery. Data source: LUMC medical records abstracted by RNs. Eighty three percent of LUMC patients receive prophylactic antibiotics consistent with current guidelines

9. Definition: Surgical patients with prophylactic antibiotics discontinued within twenty-four hours after surgery end time / Patients undergoing CABG, cardiac surgery, hip / knee arthroplasty, colon surgery, hysterectomy, or vascular surgery. Data source: LUMC medical records abstracted by RNs. Percent National Hospital Quality Measures Surgical patients receiving prophylactic antibiotics discontinued within 24 hours after surgery end time Month Apr-04 (n=62) May-04 (n=44) Jun-04 (n=57) Jul-04 (n=54) Aug-04 (n=44)Sep-04 (n=40) Oct-04 (n=48) Nov-04 (n=49)Dec-04 (n=51) 50 60 70 80 90 UCL = 87.00 LUHS Mean = 67.0 LCL = 47.07 JCAHO National Rate Q3 2004: 63.0 Two-third of LUMC patients now have prophylactic antibiotics discontinued within 24 hours after surgery end

10. Analysis of Results Loyola performs better than National JCAHO comparison hospitals for two of the measures Antibiotic selection requires ongoing attention and follow up Discontinuation of antibiotics within 24 hour has the greatest improvement potential for Cardiovascular and Orthopaedic surgeries

11. Next Steps Continue comparison with UHC and national benchmarks Post results on the LUHS portal and internet Review surgical site infection data for targeted class 1 surgeries Plan for public reporting of data Consider participation in upcoming National Surgical Care Improvement Project