Presentation on theme: "SCIP: Preventing Surgical Site Infections"— Presentation transcript:
1SCIP: Preventing Surgical Site Infections Gary Kanter, M.D.Betsy Lehman CenterDecember 4, 2007
2I 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.
3Surgical Care Improvement Project National Quality PartnershipCMS,CDCReduce nationally the incidence of surgical complications by 25% by 2010(13,027 deaths, 271,055 complications)/yrFocus onSurgical infection preventionAdverse cardiac eventsPrevention of DVTPost operative pneumoniaUsing evidence based medicine
4How often do patients receive “scientifically indicated care” in this country? Near 100%- we are doing a great job75%- not too shabby55%- flip a coinWhat 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)
5How often do patients receive “scientifically indicated care” in this country? Near 100%- we are doing a great job75%- not too shabby55%- flip a coinWhat 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)
10Surgical Infection (SI): Epidemiology & Impact Account for % of all Hospital Acquired Infections (HAI)2-5% of operative patients will develop SI0.8-2 million infections a yearSI increase LOSAverage 7.5 additional daysExcess costs$130-$845 million per yearAdds $2,734 - $26,019 per pt (average $3,000)Pain and suffering
11SI: Epidemiology & Impact Patients who develop infection are:60% more likely to spend time in an ICU5 times as likely to be readmittedHave a mortality rate twice that of noninfected patientsAn estimated 40-60% of these infections are preventable
14Baystate Medical Center 700 bed tertiary care referral center (population of ~1M)Flagship of Baystate Health41 k admissions/yearAnnual surgical volume: 29,043Western Campus of TUFTSMember CoTH, 9 residency programs, 244 residents1200 member medical staff, 206 faculty MDsLevel 1 Trauma CenterIHI Mentor Hospital Surgical Infection Prevention
15Use of antimicrobial prophylaxis for major surgery: baseline results from the National Surgical Infection Prevention Project Arch Surg Feb;140(2):
17Quality Improvement Process Benchmarking, measurement, and feedbackWork with key physician championsDisseminate recommendations to educateUse physician order entryEnlist help of case managers as quality safety netUse PDSA cycles to test and improve
18Prophylactic Antibiotics Antibiotics given for the purpose of preventing infection when infection is not present but the risk of post-operative infection is present
19Prophylactic 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?
20Recently Updated Antibiotic Recommendations Surgery TypeAntimicrobial recommendationsHip or knee arthroplastyPreferred: Cefazolin or cefuroximeIf patient high risk for MRSA: Vancomycin*Beta-lactam allergy:Vancomycin or clindamycinCardiac 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).
21Recently Updated Antibiotic Recommendations (continued) Surgery TypeAntimicrobial recommendationsHysterectomyCefotetan, cefazolin, cefoxitin, cefuroxime, or ampicillin-sulbactamBeta-lactam allergy:Clindamycin + gentamicin or fluoroquinolone* or aztreonamMetronidazole + gentamicin or fluoroquinolone*Clindamycin monotherapyColorectal †Neomycin + erythromycin base; neomycin + metronidazoleCefotetan, 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.
22Prophylactic 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?
23Timing of Antibiotic Prophylaxis GI Operations Stone HH et al. Ann Surg. 1976;184:
24Perioperative Prophylactic Antibiotics Timing of Administration 14/36915/4411/411/47Infections (%)1/812/1805/6995/1009Hours From IncisionClassen. NEJM. 1992;328:281.
25Antibiotic Timing Related to Incision Bratzler DW, Houck PM, et al. Arch Surg. 2005;140:
27Never Underestimate the Power of Competition BMC AB Timing by AnesthesiologistNever Underestimate the Power of Competition
28Memorandum DIVISION OF HEALT H CARE QUALITY TO: , MD FROM: Associate Medical DirectorDATE:, 2006SUBJECT:SCIP(Surgical Care Improvement Program)As part of the SCIP process,the medical record ofPATIENTwas reviewed. As evidenced by the attacheddocumentation,it appearsthat thepatient’sprophylactic pre-operativeantibiotic was:_____given greater than1hour prior to theinitial incisiontimenot redosed._____given after the initial surgical incision._X__not given at all ( no time of administration was documented)Pleaserememberthat current standard of practiceisoperative antibiotic administration within60 minutes prior to the incision (Levaquinand Vancomycin are within 120 minutesprior to theincision).Redosing of antibiotics if the case extends beyond 3 hourswhen cefazolins are usedPlease contactme at 44326if you have any questions. Thankyou.
32Quality Indicators National Surgical Infection Prevention Project Proportion of patients who receive prophylactic antibiotics consistent with current recommendationsThe 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.
33Antibiotic Recommendation Sources American Society of Health System PharmacistsInfectious Diseases Society of AmericaThe Hospital Infection Control Practices Advisory CommitteeMedical LetterSurgical Infection SocietySanford Guide to Antimicrobial Therapy 2003This 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.
34Antibiotic 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 patientsReviewed and revised AB selections in computer order sets (opt out, forcing function)
35The Advisory Statement published in 2004 in Clinical Infectious Diseases. Clin Infect Dis. 2004;38:
41Quality Indicator #3Proportion of patients whose prophylactic antibiotics were discontinued within 24 hours of surgery end timeThe 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.
42Discontinuation 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:
43Antibiotic Prophylaxis Duration Most studies have confirmed efficacy of 12 hoursMany studies have shown efficacy of a single doseWhenever compared, the shorter course has been as effective as the longer course
44Papers Comparing Duration of Peri-op Antibiotic Prophylaxis Colorectal 3Mixed GI 4Hysterectomy 3Gyn & GI 1Head & Neck 3Orthopedic 4Vascular 3Cardiac __7__Total 28Papers supporting longer duration 1
45Duration of prophylactic antibiotic administration should not exceed the 24-hour post-operative periodProphylactic antibiotics should be discontinued within 24 hours of the end of surgeryMedical 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
46Consequences of Prolonged AB Use Increased antibiotic and drug administration costsIncreased antibiotic-associated complicationsIncreased patterns of antibiotic resistanceClostridium difficile EnterocolitisColonization with MRSA
52Barriers – Antibiotic Use TimingConsistencySustainability (constant monitor)SelectionResistance (surgeons and organism)Availability; national consensus issuesDurationKnowledge gapIf it’s not broke, don't change it
54Duration of Antibiotic Prophylaxis: What is Best for Our Patients? Antibiotic prophylaxis is one of many methods for reducing the incidence of SSIThere is a lack of evidence that antibiotics given after the end of the operation prevent SSIsThere is evidence that increased use of antibiotics promotes antibiotic resistance
56Diabetes Complications Estimated 10 million AmericansPoor glucose control is associated with:Increased risk of infectionDelayed healingIncreased mortalityBlunts inflammatory response
57Diabetes, Glucose, Control and SI Infections (%)Latham,ICHE 2001; 22:607-12
58Glucose 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
59Survival increased with intensive insulin therapy ( nondiabetic patients included ) targeting BG mg/dLVan den Berghe et al. NEJM 2001; 345:
61Glycemic ControlEstablished 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 nursingInsulin infusions to be initiated in ORInsulin 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 utilizedConversion protocol (IV infusion to sliding scale)
62Diabetes, Glucose Control, & SIs ICHE 2001; 22: 607-12 SummaryPeri-operative hyperglycemia and diabetes are associated with increased risk of SIsEarly diagnosis of diabetes among high-risk patients may have short and long-term benefits
64Hair Removal Pre-operative Shaving Shaving the surgical site with a razor induces small skin lacerations:Potential sites for infectionDisturbs hair follicles which are often colonized with S. aureusRisk greatest when done the night beforePatient educationbe 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.
66Hair RemovalPreoperative 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 removalDo 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)
67Cochrane Database Syst Rev. 2006 Apr 19;(2) Three trials involving 3193 patientsCompared shaving with clippingStatistically significantly more SSIs when people were shaved rather than clipped (RR 2.02, 95%CI 1.21 to 3.36)
68Interventions Razors removed from OR’s Razors removed from most clinical areasPatients may use razors for personal hygiene
71Temperature and SSI Following Colectomy Normo (N=104) Hypo (N=96) PSSICollagen depTime to eat 5.6d 6.5d <.006Kurz. NEJM 1996;334:1209
72Normothermia Standardization Review by patient populations Pre warmRemoved “random number generators”One device and one measure (first PACU temp)Review by patient populationsEducation/communicationRoom set point pre-opIncreased temperature upon pt arrival to room until drapedStaff comfort balanced against patient centered careProductsForced hot airWarm fluidsCooling vestsTemporal thermometers
75Apparently Unavoidable Potentially Preventable This complication may not have occurred with the application of every indicated prevention measureApparently UnavoidableDespite the application of every indicated prevention measure the complication occurred anywayA mystery………
76SurveillanceList of patients sent to each surgeon, 30 days post procedure97% return rate (SASE, interoffice mailing)Self report: any post operative infection/ commentsDaily admissions with wound infectionReview for surgical date and s/s infectionDaily microbiology reports of all + cultures reviewed for wound, fluid cultures, e.g joint aspiratesCharts reviewed for NNIS criteria, surgical date and s/s infection
77Investigation NNIS criteria: ASA, Wound Class, Length of Procedure Presence of interventionsAntibiotic useSurgical prep and skin conditionImplantsCluster evaluationSpecific conditions of the patientSurgical environmentOrganismSurgical team
78Potentially Preventable Review All infections reviewed for potential preventability using SCIP guidelinesReviewed using other criteria as wellReview done by IC dept and fed back to multiple cmts (COI, SCIP, SPIT, SAQI)System level changes made when applicableConsistently, 50% of infections have a SCIP miss!!
79Where Do Things Fall Through the Cracks? System – information, tests, diagnosesCommunicationHand offsFailure to recognizeFailure to activateFailure to rescue
80Improvement Tools Systems Populations Cycles of Change PDSA, Six Sigma, LEANProcess AnalysisFailure Mode IdentificationBH PI Tool Kit
81Make The Right Thing The Easy Thing Keys to SuccessPersistence and reinforcement/high visibilitySenior leader supportMultidisciplinary cooperation & collaborationAccurate, timely and relevant dataRight peopleWilling to try changes and take a riskDevelop reliable systems (strive for 10-2 > 90%)Incorporate into workflowMake changes easy and transparentStress importance of impact on patient and practitionerMake The Right Thing The Easy Thing
82Lessons Learned Involve all stakeholders Leave your stripes at the doorMust have physician champions- credibleBe humbleTake more blame and give more creditBROAD shouldersMust work as teamSmall tests of change with frequent tempoSmall pilot populationWork within your cultureSteal shamelesslyMake the right thing the easy thing
83Medicine used to be simple, ineffective, and relatively safe……. Now it is complex, effective, and potentially dangerous.Sir Cyril Chantler1999 Hollister Lecture at Northwestern University, IllinoisJames, B. 16th IHI Conference
84Department of Anesthesiology Baystate Medical Center For More Information:Gary Kanter, M.D.Department of AnesthesiologyBaystate Medical CenterSpringfield MA 01199