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

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Presentation on theme: "SCIP: Preventing Surgical Site Infections Gary Kanter, M.D. Betsy Lehman Center December 4, 2007."— Presentation transcript:

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

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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? A) Near 100%- we are doing a great job B) 75%- not too shabby C) 55%- flip a coin D) 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? A) Near 100%- we are doing a great job B) 75%- not too shabby C) 55%- flip a coin D) 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)

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

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

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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? Which cases benefit? When should you start? When should you start? Which drug should you use? Which drug should you use? How much should you give? How much should you give? How long should antibiotics be continued? 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 Vancomycin or clindamycin Cardiac or vascular Preferred: Cefazolin or cefuroxime If patient high risk for MRSA: Vancomycin* Beta-lactam allergy: Vancomycin or clindamycin Vancomycin or clindamycin * 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 TypeAntimicrobial recommendations HysterectomyCefotetan, 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 Beta-lactam allergy: Clindamycin + gentamicin or fluoroquinolone* or aztreonam Metronidazole + gentamicin or fluoroquinolone* * 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? Which cases benefit? When should you start? When should you start? Which drug should you use? Which drug should you use? How much should you give? How much should you give? How long should antibiotics be continued? How long should antibiotics be continued?

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

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

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

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32 Quality Indicators National Surgical Infection Prevention Project Quality Indicator #2: Proportion of patients who receive prophylactic antibiotics consistent with current recommendations

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

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 Clin Infect Dis. 2004;38:

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39 Expanded pt populations

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41 Quality Indicator #3 Proportion of patients whose prophylactic antibiotics were discontinued within 24 hours of surgery end time

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 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  Colorectal3  Mixed GI4  Hysterectomy3  Gyn & GI1  Head & Neck3  Orthopedic4  Vascular3  Cardiac__7__  Total28 Papers supporting longer duration1

45 Duration of prophylactic antibiotic administration should not exceed the 24-hour post-operative period 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 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 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

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52 Barriers – Antibiotic Use 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 NNISS Benchmark = 2-11 % NNISS Benchmark = 2-11 % Surgical Infection Rate 1.13 %

54 Duration of Antibiotic Prophylaxis: What is Best for Our Patients? Antibiotic prophylaxis is one of many methods for reducing the incidence of SSI 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 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 There is evidence that increased use of antibiotics promotes antibiotic resistance

55 Glycemic Control

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

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

58 Furnary et al. Ann Thorac Surg 1999:67:352 Glucose Control and Deep Sternal Wound Infections

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

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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: Summary Peri-operative hyperglycemia and diabetes are associated with increased risk of SIs 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 Early diagnosis of diabetes among high- risk patients may have short and long- term benefits

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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!

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

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

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70 HYPOTHERMIA Increased myocardial ischemia & VT 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 eat5.6d6.5d <.006 Kurz. NEJM 1996;334:1209

72 Normothermia  Standardization  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

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

75 Potentially Preventable This complication may not have occurred with the application of every indicated prevention measure 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) 97% return rate (SASE, interoffice mailing) Self report: any post operative infection/ comments Self report: any post operative infection/ comments Daily admissions with wound infection Review for surgical date and s/s 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 Charts reviewed for NNIS criteria, surgical date and s/s infection

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

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

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

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

81 Keys to Success Keys to Success Persistence and reinforcement/high visibility Persistence and reinforcement/high visibility Senior leader support Senior leader support Multidisciplinary cooperation & collaboration Multidisciplinary cooperation & collaboration Accurate, timely and relevant data Accurate, timely and relevant data Right people Right people Willing to try changes and take a risk Willing to try changes and take a risk Develop reliable systems (strive for > 90%) Develop reliable systems (strive for > 90%) Incorporate into workflow Incorporate into workflow Make changes easy and transparent Make changes easy and transparent Stress importance of impact on patient and practitioner Stress importance of impact on patient and practitioner Make The Right Thing The Easy Thing 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 Sir Cyril Chantler 1999 Hollister Lecture at Northwestern University, Illinois James, B. 16 th IHI Conference

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


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