1 Surgical Infection Prevention In Washington State Where we started and where we’re going… Nancy West, RN, MPH, CPHQQualis HealthWith 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 USDespite 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 $1,398cardiovascular complications $7,789respiratory complications $52,466thromboembolic complications $18,310.Khuri and colleagues demonstrated that, independent of preoperative patient risk, the occurrence of a 30-day complication reduced median patient survival by 69%.Dimick JB, et al. J Am Coll Surg 2004;199:531-7.Khuri SF, et al. Ann Surg 2005;242:
4 Who Pays for Surgical Complications? HospitalReimbursement$Costs of careProfitProfit margin%14266(uncomplicated)10978328823.021911(complicated)211567553.4Complications 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.
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 CardiacCoronary Artery Bypass Graft (CABG)ColonHip & Knee ArthroplastyAbdominal & Vaginal HysterectomyVascular Surgery:Aneurysm repairThromboendarterectomyVein BypassThese 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 2001Bratzler DW, Houck PM, et al. Arch Surg. 2005;140:
9 Perioperative Prophylactic Antibiotics Timing of Administration 14/36915/4411/411/47Infections (%)1/812/1805/6995/1009Hours From IncisionClassen. 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 incisionSCIP INF – 2: Proportion of patients who receive prophylactic antibiotics consistent with current recommendationsSCIP 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 preventionAntibioticsAdministration within one hour before incisionUse of antimicrobial recommended in guidelineDiscontinuation within 24 hours of surgery endOther Process ImprovementGlucose control in cardiac surgery patientsProper hair removalNormothermia in colorectal surgery patients
12 INF – 1: the questionsAntibiotic 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 recordKeep abx in pre-op PyxisUtilize 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 sedationUse 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 PharmacistsInfectious Diseases Society of AmericaThe Hospital Infection Control Practices Advisory CommitteeMedical LetterSurgical Infection SocietySanford Guide to Antimicrobial TherapyThe Johns Hopkins GuideSociety 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 prophylaxisSafe and inexpensive
16 #2 – Be cautious about wanting to use vancomycin for prophylaxis Vancomycin resistance remains a public health problemVancomycin is not a particularly good antibiotic for prophylaxisChallenges with administration and slower tissue perfusionMay 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 10/07Vancomycin 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 prophylaxisInfection rates are the same regardless of duration of prophylaxisProlonged 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 SSIThere is a lack of evidence that antibiotics given after the end of the operation prevent SSI’sThere 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 typeInitiate protocol as a standard– Nursing and/or pharmacy drives protocol– No reliance on individual physician memoryInclude 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 preventionAntibioticsAdministration within one hour before incisionUse of antimicrobial recommended in guidelineDiscontinuation within 24 hours of surgery endINF – 4: Glucose control in cardiac surgery patientsINF – 6: Proper hair removalINF – 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, OR76543211585 Diabetic PatientsInfectionRate%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 ICUWhat glucose level needs to be maintained?Why only cardiac surgery patients?Corollary: we don’t do cardiac surgery but want to pursue glucose controlWhat 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 goalBaseline measurement of BG Ranges prior to institution of new protocolUse BG level by fingerstick on DAY OF surgeryMandatory Staff EducationWeekly Data CollectionData Reporting/Presentation
31 INF – 6: Hair removalShaving the surgical site with a razor induces small skin lacerationspotential 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!
32 Influence of Shaving on SSI No Hair Group Removal Depilatory ShavedNumberInfection 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 clipperRe-educate, re-check for razors: early and often!Post data and have a competitionVisual reminders (“Shave Free Zone” poster)
35 SCIP INF – 7: Temperature Control 200 colorectal surgery patientscontrol - routine intraoperative thermal care (mean temp 34.7°C)treatment - active warming (mean temp on arrival to recovery 36.6°C)Resultscontrol - 19% SSI (18/96)treatment - 6% SSI (6/104), P=0.009Kurz A, et al. N Engl J MedAlso: 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/intraoperativelyIn winter, educate scheduled patients to stay warm on the way in to the hospitalUse of temporal arterial thermometersWarmed IV fluidsIncreasing OR temperaturesInvolving technicians in OR temp maintenanceCaps, booties for patients
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 diseaseMore than 1 million cardiac events annuallyMyocardial ischemia either clinically occult or overt confers a 9 - fold increase in risk of unstable angina, nonfatal myocardial infarction, and cardiac deathSchmidt 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 eventsPerioperative beta blockers in patients who are on beta blockers prior to admissionWe’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 thatmore than 900,000 Americans suffer VTE each yearabout 400,000 of these being DVTAbout 500,000 being manifest as PEIn 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 VTEPrevious venous thromboembolismIncreased ageSurgeryTrauma - major, local legImmobilization - ? bedrest, stroke, paralysisMalignancy & its Rx (CTX, RTX, hormonal)Heart or respiratory failureEstrogen use, pregnancy, postpartum, SERMsCentral venous linesThrombophilic abnormalitiesMost hospitalized patients have at least one additional risk factor for VTE
45 Surgical Care Improvement Project Performance measures - Process Prevention of venous thromboembolismSCIP VTE 1: Proportion who have recommended VTE prophylaxis orderedSCIP VTE 2: Proportion who receive appropriate form of VTE prophylaxis (based on ACCP Consensus Recommendations) within 24 hours before or after surgeryThese have been endorsed by the NQF and are limited to surgical patientsThere are 7 refined measures recommended for endorsementProphylaxis within 24 hrs of admission or documented risk assessment indicating that the patient doesn’t need itProphylaxis documentation within 24 hours after ICU admission or surgery
47 What’s Next? MRSA VTE assessment and tracking HCAHPS Outpatient measures 2008Timing of antibioticsAntibiotic 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” programWould not include additional funding– 2-5% withhold of base DRG funding for all Medicare patientsVBP 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.