1. Making Surgery Safer: Making Surgery Safer: Surgical Infection Prevention Team Members: Anesthesia: W. Scott Jellish – chair, Maureen Kawka Infectious Disease: Paul O’Keefe, Chris Schriever Surgical Services: Jeri Katsaros, Meg Kim, Peggy Vorrier Labor & Delivery: Maureen Davey Quality Resource Management: Carmen Barc, Vada Grant, Susan Tuzik Infection Control: Jan Bartel, Alexander Tomich CCE: Mary Altier, William Barron, LuAnn Vis, Michael Wall Magnet Forces: 6 - Quality of Care 7 - Quality Improvement 13 - Interdisciplinary Relationships Confidential: For Quality Improvement Purposes Only

2. Aim 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 at the right time – is effective in preventing infections after surgery*. Other perioperative measures – glucose control, temperature control, and appropriate hair removal – have also been proven effective in reducing infections *Bratzler, DW, et al. Use of Antimicrobial Prophylaxis for Major Surgery: Baseline Results from the National Surgical Infection Prevention Project, Arch Surg Feb 2005; 140:174-182. Confidential: For Quality Improvement Purposes Only

3. Project Goals To achieve compliance for the following measures: –Administer antibiotics within one hour before surgical incision –Administer the appropriate antibiotic –Stop antibiotics within 24 hours after surgery (48 hours after cardiac surgery) –Controlled postoperative serum glucose (200mg/dl or less) – Cardiac surgery patients –Appropriate hair removal – No razors –Immediate postoperative normothermia – Colorectal surgery patients These measures are publicly reported at www. hospitalcompare.hhs.gov Confidential: For Quality Improvement Purposes Only

4. Solutions Implemented in 2007/2008 Data management and results –Reviewed all outliers to identify trends; provided follow up physician education –Created system to forward physician-specific reports to the Chairs, individual physicians, and the Chief of Staff –Forwarded results externally: Illinois Report Card Act – beginning July 07 cases The Joint Commission – beginning January 08 cases Hospital Compare - Ongoing Confidential: For Quality Improvement Purposes Only

5. Solutions Implemented in 2007/2008 Antibiotic orders –Revised order sets to address MRSA risk –Revised Endocarditis Prophylaxis Guidelines* Hair removal –Removed razors from OR, Pre-op holding; limiting access to SRP –Educated procedure areas on appropriate hair removal –Physician education to eliminate learned phrase “shaved and prepped” when a clipper was used for hair removal Normothermia –Tested warming blankets and thermal caps *Wilson et al. Prevention of infective endocarditis. Guidelines from the American Heart Association. Circulation 2007; 116:1736. Confidential: For Quality Improvement Purposes Only

6. 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. Analysis: Ninety-six percent of LUMC patients receive prophylactic antibiotics within the recommended timeframe prior to surgical incision. Confidential: For Quality Improvement Purposes Only

7. 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. Analysis: Ninety-five percent of LUMC patients now receive prophylactic antibiotics consistent with current guidelines. Additional initiatives were implemented in February and March 2007 to ensure that all surgical patients receive antibiotics consistent with current guidelines. Confidential: For Quality Improvement Purposes Only

8. Definition: Surgical patients with prophylactic antibiotics discontinued within twenty-four hours after surgery end time / Patients undergoing hip / knee arthroplasty, colon surgery, hysterectomy, or vascular surgery. CABG and other cardiac surgeries are allowed 48 hours. Data source: LUMC medical records abstracted by RNs. Analysis: Performance is consistent at 91%. Confidential: For Quality Improvement Purposes Only

9. Definition: Percent of cardiac surgery patients with controlled 6AM post-operative glucose. Control is defined as serum glucose reading of 200mg/dL or less on both post-operative day 1 and day 2. Results show cardiac surgery patients with the presence of post-operative day 1 and day 2 glucose measurements, readings closest to 6AM were selected for inclusion. Data Source: LUMC medical records abstracted by RNs. Analysis: 6AM postoperative glucose control on both postoperative days 1 and 2 has been consistent at 90% for the past 18 months. Confidential: For Quality Improvement Purposes Only

10. Definition: Number of Surgical cases abstracted without the use of razors for hair removal / Number of Surgical Cases Sampled. Appropriate hair removal includes: use of clippers, use of depilatory, or no hair removal. Data source: LUMC medical records abstracted by RNs. Analysis: The rate of appropriate hair removal decreased in late 2007 due to a change in the measure definition. The definition now assumes a patient was shaved with a razor, if physician documentation states ‘shaved’ within the chart. Education for surgeons in December 2007 has shown improvement back to baseline levels. Confidential: For Quality Improvement Purposes Only

11. Definition: Number of colorectal surgery cases with normal body temperature (normothermia) immediately after surgery/ Patient undergoing colorectal surgery cases. Normothermia is defined with as a temperature of 96.8°F – 100.4°F. Data source: LUMC medical records abstracted by RNs. Analysis: The rate of immediate post-operative normothermia in colorectal surgeries is 65%. Confidential: For Quality Improvement Purposes Only

12. Definition: Surgical patients receiving 100% of indicated antibiotic prophylaxis, glucose control, hair removal, temperature control, beta-blocker continuation, and venous thromboembolism therapy / Patients undergoing CABG, cardiac surgery, hip / knee arthroplasty, colon surgery, hysterectomy, or vascular surgery. Data source: LUMC medical records abstracted by RNs. Analysis: Seventy-eight percent of selected surgical patients are receiving all indicated care to prevent surgical infections. This performance is better than 92% of UHC academic hospitals. Confidential: For Quality Improvement Purposes Only

13. Next Steps Revise orders to address MRSA screen positive results Identify improvement opportunities for hair removal and normothermia measures Infection Control Committee to investigate surgical site infection benchmarking opportunities Incorporate related Hospital Outpatient Department Quality Measures into project –Antibiotic measures for ASC, EP Lab, L&D Confidential: For Quality Improvement Purposes Only