1. Making Surgery Safer: Surgical Infection Prevention Team Members: Anesthesia: W. Scott Jellish- chair, Maureen Kawka, Nicole Wakim Infectious Disease: Paul O’Keefe, Chris Schriever Surgical Services: Jeri Katsaros, Jo Quetsch, Peggy Vorrier Labor & Delivery: Maureen Davey Quality Resource Management: Mary Altier, Carmen Barc, Vada Grant Infection Control: Jayne Haake CCE: William Barron, LuAnn Vis, Michael Wall

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 hair removal – have also been proven effective in reducing infections.

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 –Controlled postoperative serum glucose – Cardiac surgery patients –Appropriate hair removal – No razors –Immediate postoperative normothermia – Colorectal surgeries These measures are publicly reported

4. Solutions Implemented in 2006 Data collection/analysis changes Adopted UHC’s online tool and sampling methodology Expanded data collection to new related measures –Controlled postoperative serum glucose – Cardiac surgery patients –Appropriate hair removal – No razors –Immediate postoperative normothermia – Colorectal surgeries Created physician level reports Posted 1 st round of data to CMS’s public website – www.hospitalcompare.hhs.gov www.hospitalcompare.hhs.gov

5. Solutions Implemented in 2006 Department specific initiatives: Met with Physician leaders in each Surgical specialty to identify improvement opportunities Updated relevant EPIC Perioperative standing orders to ensure evidence-based practice and compliance with national standards Added antibiotic reminder to the OR time-out process Revised OR Anesthesia record to document medication routes Operating Room removed razors from the OR’s and promoted use of clippers for appropriate hair removal

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. Charts were selected using a statistically driven and randomized sample size methodology. Analysis: Ninety-four percent of LUMC patients receive prophylactic antibiotics within the recommended timeframe prior to surgical incision. 100% of patients in the most recent 3 months received their antibiotics on time. Stretch Goal is based on Senior Management Critical Success Factors for FY07

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. Charts were selected using a statistically driven and randomized sample size methodology. Analysis: Eighty-four percent of LUMC patients receive prophylactic antibiotics consistent with current guidelines. Initiatives were implemented in February 2007 to ensure that all surgical patients receive antibiotics consistent with current guidelines. Stretch Goal is based on Senior Management Critical Success Factors for FY07 Percent Core Measures Surgical patients receiving prophylactic antibiotics consistent with current guidelines Month UCL = 101.7 Mean = 84.2 LCL = 66.7 Stretch Goal = 95% Apr 2005 (n=47) May 2005 (n=52) Jun 2005 (n=54) Jul 2005 (n=46) Aug 2005 (n=49)Sep 2005 (n=49) Oct 2005 (n=36) Nov 2005 (n=39)Dec 2005 (n=39) Jan 2006 (n=38) Feb 2006 (n=36)Mar 2006 (n=34) Apr 2006 (n=34) May 2006 (n=39) Jun 2006 (n=37) Jul 2006 (n=25) Aug 2006 (n=26)Sep 2006 (n=22) 60 70 80 90 100

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. Charts were selected using a statistically driven and randomized sample size methodology. Analysis: Performance has improved for timely discontinuation of prophylactic antibiotics in 2006 following the allowance of cardiac surgery prophylaxis to extend through 48 hours post-operatively. Stretch Goal is based on Senior Management Critical Success Factors for FY07

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. This is a Surgical Care Improvement Project (SCIP) process measure which will become a National Hospital Quality Measure in July 2006. Data Source: Clarity database, FORCE database. Analysis: 6AM postoperative glucose control on both postoperative days 1 and 2, has been at 100% for the past 3 months. Percent of Cardiac Surgery Patients with Controlled Postoperative Glucose Core Measures Surgical Care Improvement Project Controlled Postoperative Serum Glucose - Cardiac Surgery Patients Month (number of patients) Jul 2006 (n=8) Aug 2006 (n=7)Sep 2006 (n=5) 99.0 99.5 100.0 100.5 101.0

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. Charts were selected using a statistically driven and randomized sample size methodology. Analysis: The rate of appropriate hair removal is 97%.

11. Definition: Number of colorectal surgery cases with immediate post-operative normothermia / Patient undergoing colorectal surgery cases. Normothermia is defined with a range of 96.8°F – 100.4°F. Data source: LUMC medical records abstracted by RNs. Charts were selected using a statistically driven and randomized sample size methodology. Analysis: The rate of immediate post-operative normothermia in colorectal surgeries is 54%.

12. Next Steps Quarterly distribution of physician level reports Identify improvement opportunities with surgical specialties that are not meeting targets Identify opportunities to streamline data collection processes within EPIC Benchmark with other organizations to become a National “Top Performer” in all of the measures