Surgical Site Infections The Medicare Quality Improvement Organization for Arizona

What is SCIP? Surgical Care Improvement Project Evolved from SIP Encompasses additional aspects of surgical care –Reduce/prevent: Cardiac events, emboli, and ventilator-associated pneumonia

Opportunities to Improve Care SSI: occurs in 14%–16% surgical patients –40%–60% of SSIs are preventable Cardiac: 2%–5% noncardiac surgery, 34% in vascular, AMI mortality rate as high as 70% DVT/PE: without prophylaxis: general surgery cases 25%, 7% orthopedic cases, > 50% DVT, 30% PE VAP: occurs 9%–40%, with associated mortality rates of 30%–46%

SCIP Goals Reduce postoperative mortality and morbidity by 25% over 5 years

A Closer Look at SSI SSI in a 51-case day –7.65 patients at risk for infection –4.59 of those infections are preventable

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SCIP in the News Newsweek, December 12, 2005 –6 Keys to Safer Hospitals USA Today ABC News 20/20 –More Killed Annually Than by Auto Accidents and Homicides ( )

SCIP Support American College of Surgeons American Society of Anesthesiology American Hospital Association CDC JCAHO AORN Veterans Administration AHRQ

Evidence Based “Evidence-based medicine is the process of systematically finding, appraising, and using contemporaneous research findings as the basis for clinical decisions.” “Evidence-based medicine is about asking questions, finding and appraising the relevant data, and harnessing that information for everyday clinical practice.” BMJ 1995;310: (29 April) William Rosenberg, Anna Donald Evidence-based Medicine: An Approach to Clinical Problem-solving

SSI Quality Measures 1: Prophylactic antibiotic received within 1 hour prior to surgical incision 2: Prophylactic antibiotic selection for surgical patients 3: Prophylactic antibiotics discontinued within 24 hours after surgery end time (48 hours for cardiac patients) 4: Cardiac surgery patients with controlled 6 a.m. postoperative serum glucose

SSI Quality Measures 5: Postoperative wound infection diagnosed during index hospitalization 6: Surgery patients with appropriate surgical site hair removal 7: Colorectal surgery patients with immediate postoperative normothermia

VTE Quality Measures 1: Surgery patients with recommended venous thromboembolism prophylaxis ordered 2: Surgery patients who received appropriate venous thromboembolism prophylaxis, within 24 hours prior to surgery to 24 hours after surgery 3: Intra- or postoperative pulmonary embolism (PE) diagnosed during index hospitalization and within 30 days of surgery 4: Intra- or postoperative deep vein thrombosis (DVT) diagnosed during index hospitalization and within 30 days of surgery

VAP Quality Measures 1: Number of days ventilated surgery patients had documentation of the head of the bed (HOB) being elevated, from recovery end date (day zero) through postoperative day seven. 2: Patients diagnosed with postoperative ventilator-associated pneumonia (VAP) during index hospitalization 3: Number of days ventilated surgery patients had documentation of stress ulcer disease (SUD) prophylaxis, from recovery end date (day zero) through postoperative day seven. 4: Surgery patients whose medical record contained an order for a ventilator-weaning program (protocol or clinical pathway)

Cardiac Quality Measures 2: Surgery patients on a beta-blocker prior to arrival that received a beta-blocker during the perioperative period 3: Intra- or postoperative acute myocardial infarction (AMI) diagnosed during index hospitalization and within 30 days of surgery.

Arizona’s Ranking

Before SCIP Alcohol scrubs –Most rapid reduction of bacteria counts –1 minute = 4–7 minutes of other agents Transfer of 1,000 organisms –Bacterial survival 20–150 minutes –Virus survival 20–30 minutes Chapters from ACS Surgery Prevention of Postoperative Infection Jonathan L. Meakins, M.D., D. Sc., F.A.C.S.

Impact InfectedUninfected Mortality (in-hospital) 7.8%3.5% ICU admission 29%18% Readmission 41%7% Median initial LOS 11d6d Median total LOS 18d7d Initial excess cost +$3,644 (median) Total excess cost +$5,038 (median) *Pairs matched for procedure, NNIS index, age *General inpatient surgical population; 22, 742 procedures included Kirkland. Infect Control Hosp Epidemiol. 1999;20:725. Prospective, case-controlled study of 22,742 patients undergoing inpatient surgical procedures between 1991–1995. Information adapted from the Institute for Healthcare Improvement (

Opportunity Decreasing the rate of SSI is an opportunity to: –Improve care –Promote improved outcomes –Increase patient satisfaction –Reduce costs

Components of SSI Antibiotic Administration Hair Removal Glucose Control Normothermia

CATS Clipping (Hair Removal) Antibiotic Administration Thermia (Normothermia) Sugar (Glucose Control)

Antibiotics Timely administration Selection Timely discontinuation

Timely Administration Most studies indicate that optimum timing for prophylactic antibiotic is within 1 hour of incision time. (Cephalosporins) When cuff is used, make sure all antibiotic is infused prior to inflation of cuff. Note: Because of the longer required infusion time, vancomycin, when indicated for beta-lactam allergy, should be started within 2 hours before the incision. Information adapted from the Institute for Healthcare Improvement (

Timing of Abx. Prophylaxis Classen, et al. N Engl J Med. 1992;328:281. Information adapted from the Institute for Healthcare Improvement (

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Antibiotic Selection Choose prophylactic antibiotics consistent with national guidelines –Special cases: Allergy (anaphylactoid) to  -lactam antibiotics High rate of MRSA wound infections locally Recent prolonged course of antibiotics or ICU stay Information adapted from the Institute for Healthcare Improvement (

Ancef Cefazolin –Effective against gram positive and negative –Low rate of allergic responses –Easy to administer –Inexpensive

Prophylaxis Dosing Always give at least a full therapeutic dose of antibiotic. Consider the upper range of doses for large patients and/or long operations. Repeat doses for long operations (> 4 hours) Information adapted from the Institute for Healthcare Improvement (

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. There is no need to continue coverage beyond 24 hours. Information adapted from the Institute for Healthcare Improvement (

Duration Concerns 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 evidence that unnecessary or prolonged use of antibiotics promotes antibiotic resistance. Information adapted from the Institute for Healthcare Improvement (

Tubes, Lines, and Drains “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.” Advisory Statement: Recommendations for the Use of Intravenous Antibiotic Prophylaxis in Primary Total Joint Arthroplasty American Association of Orthopedic Surgeons (AAOS)

Duration in Cardiac Surgery “Our findings confirm that continuing ABP beyond 48 hours after CABG surgery is still widespread; however, this practice is ineffective in reducing SSI, increases antimicrobial resistance, and should therefore be avoided.” Prolonged Antibiotic Prophylaxis After Cardiovascular Surgery and Its Effect on Surgical Site Infections and Antimicrobial Resistance Stephan Harbarth, MD, MS; Matthew H. Samore, MD; Debi Lichtenberg, RN; Yehuda Carmeli, MD, MPH Circulation. 2000;101:

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Hair Removal Quality Measure Surgery patients with appropriate surgical site h hair removal.

Hair Removal Appropriate: –No hair removal at all –Clipping –Depilatory use Inappropriate: –Razors Information adapted from the Institute for Healthcare Improvement (

Shaving Influence No Hair GroupRemovalDepilatoryShaved Number Infection rate0.6%0.6%5.6% Seropian. Am J Surg. 1971; 121: 251. Information adapted from the Institute for Healthcare Improvement (

Glucose Control Cardiac surgery patients with controlled 6:00 a.m. postoperative serum glucose. The measure looks at the glucose result for postoperative day 1 and day 2.

Risk, Glucose Control, Cardiac Surgery Increased risk: Diagnosed diabetes Undiagnosed diabetes Post-op glucose > 200 mg% within 48h Latham. Inf Contr Hosp Epidemiol. 2001;22:607. Dellinger. Inf Contr Hosp Epidemiol. 2001;22:604.

SSI Related to Glucose Control Cardiac Surgery after Median Sternotomy Latham. ICHE. 2001; 22: Information adapted from the Institute for Healthcare Improvement (

Additional Benefits of Glucose Control Decreased: –Acute renal failure –Red cell transfusions –Ventilator support –Time spent in intensive care van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in the critically ill patients. N Engl J Med Nov. 8; 345(19): PMID:

Normothermia Quality Measure Colorectal surgery patients with immediate normothermia (96.8–100.4° F) within the first hour after leaving the operating room.

Normothermia Patients who had a decrease of only 1.9°C in core temperature were three times as likely to develop surgical wound infections as were those in whom a normal body temperature of 37°C was maintained. Kurz A, Sessler DI, Lenhardt RA. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. N Engl J Med 1996; 334:1209–15.

Be An Advocate Advocate to reduce the risk of surgical site infections by using evidence-based care. Your patients will thank you.

Be Aware Be aware of evidence-based measures to reduce surgical site infection –Hair Removal (Clipping) –Antibiotic Usage (Antibiotic) –Normothermia (Thermia) –Glucose Control (Sugar)

Be Alert Be alert to the care your surgical patient is receiving. Is the care evidence-based or something else?

Be Active Ask the surgeon if he or she wants an antibiotic administered. Throw every razor away. Check the glucose on cardiac patients. Keep your patients warm. Work with a team to improve surgical care, increase patient satisfaction, improve patient outcomes, and decrease costs.

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Be Active WASH YOUR HANDS

This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for Arizona, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. AZ-8SOW-1C