1. The Joint Commission Center for Transforming Healthcare (CTH)
Surgical Site Infections in Colorectal Surgeries Project: 2012
Sasha Madison, MPH, CIC
Director Infection Prevention & Control Dept.
May 14, 2014

2. Project #4: Surgical Site Infection
Collaborate with American College of Surgeons & NSQIP measurement system leveraged.
Seven participating hospitals:
Mayo Clinic, MN
Cleveland Clinic, OH
Stanford Hospital & Clinics, CA
OSF Saint Francis, IL
Northwestern Memorial Hospital, IL
North Shore LIJ, NY
Cedars-Sinai Medical Center, CA
Siew Lee will go over the list of participants for the project and point out the video available at the website. Siew Lee will play the video for 2 +minutes.

3. Systematic Approach to Problem Solving – Surgical Site Infections (1)
The Center worked with the American College of Surgeons to determine the scope of the SSI project, since there is a wide range of surgeries and procedures that can develop SSIs – each with its own unique set of complications and challenges.
To help narrow the scope of the project, the following criteria were used to identify a specific procedure that:
Is common across different types of hospitals
Has significant complications with an adverse clinical impact
Hospitals have significant opportunities to improve performance
Has high variability in performance across hospitals
Siew Lee will explain the kick off experience of working with ACS and participating hospitals in coming out with the criteria to narrow down the scope for the project and how we landed on colorectal as the focus.

4. Collaborative Project Definition
DMAIC
Problem Statement:
The incidence of Surgical Site Infections in colorectal surgery is high, variable, and represents opportunity for improvement.
Goal:
Reduce colorectal surgical site infections by 50% (Observed and Observed/Expected)
Scope:
Process Begins: Pre-Operative Processes (Pre-Op Clinic with Surgeon)
Process Ends: 30 Days Post-Surgery
Includes: All emergent & elective surgical procedures
Excludes: Trauma and Transplant patients & Patients under 18 years of age
Timeline:
August 2010 – March 2012
Kinjal

5. 2009 Metrics: Observed & O/E Baseline Performance
DMAIC
Metric 1- Observed Colorectal SSIs
Baseline: 18.5% Target: 9.3%
(50% reduction)
Metric 2- O/E* Ratio for Colorectal SSIs
Baseline: Target: 0.74
(50% reduction)
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1st graph (left): P= Overall Rate of CY 09’
2nd graph (right): X= Mean O/E
Average SSI Cases / Month = 3
Note: Observed/Expected / Index Value
Expected Value is Dependent on “Expected” influence/calculation

6. SHC SSI Project Phases & Elements
DMAIC
Milestone
Key Elements
Define
Incidence of Surgical Site Infections in colorectal surgery is high, variable, and represents opportunity for improvement.
Measure
Reduce colorectal surgical site infections by 50% (Observed and Observed/Expected)
Analyze
(Based on statistical analysis of SHC data)
Improve
Focus on identified causes, target solutions, patient outcomes
Control
Correlate interventions with SSI outcomes and create sustainability plans for any intervention that successfully decreased SSIs
Statistically Significant Variables
(Potential Risk Factors for SSI)
Potential Identified Variables /Opportunities
Wound Disruption (0.003)
OR Duration (0.066)
ASA Class > 2 (0.015)
Open/Laparoscopic Procedure (0.054)
Total Hospital LOS (0.036)
Lowest Patient Intra-Operative Temperature
Post-Operative Wound Care
Hand Hygiene
Dressing Removal at 48hrs
Post-Operative Bathing
Surgical Closure
Glove Change Prior to Closing Fascia
Separate Colorectal Closure Tray
Tissue Irrigation
- Irrigation Solution Type
Note: Actual Interventions in blue & Monitoring in green
Note: Above variables found to be statistically significant, however not entirely modifiable.
- No Interventions Made
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7. Project Interventions & Monitoring
DMAIC
Improvement
Baseline
Target & Measurement Tools
Implementation Month-Year
Glove Changes
Standardize closing process
59% of clinicians responded “No” to changing gloves before closure
100% glove changes before closing fascia
MIDAS Focus Audit
February 2011
Colorectal Closure Tray
Standardize major set closing tray
No separate closing tray
100% separate and clean closing instruments
April 2011
Patient and Room Temperature Guidelines Given to OR & ASC
No baseline measurement
Per SCIP & AORN Guidelines:
Patient temperature should be equal to or greater than 36 Degrees Celcius
Ambient OR room temperature should be Degrees Fahrenheit
August 2011
Post Op Wound Care Protocol (Collaborative best practice)
Dressing marked by surgical team
Dressing Removal Goal = 48 hours
100% Dressing marked by surgical team
100% Dressing Removal: Goal = 48 hours
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8. MIDAS Focus Objectives:
DMAIC
NHSN Publicly Reported Cases- MIDAS Focus Study
MIDAS Focus Objectives:
Detailed abstraction of elements with identified areas of opportunity
Data will be analyzed for any potential trends and to serve as a guide for further interventions
Surgeon specific SSI rates
Surgical Quality Council Dashboard will include SSI outcomes
Sasha

9. Antibiotic Stewardship Program
DMAIC
Dosing of Ertapenem for patients with BMI greater than 30
Assessment of empiric therapy recommendations for contaminated and dirty cases
Measuring timing of prophylactic antibiotics prior to incision:
0-15 minutes
16-30 “ ”
31-45 “ ”
46-60 “ ”
Sasha

10. DMAIC
Sasha

11. Improvement ‘Bundle’ Interventions across the episode of care
Multi-disciplinary
Engage staff, patient, and families
Standardize as many processes as possible
Ensure high compliance with elements
Quick audits
Build the elements into the system
Frequent feedback and communication

12. Pre-operative Interventions
Pre-operative Chlorhexidine packets
Provided to all patients preoperatively with instructions
Use monitored morning of admission
If not reported as not being used, SAGE wipes used on the entire body
Patients with BMI > 30 (Mayo)
SAGE wipes applied even if preoperative bath performed
Procedure listing software automatically identifies patients with BMI > 30
Pre-op antibiotic ordering (Mayo)
Procedure scheduling software automatically provides SCIP appropriate choices
Weight-based dosing
Software automatically orders intra-operative re-dosing dose if historical data for the specific procedure and surgeon demonstrated an average case duration >3 hours

13. Pre-Operative Interventions (cont’d)
Hair removal by electric clipper
Outside of the operating room
Standardized to Chlorhexidine-Alcohol (Chloraprep™) skin preparation for all abdominal cases
Surgical assistant applies skin preparation
All in-serviced on appropriate application
Must dry for 3 minutes before drapes applied

14. Intra-Operative Interventions
Pre-procedural pause includes confirming appropriate antibiotics administered and documented
Re-dosing of cefazolin for cases longer than 3 hours. (Mayo)
Circulating nurse has the preop order and pulls medication at the beginning of the case
Reminder window on anesthesia provider’s computer screen
Triggered off time of first dose administration
Appropriate weight-based dosing

15. Intra-Operative Interventions (cont’d)
“Closing” Process
At the time of fascia closure
All staff change gloves
Gowns if soiled
Field re-blocked with sterile towels
Instruments used during case removed and “closing tray” brought onto the field

16. Post-Operative Interventions
All order-sets discontinue SCIP compliant antibiotics after two postop doses or single dose when appropriate (Mayo)
Pharmacist part of team and queries service
Hand hygiene essential on floor
Physician/Nursing initiative
Patient and Family initiative
Sterile dressing on until morning of POD 2
Document removal
Chlorhexidine shower/wipes daily after dressing removal (Mayo)
Standard postop order-sets orders urinary catheter removal at 8am the morning after surgery (Mayo)
Dismiss with chlorhexidine soap bottle for use at home (Mayo)

17. Important Lessons: Multidisciplinary approach is essential
Physicians, nursing (pre, intrao-p, floor), pharmacy, CST, SA, administration, supply chain, quality, S&P, IT, Patient Education, Infection Control, WOCN, NSQIP team
Address the entire surgical episode of care
Pre, intra, and postoperative elements may influence SSI rates
Interventions designed for each phase
Introduce elements of change and audit compliance
Build ‘clues’ into the process to ensure better compliance: convenient hand hygiene supplies (Purell wipes, Hibiclens bottles), signage, Hibiclens packets, etc.
Build process improvements into the system to ensure task completion
No evidence for which of element(s) makes a difference in the “bundle”: the outcome is all that matters

18. Challenges Encountered
DMAIC
Learnings:
Reduction of our SSI rates continue to be challenging.
Questions 2012:
Could we learn more by studying the elements of the National Healthcare Safety Network(NHSN) colorectal SSI cases?
Could we focus our efforts on the ‘bulk’ of our infections; Organ Space (asked in 2012)
Focused our efforts on organ space infections beginning after this collaborative – later part of 2102
Decrease seen in 2013 (decrease seen in colo-rectal SIR)
Found part of the issue was appropriate classification of cases: major educational focus later part 2012/2013
Experienced & Foreseeable Challenges:
Strategies for preventing infections are different based on culture, environment, surgeon practice, patient pre- existing conditions
Lag time in collection and receipt of data to assess improvements
Nursing time for documentation of audits takes away from patient care
Insufficient and incomplete audits
Resources needed for this improvement project
Best Practice:
Standardization of approach was sequential and we may not see full term change yet (glove changing, closing trays, etc. occurred in sequence not parallel)
Best practices identified elsewhere may not have same level of impact in our organization
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19. Next Steps & Opportunities
DMAIC
Based on best practice learnings through collaborative, continue glove changes & separate/clean closing instruments
MIDAS Focus Study on Publicly Reported Cases
Infection Control SSI surveillance in July/Aug 2011 identified an opportunity in colorectal surgery
Data collection focused on elements which are not captured elsewhere
Need for individual physician communication of infections identified
Opportunity for Physician review of case with abstracted data elements
Antibiotic Stewardship
Instituted February 2012
Review of current prophylaxis guidelines and empiric therapy
SSI Deep/Organ Space and Sepsis commonalities
Drill down on each Organ/Space and Deep SSI
Leaks (i.e. CT scans, physician documentation, abscessogram results)
Antibiotic prophylaxis dosing for patients with BMI greater than 30
Empiric therapy and treatment protocols
Pursue Pre-Operative Warming Improvements
Preoperative strategies for surgery admission unit
Potential partnership with vendors to pilot new interventions
Sasha