1. 1 © 2010 TMIT NQF-Endorsed ® Safe Practices for Better Healthcare Safe Practice 22 Surgical-Site Infection Prevention Chapter 7: Improving Patient Safety Through Prevention of Healthcare-Associated Infections

2. © 2006 HCC, Inc. CD000000-0000XX 2 © 2010 TMIT Slide Deck Overview Slide Set Includes:  Section 1: NQF-Endorsed ® Safe Practices for Better Healthcare Overview  Section 2: Harmonization Partners  Section 3:The Problem  Section 4: Practice Specifications  Section 5: Example Implementation Approaches  Section 6: Front-line Resources

3. 3 © 2010 TMIT Safe Practice 22 Surgical-Site Infection Prevention Chapter 7: Improving Patient Safety Through Prevention of Healthcare-Associated Infections NQF-Endorsed ® Safe Practices for Better Healthcare Overview

4. 4 © 2010 TMIT 2010 NQF Safe Practices for Better Healthcare: A Consensus Report 34 Safe Practices Criteria for Inclusion Specificity Benefit Evidence of Effectiveness Generalization Readiness

5. 5 © 2010 TMIT Culture SP 1 2010 NQF Report

6. CHAPTER 7: Hospital-Associated Infections Hand Hygiene Influenza Prevention Central Venous Catheter-Related Blood Stream Infection Prevention Surgical-Site Infection Prevention Care of the Ventilated Patient and VAP MDRO Prevention UTI Prevention Information Management and Continuity of Care Medication Management Healthcare-Associated Infections Condition-, Site-, and Risk-Specific Practices Consent & Disclosure Wrong-site Sx Prevention Press. Ulcer Prevention DVT/VTE Prevention Anticoag. Therapy VAP Prevention Central V. Cath. BSI Prevention Sx-Site Inf. Prevention Contrast Media Use Hand Hygiene Influenza Prevention Pharmacist Systems Leadership: High-Alert, Std. Labeling/Pkg., and Unit-Dose Med. Recon. Culture CPOE Read-Back & Abbrev. Discharge System Patient Care Info. Labeling Studies Culture Meas., FB., and Interv. Structures and Systems ID and Mitigation Risk and Hazards Team Training and Team Interv. Nursing Workforce ICU Care Direct Caregivers Workforce CHAPTER 4: Workforce Nursing Workforce Direct Caregivers ICU Care CHAPTER 2: Creating and Sustaining a Culture of Patient Safety (Separated into Practices]  Leadership Structures and Systems  Culture Measurement, Feedback, and Interventions  Teamwork Training and Team Interventions  Identification and Mitigation of Risks and Hazards CHAPTER 5: Information Management and Continuity of Care  Patient Care Information  Order Read-Back and Abbreviations  Labeling Studies  Discharge Systems  Safe Adoption of Integrated Clinical Systems including CPOE CHAPTER 6: Medication Management  Medication Reconciliation  Pharmacist Leadership Role Including: High-Alert Med. and Unit-Dose Standardized Medication Labeling and Packaging CHAPTER 8: Wrong-Site, Wrong-Procedure, Wrong-Person Surgery Prevention Pressure Ulcer Prevention DVT/VTE Prevention Anticoagulation Therapy Contrast Media-Induced Renal Failure Prevention Organ Donation Glycemic Control Falls Prevention Pediatric Imaging Informed Consent Life-Sustaining Treatment Disclosure CHAPTER 3: Informed Consent and Disclosure Informed Consent Life-Sustaining Treatment Disclosure Care of the Caregiver Consent and Disclosure Care of Caregiver MDRO Prevention UTI Prevention Falls Prevention Organ Donation Glycemic Control Pediatric Imaging

7. 7 © 2010 TMIT Safe Practice 22 Surgical-Site Infection Prevention Chapter 7: Improving Patient Safety Through Prevention of Healthcare-Associated Infections Harmonization Partners

8. 8 © 2010 TMIT Harmonization – The Quality Choir

9. 9 © 2010 TMIT The Patient – Our Conductor

10. © 2006 HCC, Inc. CD000000-0000XX 10 © 2010 TMIT The Objective Surgical-Site Infection Prevention  Prevent healthcare-associated surgical-site infections

11. 11 © 2010 TMIT Safe Practice 22 Surgical-Site Infection Prevention Chapter 7: Improving Patient Safety Through Prevention of Healthcare-Associated Infections The Problem

12. © 2006 HCC, Inc. CD000000-0000XX 12 © 2010 TMIT The Problem

13. 13 © 2010 TMIT [http://www.cnn.com/2010/HEALTH/02/09/murtha.gallbladder.surgery/index.html]

14. 14 © 2010 TMIT [http://online.wsj.com/article/SB10001424052970204488304574428950126681432.html]

15. 15 © 2010 TMIT [http://www.nytimes.com/2010/01/07/health/research/07infection.html?ref=todayspaper]

16. © 2006 HCC, Inc. CD000000-0000XX 16 © 2010 TMIT The Problem Frequency  Second highest frequency of any adverse event in hospitalized patients  Approximately 500,000 SSIs occur each year  40%-60% of SSIs are preventable [Kirkland, Infect Control Hosp Epidemiol 1999 Nov;20(11):725-30; Anderson, Infect Control Hosp Epidemiol 2008 Oct;29 Suppl 1:S51-61; de Lissovoy, Am J Infect Control 2010 Jun;37(5):387-97]

17. © 2006 HCC, Inc. CD000000-0000XX 17 © 2010 TMIT The Problem Severity  Average of 9.7 additional postoperative hospital days  Patients with SSI have a 2 to 11 times higher risk of death compared to operative patients without SSI  Approximately 8,205 patients die from an SSI each year  77% of SSI deaths are directly attributable to the infection [Cruse, Rev Infect Dis 1981 Jul-Aug;3(4):734-7; Kirkland, Infect Control Hosp Epidemiol 1999 Nov;20(11):725-30; Mangram, Infect Control Hosp Epidemiol 1999 Apr;20(4):250-7; Engemann, Clin Infect Dis 2003 Mar 1; 36(5): 592-8; Klevens, Public Health Rep 2007 Mar-Apr;122(2):160-72; de Lissovoy, Am J Infect Control 2010 Jun;37(5):387-97]

18. © 2006 HCC, Inc. CD000000-0000XX 18 © 2010 TMIT The Problem Preventability  Proper selection and administration of antimicrobial prophylaxis and timely discontinuation postoperatively  Surveillance for SSI should be performed and communicated to surgical personnel and organizational leadership [Anderson, Infect Control Hosp Epidemiol 2008 Oct;29 Suppl 1:S51-61; Kirby, Surg Clin North Am 2010 Apr;89(2):365-89, viii; Pan, Infection 2010 Apr;37(2):148-52; Quinn, Surgeon 2010 Jun;7(3):170-2]

19. © 2006 HCC, Inc. CD000000-0000XX 19 © 2010 TMIT The Problem Cost Impact  Estimates range from $3K-$29K  Median cost of an SSI was $153.1K, compared to a hospital stay with no infection of $33.2K  Increase in cost of $20.8K per admission  Readmissions of patients for treatment of SSI resulted in costs of nearly $700 million in 2005 [Vegas, Eur J Epidemiol 1993 Sep;9(5):504-10; Kirkland, Infect Control Hosp Epidemiol 1999 Nov;20(11):725-30; Hollenbeak, Chest 2000 Aug;118(2):397-402; PHC4, Statewide Summary Data, 2008; de Lissovoy, Am J Infect Control 2010 Jun;37(5):387-97]

20. 20 © 2010 TMIT Safe Practice 22 Surgical-Site Infection Prevention Chapter 7: Improving Patient Safety Through Prevention of Healthcare-Associated Infections Practice Specifications

21. © 2006 HCC, Inc. CD000000-0000XX 21 © 2010 TMIT Additional Specifications

22. © 2006 HCC, Inc. CD000000-0000XX 22 © 2010 TMIT Safe Practice Statement Surgical-Site Infection Prevention  Take actions to prevent surgical-site infections by implementing evidence-based intervention practices [Mangram, Infect Control Hosp Epidemiol 1999 Apr;20(4):250-78; quiz 279-80; WHO, Surgical safety checklist and implementation manual, 2008; Institute for Healthcare Improvement, Surgical Complications Core Processes: IHI Improvement Map, 2010; Joint Commission Resources, National Patient Safety Goal: NPSG.07.05.01, 2010]

23. © 2006 HCC, Inc. CD000000-0000XX 23 © 2010 TMIT Additional Specifications  Document the education of HAIs in persons involved in surgical procedures  Prior to all surgical procedures, educate the patient and family about SSI prevention  Implement policies and practices aimed at reducing the risk of SSI that meet regulatory requirements and that are aligned with evidence-based standards [Torpy, JAMA 2005 Oct 26;294(16):2122; Bratzler, Clin Infect Dis 2004 Jun 15;38(12):1706-15; Schweon, RN 2006 Aug;69(8):36-40; Anderson, Infect Control Hosp Epidemiol 2008 Oct;29 Suppl 1:S51-61; TMIT, Are You Preventing Surgical- Site Infections? No Outcome, No Income, 2008; Chatzizacharias, Infect Control Hosp Epidemiol 2010 Mar;30(3):308-9; Rosenthal, World J Surg 2010 Jun;33(6):1165-73; WHO, WHO Guidelines on Hand Hygiene in Health Care, 2010]

24. © 2006 HCC, Inc. CD000000-0000XX 24 © 2010 TMIT Additional Specifications  Conduct periodic risk assessments for SSI, select SSI measures using evidence-based guidelines to evaluate effectiveness  Ensure SSI rates are thoroughly measured  Provide SSI rate data and prevention outcome measures to key stakeholders [Horan, Infect Control Hosp Epidemiol 1992 Oct;13(10):606-8; Mangram, Infect Control Hosp Epidemiol 1999 Apr;20(4):250- 78; Bratzler, Clin Infect Dis 2004 Jun 15;38(12):1706-15; Biscione, Infect Control Hosp Epidemiol 2010 May;30(5):433-9]

25. © 2006 HCC, Inc. CD000000-0000XX 25 © 2010 TMIT Additional Specifications  Administer antimicrobial agents for prophylaxis with a particular procedure or disease  When hair removal is necessary, use clippers or depilatories  Maintain normothermia immediately following colorectal surgery  Control blood glucose during the immediate postoperative period [Bratzler, Clin Infect Dis 2006 Aug 1;43(3):322-30; Dronge, Arch Surg 2006 Apr;141(4):375-80; discussion 380; Institute for Healthcare Improvement, Antibiotic Stewardship: IHI Improvement Map, 2010Kao, Cochrane Database Syst Rev 2010 Jul 8;(3):CD006806; Kurz, N Engl J Med 1996 May 9;334(19):1209-15; Antimicrobial, Med Lett Drugs Ther 2001 Oct 29;43(1116- 1117):92-7; ]

26. 26 © 2010 TMIT Safe Practice 22 Surgical-Site Infection Prevention Chapter 7: Improving Patient Safety Through Prevention of Healthcare-Associated Infections Example Implementation Approaches

27. © 2006 HCC, Inc. CD000000-0000XX 27 © 2010 TMIT Example Implementation Approaches

28. © 2006 HCC, Inc. CD000000-0000XX 28 © 2010 TMIT Example Implementation Approaches  Perform expanded SSI surveillance to determine the source and extent of high SSI rates  Successful hospitals have incorporated:  Appropriate use and dosage of antibiotics  Appropriate hair removal around site [Mangram, Infect Control Hosp Epidemiol 1999 Apr;20(4):250-78; quiz 279-8; Agency for Healthcare Research and Quality, National Healthcare Disparities Report, 2008; Graf, Interact Cardiovasc Thorac Surg 2010 Aug;9(2):282-6; Pan, Infection 2010 Apr;37(2):148-52; Ryckman, Jt Comm J Qual Patient Saf 2010 Apr;35(4):192-8]

29. © 2006 HCC, Inc. CD000000-0000XX 29 © 2010 TMIT Example Implementation Approaches Strategies of Progressive Organizations  Maintain perioperative glucose at specific target levels

30. 30 © 2010 TMIT Safe Practice 22 Surgical-Site Infection Prevention Chapter 7: Improving Patient Safety Through Prevention of Healthcare-Associated Infections Front-line Resources

31. 31 © 2010 TMIT [http://www.azdhs.gov/infectioncontrol/pdfs/HAI%20Prevention%20Compendium%20PDFs/HAI%20SSI.pdf; http://www.shea-online.org/about/compendium.cfm]

32. 32 © 2010 TMIT [http://content.nejm.org/cgi/content/short/362/1/18; http://content.nejm.org/cgi/content/full/NEJMsa0810119]

33. 33 © 2010 TMIT [http://www.cdc.gov/media/pressrel/2010/s100202.htm]

34. 34 © 2010 TMIT [http://www.shea-online.org/Assets/files/patient%20guides/NNL_SSI.pdf]

35. 35 © 2010 TMIT [http://www.jointcommission.org/PatientSafety/SpeakUp/] Poster available in Spanish

36. 36 © 2010 TMIT [http://www.jointcommission.org/PatientSafety/SpeakUp/] Poster available in Spanish

37. 37 © 2010 TMIT [http://www.who.int/patientsafety/safesurgery/tools_resources/SSSL_Checklist_finalJun08.pdf]

38. © 2006 HCC, Inc. CD000000-0000XX 38 © 2010 TMIT TMIT National Webinar Series Healthcare-Associated Infection and You: Cleaner, Safer Care (Safe Practices 19-25)  Kathy Warye – Topic: Perspective on the Development of the Implementation Examples of the NQF Safe Practices  Peter Angood, MD – Topic: HAI National Attention and Harmonization  David Classen, MD – Topic: HAI Compendium Harmonization with the Safe Practices  Julianne Morath, RN – Topic: Implementation  Jennifer Dingman – Topic: Call to Action  Go to: http://www.safetyleaders.org/pages/idPage.jsp?ID=4932 (May 14, 2009)

39. © 2006 HCC, Inc. CD000000-0000XX 39 © 2010 TMIT TMIT National Webinar Series Are You Preventing Surgical-Site Infections? No Outcome, No Income (Safe Practice 21)  Dale W. Bratzler, DO, MPH – QIOSC Medical Director, Oklahoma Foundation for Medical Quality  Frances A. Griffin, RRT, MPA – Director, The Institute for Healthcare Improvement  Kathy Haig, RN – Corporate Patient Safety Officer, OSF Healthcare System  Go to: http://www.safetyleaders.org/pages/idPage.jsp?ID=4872 (February 25, 2008)