1. © The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011 Surgical Site Infection Tools for Improvement SUSP

2. Learning Objectives Review approach to SSI reduction as part of SUSP project. Review auditing tools to help identify local defects contributing to SSIs. Next steps Armstrong Institute for Patient Safety and Quality 2

3. Surgical Care Improvement Project (SCIP) Armstrong Institute for Patient Safety and Quality 3

4. No single SSI prevention bundle Deeper dive into SCIP measures to identify local defects Emerging evidence –Abx redosing and weight based dosing –Maintenance of normogylcemia –Mechanical bowel preparation with oral abx –Standardization of skin preparation Capitalize on frontline wisdom –CUSP/Staff Safety Assessment Armstrong Institute for Patient Safety and Quality 4

5. DEEPER DIVE INTO SCIP MEASURES TO IDENTIFY LOCAL DEFECTS 5 Armstrong Institute for Patient Safety and Quality

6. Deeper Dive: Auditing 6 “…to make an audit of (performance) to evaluate or improve its safety, efficiency, or the like” http://dictionary.reference.com www.visualthesaurus.com

7. Evaluate a sample of patients –(ie: the next 5-10 patients) Practical and feasible strategy to evaluate performance and surface defects Needs to be adapted to local environment Empowers frontline staff Armstrong Institute for Patient Safety and Quality 7 Auditing Practice

8. Auditing tools Antibiotic –Selection, dosing, redosing Normothermia Glucose Control Skin Prep Others? Armstrong Institute for Patient Safety and Quality 8

9. SCIP Measures Quality IndicatorNumeratorDenominator Appropriate antibiotic choiceNumber of patients who received the appropriate prophylactic antibiotic All patients for whom prophylactic antibiotics are indicated Appropriate timing of prophylactic antibiotics Number of patients who received the prophylactic antibiotic within 60 minutes prior to incision All patients for whom prophylactic antibiotics are indicated Appropriate discontinuation of antibioticsNumber of patients who received prophylactic antibiotics and had them discontinued in 24 hours All patients who received prophylactic antibiotics Appropriate hair removalNumber of patients who did not have hair removed or who had hair removed with clippers All surgical patients Perioperative normothermiaNumber of patients with postoperative temperature ≥36.0 o C Patients undergoing surgery colorectal surgery Armstrong Institute for Patient Safety and Quality 9

10. Antibiotics practices All cases (n = 3002) number (%) Nonemergency (n = 2743) number (%) Emergency cases (n = 248) number (%) Was an SCIP-compliant antibiotic chosen? 2,431 (81.4%)2,293 (83.6%)130 (52.4%) Was antibiotic given within 1 h before incision? 2,712 (90.8%)2,544 (92.7%)159 (64.1%) Antibiotics weight-adjusted (n = 972)552 (56.8%) Antibiotics redosed (n = 398)24 (6.0%) Total surgical site infection269 (9.0%)245 (8.9%)24 (9.7%) 10 Perioperative Antibiotic Compliance: Michigan Surgical Quality Collaborative Hendren et al. Am. J Surg 2011

11. SCIP measure performance Johns Hopkins Comparison Hospitals Surgery patients who were given an antibiotic at the right time (within one hour before surgery) to help prevent infection 98%97% Surgery patients who were given the right kind of antibiotic to help prevent infection 98% Surgery patients whose preventive antibiotics were stopped at the right time (within 24 hours after surgery) 97%96% Surgery patients needing hair removed from the surgical area before surgery, who had hair removed using a safer method (electric clippers or hair removal cream – not a razor) 100% Patients having surgery who were actively warmed in the operating room or whose body temperature was near normal by the end of surgery. 98%99% Johns Hopkins Hospital May 2010 SCIP Hospital Compare www.medicare.gov Armstrong Institute for Patient Safety and Quality 11

12. 12 SUSP Antibiotic Audit Tool

13. Antibiotic Compliance Project Johns Hopkins Interventions: Increased amount of gentamicin available in the room Added dose calculator in anesthesia record Educated surgeons, anesthesia and nursing, anesthesia and nursing in grand rounds Wick et al, JACS 2012 Armstrong Institute for Patient Safety and Quality 13

14. SCIP Measures Quality IndicatorNumeratorDenominator Appropriate antibiotic choiceNumber of patients who received the appropriate prophylactic antibiotic All patients for whom prophylactic antibiotics are indicated Appropriate timing of prophylactic antibiotics Number of patients who received the prophylactic antibiotic within 60 minutes prior to incision All patients for whom prophylactic antibiotics are indicated Appropriate discontinuation of antibioticsNumber of patients who received prophylactic antibiotics and had them discontinued in 24 hours All patients who received prophylactic antibiotics Appropriate hair removalNumber of patients who did not have hair removed or who had hair removed with clippers All surgical patients Perioperative normothermiaNumber of patients with postoperative temperature ≥36.0 o C Patients undergoing surgery colorectal surgery Armstrong Institute for Patient Safety and Quality 14

15. Johns Hopkins Comparison Hospitals Surgery patients who were given an antibiotic at the right time (within one hour before surgery) to help prevent infection 98%97% Surgery patients who were given the right kind of antibiotic to help prevent infection 98% Surgery patients whose preventive antibiotics were stopped at the right time (within 24 hours after surgery) 97%96% Surgery patients needing hair removed from the surgical area before surgery, who had hair removed using a safer method (electric clippers or hair removal cream – not a razor) 100% Patients having surgery who were actively warmed in the operating room or whose body temperature was near normal by the end of surgery. 98%99% Johns Hopkins Hospital May 2010 SCIP Hospital Compare www.medicare.gov Armstrong Institute for Patient Safety and Quality 15 SCIP measure performance

16. Armstrong Institute for Patient Safety and Quality 16 SUSP Normothermia Audit Tool

17. Normothermia Project Johns Hopkins Interventions: Confirmed that temperature probes were accurate (trial comparing foley and esophageal sensors) Initiated forced air warming in the pre- operative area Heightened awareness Armstrong Institute for Patient Safety and Quality 17

18. Armstrong Institute for Patient Safety and Quality 18 Use your hospitals glucose goal SUSP Glucose Control Audit Tool

19. How Do We Conduct Audits? Retrospective chart review Concurrent review –Place audit tool on chart –Complete over continuum of care We recommend auditing 5-10 patients –Larger samples yield better estimates of performance Your data does not need to be submitted Armstrong Institute for Patient Safety and Quality 19

20. Summary No single SSI prevention bundle –Need to identify local defects Auditing is a practical and feasible strategy to evaluate performance and surface defects Tools are adaptable to local environment Empowers frontline staff Armstrong Institute for Patient Safety and Quality 20

21. Action Items Pick 2-3 audit tools –[Add website for tools] Audit 5-10 patients with each tool Be prepared to share your experience with other teams on upcoming call Share your tools and ideas for new tools on our next coaching call! Armstrong Institute for Patient Safety and Quality 21