Eating the Elephant Getting Started in SSI Claude Laflamme Marlies van Dijk June 17, 2008. This Presentation. Introduction Antibiotic Prophylaxis and Challenges Hair Removal and Challenges Prevention of hypothermia Glucose control SSI rates Team example.
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4 evidence-based interventions to reduce the risk of SSI
Each has an associated performance indicator (process measure)
Performance indicators have set goals intentionally high (≥95%)
Complexity issues with regards to expected outcome measures (visible reduction of SSI rates)
*Pairs matched for procedure, NNIS index, age
Kirkland. Infect Control Hosp Epidemiol. 1999;20:725. Prospective, case-controlled study of 22,742 patients undergoing inpatient surgical procedures between 1991–1995.
“Appropriate use of prophylactic antibiotics”
The right drug
At the right time*
For the right duration
Performance measure (target):
% surgical patients given pre-op ABx within 60 min* ( Goal 95% )
% surgical patients having ABx , discontinued within 24 hrs ( Goal ≥95% )
Classen. NEJM. 1992;328:281.
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
Consider the upper range of doses for large patients
Gastroplasty: SSI rates 16.5% vs 5.6% (Forse, Surgery, 1989)
Repeat doses for long operations (> 4 hours)
Cardiac surgery: SSI rates 16% vs 7% (Zanetti, Emerg Infect Dis 2001)
Antibiotics disrupt normal flora
Increased or improper use is implicated in:
Clostridium difficile associated diarrhea
Printed order sets
Moving Antibiotics closer to time of incision (holding area or OR)
Roles in the Operating Room (anesthesia vs. nursing)
Each site/team is unique
Data collection at the start
Cruse. Arch Surg 1973; 107: 206
For every 1000 patients, $270,000 could be saved by switching from a razor to a clipper
Alexander. Arch Surg 1983; 118: 347
Percentage of selected surgical patients receiving hair removal without use of razors
Not as simple as it sounds
Convincing docs that a smooth surface is not essential
Motility of macrophages Production of antibody
Cardiac Surgery Patients
Discontinuation of prophylaxis:
Is there buy in from the surgeons on this item? What is the root of the challenges with this issue? Who needs to be involved in getting this resolved?
Clinical leadership engagement:
How do you engage the surgeons and anesthetists? (do they believe the evidence?, what are some strategies for engaging them? Who is your clinical champion?
Measurement is manual. ie., You’re using paper and pen and a data collection form to capture bundle components. How might you do this reliably in your area?
Is there only one or two people doing the work, how can you best use your team members without a lot of time commitment. How often should you meet or connect and what is the best forum (huddles, e-mail, meetings) to keep the work moving?
Long term trending
Consistent definitions and case finding
Clinicians very motivated by SSI rates
Measure improvement in process and outcome measures over time…
Difficult to compare between hospitals or facilities
Consider this as you send your date to CMT
Establish facility/program baseline
Identify abnormal patterns and/or sentinel events
Evidence that reportingto operators lowersrates
Please take care when interpreting rates!
Don’t expect to see immediate results from new interventions
Rates can be affected by:
Numbers of procedures