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Making Surgery Safer: Surgical Infection Prevention PowerPoint PPT Presentation

Making Surgery Safer: Surgical Infection Prevention Team Members: Anesthesia: W. Scott Jellish – chair, Maureen Kawka Infectious Disease: Paul O’Keefe, Chris Schriever Surgical Services: Jeri Katsaros, Meg Kim, Peggy Vorrier Labor & Delivery: Maureen Davey

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Making Surgery Safer: Surgical Infection Prevention

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Making surgery safer surgical infection prevention l.jpg

Making Surgery Safer:Surgical Infection Prevention

Team Members:

Anesthesia: W. Scott Jellish – chair, Maureen Kawka

Infectious Disease: Paul O’Keefe, Chris Schriever

Surgical Services: Jeri Katsaros, Meg Kim, Peggy Vorrier

Labor & Delivery: Maureen Davey

Quality Resource Management: Carmen Barc, Vada Grant, Susan Tuzik

Infection Control: Jan Bartel, Alexander Tomich

CCE: Mary Altier, William Barron, LuAnn Vis, Michael Wall

Magnet Forces:

6 - Quality of Care

7 - Quality Improvement

13 - Interdisciplinary Relationships

Confidential: For Quality Improvement Purposes Only


Aim statement l.jpg

Aim Statement

Surgical site infections are a major complication after surgery, resulting in considerable morbidity, mortality, and resource utilization. Proper use of antibiotics – giving the right drug at the right time – is effective in preventing infections after surgery*. Other perioperative measures – glucose control, temperature control, and appropriate hair removal – have also been proven effective in reducing infections

*Bratzler, DW, et al. Use of Antimicrobial Prophylaxis for Major Surgery: Baseline Results from the National Surgical Infection Prevention Project, Arch Surg Feb 2005; 140:174-182.

Confidential: For Quality Improvement Purposes Only


Project goals l.jpg

Project Goals

To achieve compliance for the following measures:

  • Administer antibiotics within one hour before surgical incision

  • Administer the appropriate antibiotic

  • Stop antibiotics within 24 hours after surgery (48 hours after cardiac surgery)

  • Controlled postoperative serum glucose (200mg/dl or less) – Cardiac surgery patients

  • Appropriate hair removal – No razors

  • Immediate postoperative normothermia – Colorectal surgery patients

    These measures are publicly reported at www. hospitalcompare.hhs.gov

Confidential: For Quality Improvement Purposes Only


Solutions implemented in 2007 2008 l.jpg

Solutions Implemented in 2007/2008

Data management and results

  • Reviewed all outliers to identify trends; provided follow up physician education

  • Created system to forward physician-specific reports to the Chairs, individual physicians, and the Chief of Staff

  • Forwarded results externally:

    • Illinois Report Card Act – beginning July 07 cases

    • The Joint Commission – beginning January 08 cases

    • Hospital Compare - Ongoing

Confidential: For Quality Improvement Purposes Only


Solutions implemented in 2007 20085 l.jpg

Solutions Implemented in 2007/2008

Antibiotic orders

  • Revised order sets to address MRSA risk

  • Revised Endocarditis Prophylaxis Guidelines*

    Hair removal

  • Removed razors from OR, Pre-op holding; limiting access to SRP

  • Educated procedure areas on appropriate hair removal

  • Physician education to eliminate learned phrase “shaved and prepped” when a clipper was used for hair removal

    Normothermia

  • Tested warming blankets and thermal caps

    *Wilson et al. Prevention of infective endocarditis. Guidelines from the American Heart Association. Circulation 2007; 116:1736.

Confidential: For Quality Improvement Purposes Only


Slide6 l.jpg

Surgical patients receiving prophylactic antibiotics

within one hour prior to surgical incision

UCL = 106.3

100

Mean = 96%

LCL = 86.1

80

Antibiotics added to ‘time out’ process

60

Percent

40

20

0

Jul 2006 (n=25)

Jul 2007 (n=30)

Apr 2006 (n=31)

Apr 2007 (n=32)

Jun 2006 (n=35)

Oct 2006 (n=33)

Jun 2007 (n=25)

Oct 2007 (n=32)

Jan 2006 (n=38)

Jan 2007 (n=29)

Jan 2008 (n=34)

Mar 2006 (n=34)

Aug 2006 (n=26)

Mar 2007 (n=35)

Aug 2007 (n=36)

Sep 2006 (n=22)

Nov 2006 (n=35)

Dec 2006 (n=34)

Sep 2007 (n=34)

Nov 2007 (n=35)

Dec 2007 (n=34)

Feb 2006 (n=37)

May 2006 (n=37)

Feb 2007 (n=34)

May 2007 (n=33)

Feb 2008 (n=30)

Month (number of patients)

Confidential: For Quality Improvement Purposes Only

Definition: Surgical patients who received prophylactic antibiotics within 60 minutes prior to surgical incision / Patients undergoing CABG, cardiac surgery, hip / knee arthroplasty, colon surgery, hysterectomy, or vascular surgery. Vancomycin and fluoroquinolones timeframe is extended to 120 minutes prior to incision.

Data source: LUMC medical records abstracted by RNs.

Analysis: Ninety-six percent of LUMC patients receive prophylactic antibiotics within the recommended timeframe prior to surgical incision.


Slide7 l.jpg

Surgical patients receiving prophylactic antibiotics

consistent with current guidelines

UCL = 106.1

100

Mean = 91%

80

LCL = 76.7

Order set modification to assist in prescribing within guidelines

60

Percent

40

20

0

Jul 2006 (n=25)

Jul 2007 (n=32)

Apr 2006 (n=34)

Apr 2007 (n=32)

Jun 2006 (n=37)

Oct 2006 (n=35)

Jun 2007 (n=25)

Oct 2007 (n=32)

Jan 2006 (n=38)

Jan 2007 (n=31)

Jan 2008 (n=34)

Mar 2006 (n=34)

Aug 2006 (n=26)

Mar 2007 (n=36)

Aug 2007 (n=36)

Sep 2006 (n=23)

Nov 2006 (n=35)

Dec 2006 (n=35)

Sep 2007 (n=34)

Nov 2007 (n=33)

Dec 2007 (n=32)

Feb 2006 (n=36)

May 2006 (n=39)

Feb 2007 (n=34)

May 2007 (n=33)

Feb 2008 (n=30)

Month (number of patients)

Confidential: For Quality Improvement Purposes Only

Definition: Surgical patients receiving prophylactic antibiotics consistent with current guidelines / Patients undergoing CABG, cardiac surgery, hip / knee arthroplasty, colon surgery, hysterectomy, or vascular surgery.

Data source: LUMC medical records abstracted by RNs.

Analysis: Ninety-five percent of LUMC patients now receive prophylactic antibiotics consistent with current guidelines. Additional initiatives were implemented in February and March 2007 to ensure that all surgical patients receive antibiotics consistent with current guidelines.


Slide8 l.jpg

Surgical patients with prophylactic antibiotics

discontinued within the recommended timeframe

UCL = 106.3

100

Mean = 91%

80

LCL = 75.7

60

Percent

40

20

0

Jul 2006 (n=25)

Jul 2007 (n=30)

Apr 2006 (n=31)

Apr 2007 (n=32)

Jun 2006 (n=36)

Oct 2006 (n=33)

Jun 2007 (n=24)

Oct 2007 (n=30)

Jan 2006 (n=37)

Jan 2007 (n=28)

Jan 2008 (n=34)

Mar 2006 (n=33)

Aug 2006 (n=26)

Mar 2007 (n=34)

Aug 2007 (n=35)

Sep 2006 (n=21)

Nov 2006 (n=35)

Dec 2006 (n=34)

Sep 2007 (n=34)

Nov 2007 (n=33)

Dec 2007 (n=32)

Feb 2006 (n=33)

May 2006 (n=36)

Feb 2007 (n=33)

May 2007 (n=33)

Feb 2008 (n=29)

Month (number of patients)

Confidential: For Quality Improvement Purposes Only

Definition: Surgical patients with prophylactic antibiotics discontinued within twenty-four hours after surgery end time / Patients undergoing hip / knee arthroplasty, colon surgery, hysterectomy, or vascular surgery. CABG and other cardiac surgeries are allowed 48 hours.

Data source: LUMC medical records abstracted by RNs.

Analysis: Performance is consistent at 91%.


Slide9 l.jpg

Controlled Postoperative Serum Glucose - Cardiac Surgery Patients

UCL = 117.1

120

Mean = 90%

100

80

Percent

60

LCL = 63.7

40

20

0

Jul 2006 (n=8)

Feb 2008 (n=9)

Aug 2006 (n=7)

Jul 2007 (n=12)

Sep 2006 (n=5)

Apr 2007 (n=11)

Oct 2006 (n=12)

Oct 2007 (n=11)

Jun 2007 (n=11)

Jan 2007 (n=14)

Jan 2008 (n=11)

Feb 2007 (n=13)

Mar 2007 (n=12)

Aug 2007 (n=11)

Nov 2006 (n=10)

Dec 2006 (n=13)

Sep 2007 (n=12)

Nov 2007 (n=12)

Dec 2007 (n=12)

May 2007 (n=13)

Month (number of patients)

Confidential: For Quality Improvement Purposes Only

Definition: Percent of cardiac surgery patients with controlled 6AM post-operative glucose. Control is defined as serum glucose reading of 200mg/dL or less on both post-operative day 1 and day 2. Results show cardiac surgery patients with the presence of post-operative day 1 and day 2 glucose measurements, readings closest to 6AM were selected for inclusion.

Data Source: LUMC medical records abstracted by RNs.

Analysis: 6AM postoperative glucose control on both postoperative days 1 and 2 has been consistent at 90% for the past 18 months.


Slide10 l.jpg

Surgical Patients with Appropriate Hair Removal - (Not Razors)

UCL = 103.8

100

Mean = 94%

LCL = 84.8

80

60

Percent

40

20

0

Jul 2006 (n=40)

Jul 2007 (n=54)

Apr 2007 (n=53)

Oct 2006 (n=58)

Oct 2007 (n=56)

Jun 2007 (n=57)

Jan 2007 (n=57)

Jan 2008 (n=51)

Aug 2006 (n=40)

Feb 2007 (n=57)

Mar 2007 (n=57)

Aug 2007 (n=58)

Feb 2008 (n=56)

Sep 2006 (n=40)

Nov 2006 (n=58)

Dec 2006 (n=57)

Sep 2007 (n=56)

Nov 2007 (n=56)

Dec 2007 (n=57)

May 2007 (n=55)

Month (number of patients)

Confidential: For Quality Improvement Purposes Only

Definition: Number of Surgical cases abstracted without the use of razors for hair removal / Number of Surgical Cases Sampled. Appropriate hair removal includes: use of clippers, use of depilatory, or no hair removal.

Data source: LUMC medical records abstracted by RNs.

Analysis: The rate of appropriate hair removal decreased in late 2007 due to a change in the measure definition. The definition now assumes a patient was shaved with a razor, if physician documentation states ‘shaved’ within the chart. Education for surgeons in December 2007 has shown improvement back to baseline levels.


Slide11 l.jpg

Immediate Postoperative Normothermia - Colorectal Surgeries

160

140

UCL = 134.07

120

100

Percent

80

Mean = 65%

60

40

20

LCL = 0.00

0

Jul 2006 (n=4)

Jul 2007 (n=3)

Apr 2007 (n=4)

Oct 2006 (n=5)

Jun 2007 (n=3)

Oct 2007 (n=4)

Jan 2007 (n=2)

Jan 2008 (n=5)

Feb 2007 (n=5)

Mar 2007 (n=5)

Feb 2008 (n=6)

Aug 2006 (n=5)

Aug 2007 (n=6)

Nov 2006 (n=4)

Nov 2007 (n=5)

Sep 2006 (n=4)

Dec 2006 (n=4)

Sep 2007 (n=3)

Dec 2007 (n=4)

May 2007 (n=5)

Month (number of patients)

Confidential: For Quality Improvement Purposes Only

Definition: Number of colorectal surgery cases with normal body temperature (normothermia) immediately after surgery/ Patient undergoing colorectal surgery cases. Normothermia is defined with as a temperature of 96.8°F – 100.4°F.

Data source: LUMC medical records abstracted by RNs.

Analysis: The rate of immediate post-operative normothermia in colorectal surgeries is 65%.


Slide12 l.jpg

Surgical Care Improvement Project Composite Performance

100

UCL = 94.9

Loyola Goal = 90%

80

Mean = 77%

60

LCL = 59.1

Percent

40

20

0

Jul 2006 (n=40)

Jul 2007 (n=54)

Apr 2006 (n=34)

Apr 2007 (n=54)

Jan 2006 (n=38)

Jun 2006 (n=37)

Oct 2006 (n=58)

Jun 2007 (n=57)

Oct 2007 (n=56)

Jan 2007 (n=57)

Jan 2008 (n=51)

Mar 2006 (n=34)

Aug 2006 (n=40)

Mar 2007 (n=57)

Aug 2007 (n=58)

Sep 2006 (n=40)

Nov 2006 (n=58)

Dec 2006 (n=57)

Sep 2007 (n=56)

Nov 2007 (n=56)

Dec 2007 (n=57)

Feb 2006 (n=37)

May 2006 (n=39)

Feb 2007 (n=58)

May 2007 (n=55)

Feb 2008 (n=56)

Month (number of patients)

Confidential: For Quality Improvement Purposes Only

Definition: Surgical patients receiving 100% of indicated antibiotic prophylaxis, glucose control, hair removal, temperature control, beta-blocker continuation, and venous thromboembolism therapy / Patients undergoing CABG, cardiac surgery, hip / knee arthroplasty, colon surgery, hysterectomy, or vascular surgery.

Data source: LUMC medical records abstracted by RNs.

Analysis: Seventy-eight percent of selected surgical patients are receiving all indicated care to prevent surgical infections. This performance is better than 92% of UHC academic hospitals.


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Next Steps

  • Revise orders to address MRSA screen positive results

  • Identify improvement opportunities for hair removal and normothermia measures

  • Infection Control Committee to investigate surgical site infection benchmarking opportunities

  • Incorporate related Hospital Outpatient Department Quality Measures into project

    • Antibiotic measures for ASC, EP Lab, L&D

Confidential: For Quality Improvement Purposes Only


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