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Performance Improvement for the Surgeon: SIPP and SCPP

Performance Improvement for the Surgeon: SIPP and SCPP. Twelfth G. Rainey Williams Surgical Symposium September 29 th , 2005. Performance Improvement for the Surgeon: SIPP and SCPP. Surgical Infection Prevention Project National program funded by CMS Can be used as JCAHO PI project

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Performance Improvement for the Surgeon: SIPP and SCPP

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  1. Performance Improvement for the Surgeon: SIPP and SCPP Twelfth G. Rainey Williams Surgical Symposium September 29th, 2005

  2. Performance Improvement for the Surgeon: SIPP and SCPP Surgical Infection Prevention Project • National program funded by CMS • Can be used as JCAHO PI project • Oklahoma collaborative project

  3. Performance Improvement for the Surgeon: SIPP and SCPP Why SIPP?

  4. Public Health Importance • SSI occurs in 2-5% of extra abdominal surgeries and up to 20% of intra-abdominal surgeries • SSI patients are • 60% more likely to spend time in the ICU • 5x more likely to be re-admitted • 2x the incidence of mortality

  5. Impact of SSI’sCase Control* Study of 255 Pairs Infected Uninfected Mortality 7.8% 3.5% ICU admission 29% 18% L.O.S. 11d 6d Median direct cost $7531 $3844 Readmission 41% 7% * matched for procedure, NNIS index, age Kirkland. Infect Control Hosp Epidemiol 1999; 20: 725

  6. Most Common Hospital-acquired Infections, 1995 Urinary tract infections Other Pneumonia Bloodstream infections Surgical site infections

  7. Estimated Annual Impact of SSIs After Specific Procedures

  8. SSI SurveillanceNNIS Risk Index

  9. SSI Rates* by Surgery Type and NNIS Risk Score *Infections per 100 procedures †Risk index categories 2 and 3 combined

  10. Age Obesity Diabetes Malnutrition Prolonged pre-operative stay Infection at a remote site Shaving site Duration of surgery Surgical technique Presence of drains Inappropriate use of antimicrobial prophylaxis SSI Risk Factors Newly Identified: Hyperglycemia, hypothermia, and tissue hypoxemia

  11. Surgical Procedures of InterestNational Surgical Infection Prevention Project • Cardiac • Coronary Artery Bypass Graft (CABG) • Colon • Hip & Knee Arthroplasty • Hysterectomy (abdominal and vaginal) • Vascular Surgery: • Aneurysm repair • Thromboendarterectomy • Vein Bypass These procedures are being evaluated in the Medicare project because there is no controversy over the use of antibiotics for these operations. This does not imply that antibiotic prophylaxis should not be used for other procedures.

  12. Quality IndicatorsNational Surgical Infection Prevention Project • Quality Indicator #1 • Proportion of patients who receive antibiotics within 1 hour before surgical incision Because of the longer required infusion time, vancomycin, when indicated for beta-lactam allergy, may be started within 2 hours before the incision.

  13. Impact of Timing of Antibiotic Prophylaxis Classen DC, et al. N Engl J Med. 1992.

  14. Perioperative AntibioticsTiming of Administration 14/369 15/441 1/41 1/47 Infections (%) 1/81 2/180 5/699 5/1009 Hours From Incision Classen, et al. N Engl J Med. 1992;328:281.

  15. Prophylactic Antibiotics TimingCefoxitin Incision 2 hours 3 hours Serum Levels On Call Induction 34 11 7 99 22 11 DiPiro JT, et al. Arch Surg. 1985;120:829-832. Blood levels at the time of the incision are important to reduce infection!

  16. Dose of Antibiotic for Prophylaxis • Always give at least a full therapeutic dose of antibiotic • Consider the upper range of doses for large patients and/or long operations • Consider repeating doses for long operations

  17. Quality IndicatorsNational Surgical Infection Prevention Project • Quality Indicator #2 • Proportion of patients who receive prophylactic antibiotics consistent with current recommendations

  18. Appropriate AntibioticsNational Surgical Infection Prevention Project • Cardiac and vascular surgery • cefazolin, cefuroxime, cefamandole • (vancomycin only if documented beta-lactam allergy) • Hip and knee arthroplasty • cefazolin, cefuroxime • (vancomycin only if documented beta-lactam allergy)

  19. Appropriate AntibioticsNational Surgical Infection Prevention Project • Hysterectomy • cefazolin, cefotetan, cefoxitin, or cefuroxime • (fluoroquinolone + clindamycin if documented beta-lactam allergy)

  20. Appropriate AntibioticsNational Surgical Infection Prevention Project • Colorectal surgery • Oral (after effective mechanical bowel prep) administered for 18 hours preop • neomycin sulfate + erythromycin base, or • neomycin sulfate + metronidazole • Parenteral • cefoxitin, cefotetan, cefmetazole, or cefazolin + metronidazole • (fluoroquinolone + clindamycin if documented beta-lactam allergy)

  21. Antibiotic Recommendation Sources • American Society of Health System Pharmacists • Infectious Diseases Society of America • The Hospital Infection Control Practices Advisory Committee • Medical Letter • Surgical Infection Society • Sanford Guide to Antimicrobial Therapy 2001

  22. Quality IndicatorsNational Surgical Infection Prevention Project • Quality Indicator #3 • Proportion of patients whose prophylactic antibiotics were discontinued within 24 hours of surgery end time

  23. Duration of ProphylaxisGastrointestinal Author Drug Duration Infection Strachan 1977 cefazolin 1 dose 3%(biliary) 5 days 6% placebo 17% Stone 1979 cefamandole 3 doses 0(mixed) 5 days 3% cephaloridine 5 days 4% Hall 1989 moxalactam 1 dose 5%(mixed) 2 days 6%

  24. Duration of ProphylaxisCardiac Author Drug Duration Infection Conte 1972 cephalothin 1 dose 10% 4 days 9% Goldmann 1977 cephalothin 2 days 4% 6 days 6% Austin 1980 cephalothin 2 doses 11% 3 days 9% Geroulanos 1986 cefuroxime 2 days 1.1% cefazolin 4 days 2.5%

  25. Duration of ProphylaxisJoint Replacement Author Drug Duration Infection Pollard 1979 cephaloridine 12 hours 1.4%(hips) flucloxacillin 14 days 1.3% Heydemann 1986 cefazolin 1 dose 0(hips and knees) 24 hours 1% 48 hours 0 7 days 1.5%

  26. Impact of Prolonged Antibiotic Prophylaxis • 2,641 CABG patients • Grp 1 - < 48 hours of antibiotics • Grp 2 - > 48 hours of antibiotics • SSI Rates • Grp 1 - 8.7% (131/1502) • Grp 2 - 8.8 % (100/1139) • Antibiotic resistant pathogen - Grp 2 • Odds Ratio 1.6 (95% CI: 1.1-2.6) Harbarth S, et al. Circulation. 2000.

  27. Antibiotic ProphylaxisDuration • In summary - • Most studies have confirmed efficacy of 12 hrs of prophylactic antibiotics • Many studies have shown efficacy of a single dose • Whenever compared, the shorter course has been as effective as the longer course and results in less antibiotic resistance

  28. Surgical Infection Prevention • Besides appropriate antibiotic selection, what else reduces infection?

  29. HICPAC - SSI Prevention Guidelines - 1999 Category 1 No prior infections 15 air changes/hr in O.R.Do not shave in advance1 Keep O.R. doors closed Control glucose in D.M. ptsUse sterile instrumentsStop tobacco use Wear a mask*Shower with antiseptic soap Cover hair*Prep skin with approp. agent Wear sterile gloves*Surgeon’s nails short Gentle tissue handlingSurgeons scrub hands DPC for heavily contaminated Exclude infected surgeons wounds Give prophylactic antibiotics Closed suction drains (when used)Pos pressure ventilation in O.R. Sterile dressing x 24-48 hrSSI surveillance with feedback to surgeons 1Every published study of razor shaving has shown increased infection rates!

  30. Enhanced Perioperative Glucose Control in Diabetics • 2,467 diabetic patients undergoing cardiac surgery • Control group - subcutaneous insulin • Treatment group - IV insulin infusion • Results • Controls - 2.0% SSI rate (19/968) • Treatment- 0.8% SSI rate (12/1499), P=0.01 Furnary AP, et al. Ann Thorac Surg. 2000.

  31. Perioperative Glucose Control • 1,000 cardiothoracic surgery patients • Diabetics and non-diabetics with hyperglycemia Patients with a blood sugar > 300 mg/dL during or within 48 hours of surgery had more than 3X the likelihood of a wound infection! Latham R, et al. Infect Control Hosp Epidemiol. 2001.

  32. Temperature Control • 200 colorectal surgery patients • control - routine intraoperative thermal care (mean temp 34.7°C) • treatment - active warming (mean temp on arrival to recovery 36.6°C) • Results • control - 19% SSI (18/96) • treatment - 6% SSI (6/104), P=0.009 Kurz A, et al. N Engl J Med. 1996. Also: Melling AC, et al. Lancet. 2001. (preop warming)

  33. Supplemental Perioperative O2 • 500 colorectal surgery patients • control - 30% FiO2 intra- and post-op* • treatment - 80% FiO2 intra- and post-op* • Results • control - 11.2% SSI (28/250) • treatment - 5.2% SSI (13/250), P=0.01 *2 hours postoperatively Greif R, et al. N Engl J Med. 2000.

  34. Reducing Surgical InfectionsSummary • In addition to usual infection control: • Appropriate antibiotic treatment • timing, selection, duration (intra-op dosing for long cases or excess blood loss) • Avoid shaving and other HICPAC recommendations • Blood glucose control (diabetics and non-diabetics) • Temperature control (goal 37°C) • Supplemental O2

  35. Website Resource www.surgicalinfectionprevention.org

  36. Performance Improvement for the Surgeon: SIPP and SCPP Surgical Complication Prevention Project • New project being piloted now • More broad than SIPP • Will probably become routine PPI project

  37. Performance Improvement for the Surgeon: SIPP and SCPP What does this mean for you? • It will improve your patient outcomes • It may satisfy MOC requirements • It may become your hospital’s PPI project • Surgeons should remain quality leaders

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