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SCIP: Preventing Surgical Site Infections . Gary Kanter, M.D. Betsy Lehman Center December 4, 2007. S urgical C are I mprovement P roject . National Quality Partnership CMS,CDC Reduce nationally the incidence of surgical complications by 25% by 2010

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scip preventing surgical site infections

SCIP:Preventing Surgical Site Infections

Gary Kanter, M.D.

Betsy Lehman Center

December 4, 2007

s urgical c are i mprovement p roject
Surgical Care Improvement Project
  • National Quality Partnership
    • CMS,CDC
  • Reduce nationally the incidence of surgical complications by 25% by 2010
  • (13,027 deaths, 271,055 complications)/yr
  • Focus on
    • Surgical infection prevention
    • Adverse cardiac events
    • Prevention of DVT
    • Post operative pneumonia
  • Using evidence based medicine
how often do patients receive scientifically indicated care in this country
How often do patients receive “scientifically indicated care” in this country?
  • Near 100%- we are doing a great job
  • 75%- not too shabby
  • 55%- flip a coin
  • What does science have to do with medicine?

McGlynn, et al: The quality of health care delivered to adults in the United States. NEJM 2003; 348: 2635-2645 (June 26, 2003)

how often do patients receive scientifically indicated care in this country5
How often do patients receive “scientifically indicated care” in this country?
  • Near 100%- we are doing a great job
  • 75%- not too shabby
  • 55%- flip a coin
  • What does science have to do with medicine?

McGlynn, et al: The quality of health care delivered to adults in the United States. NEJM 2003; 348: 2635-2645 (June 26, 2003)

surgical infection si epidemiology impact
Surgical Infection (SI): Epidemiology & Impact
  • Account for 14-16 % of all Hospital Acquired Infections (HAI)
  • 2-5% of operative patients will develop SI
    • 0.8-2 million infections a year
  • SI increase LOS
    • Average 7.5 additional days
  • Excess costs
    • $130-$845 million per year
    • Adds $2,734 - $26,019 per pt (average $3,000)
  • Pain and suffering

SI: Epidemiology & Impact

Patients who develop infection are:

  • 60% more likely to spend time in an ICU
  • 5 times as likely to be readmitted
  • Have a mortality rate twice that of noninfected patients

An estimated 40-60% of these infections are preventable

business case for scip
Business Case for SCIP

APU increased to 2%

baystate medical center
Baystate Medical Center
  • 700 bed tertiary care referral center (population of ~1M)
  • Flagship of Baystate Health
  • 41 k admissions/year
  • Annual surgical volume: 29,043
  • Western Campus of TUFTS
  • Member CoTH, 9 residency programs, 244 residents
  • 1200 member medical staff, 206 faculty MDs
  • Level 1 Trauma Center
  • IHI Mentor Hospital Surgical Infection Prevention

Use of antimicrobial prophylaxis for major surgery: baseline results from the National Surgical Infection Prevention Project Arch Surg. 2005 Feb;140(2):174-82.


Quality Improvement Process

  • Benchmarking, measurement, and feedback
  • Work with key physician champions
  • Disseminate recommendations to educate
  • Use physician order entry
  • Enlist help of case managers as quality safety net
  • Use PDSA cycles to test and improve
prophylactic antibiotics
Prophylactic Antibiotics

Antibiotics given for the purpose of preventing infection when infection is not present but the risk of post-operative infection is present

prophylactic antibiotics questions
Prophylactic AntibioticsQuestions
  • Which cases benefit?
  • When should you start?
  • Which drug should you use?
  • How much should you give?
  • How long should antibiotics be continued?
recently updated antibiotic recommendations
Recently Updated Antibiotic Recommendations

* For the purposes of national performance measurement a case will pass the antibiotic selection performance measure if vancomycin is used for prophylaxis (in the absence of a documented beta-lactam allergy) if there is physician documentation of the rationale for vancomycin use (effective for July 2006 discharges).

recently updated antibiotic recommendations continued
Recently Updated Antibiotic Recommendations (continued)

* Ciprofloxacin, levofloxacin, gatifloxacin, or moxifloxacin (effective for July 2006 discharges).

† For the purposes of national performance measurement, a case will pass the antibiotic selection indicator if the patient receives oral prophylaxis alone, parenteral prophylaxis alone, or oral prophylaxis combined with parenteral prophylaxis.

prophylactic antibiotics questions22
Prophylactic AntibioticsQuestions
  • Which cases benefit?
  • When should you start?
  • Which drug should you use?
  • How much should you give?
  • How long should antibiotics be continued?
timing of antibiotic prophylaxis gi operations
Timing of Antibiotic ProphylaxisGI Operations

Stone HH et al. Ann Surg. 1976;184:443-452.

perioperative prophylactic antibiotics timing of administration
Perioperative Prophylactic AntibioticsTiming of Administration





Infections (%)





Hours From Incision

Classen. NEJM. 1992;328:281.


Antibiotic Timing Related to Incision

Bratzler DW, Houck PM, et al. Arch Surg. 2005;140:174-182.0

never underestimate the power of competition
Never Underestimate the Power of Competition

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Associate Medical Director


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(Surgical Care Improvement Program)

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_____given after the initial surgical incision.



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that current standard of practice



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tibiotic administration within

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rior to the incision (Levaq


and Vancomycin are within 120 minutes


or to the






dosing of antibiotics if the case extends beyond 3 hours

when cefazolins are used

Please contact

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if you have any questions. Thank



quality indicators national surgical infection prevention project
Quality IndicatorsNational Surgical Infection Prevention Project

Quality Indicator #2:

Proportion of patients who receive prophylactic antibiotics consistent with current recommendations

antibiotic recommendation sources
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 2003
antibiotic selection successful interventions
Antibiotic Selection - Successful Interventions
  • Distribution of guidelines to perioperative staff (standardize practice)
  • Antibiotic selection and ordering (standardize process, opt out for selection)
  • Decision aids in the system (active prompt )
    • Use of cephalosporins and vancomycin/gentamicin in penicillin allergic patients
  • Reviewed and revised AB selections in computer order sets (opt out, forcing function)
Quality Indicator #3

Proportion of patients whose prophylactic antibiotics were discontinued within 24 hours of surgery end time


Discontinuation of Antibiotics

Patients were excluded from the denominator of this performance measure if there was any documentation of an infection during surgery or in the first 48 hours after surgery.

Bratzler DW, Houck PM, et al. Arch Surg. 2005;140:174-182.

antibiotic prophylaxis duration
Antibiotic Prophylaxis Duration
  • Most studies have confirmed efficacy of  12 hours
  • Many studies have shown efficacy of a single dose
  • Whenever compared, the shorter course has been as effective as the longer course
papers comparing duration of peri op antibiotic prophylaxis
Papers Comparing Duration of Peri-op Antibiotic Prophylaxis
  • Colorectal 3
  • Mixed GI 4
  • Hysterectomy 3
  • Gyn & GI 1
  • Head & Neck 3
  • Orthopedic 4
  • Vascular 3
  • Cardiac __7__
  • Total 28

Papers supporting longer duration 1

Duration of prophylactic antibiotic administration should not exceed the 24-hour post-operative period
  • Prophylactic antibiotics should be discontinued within 24 hours of the end of surgery
  • Medical literature does not support the continuation of antibiotics until all drains or catheters are removed and provides no evidence of benefit when they are continued past 24 hours

consequences of prolonged ab use
Consequences of Prolonged AB Use
  • Increased antibiotic and drug administration costs
  • Increased antibiotic-associated complications
  • Increased patterns of antibiotic resistance
  • Clostridium difficile Enterocolitis
  • Colonization with MRSA
barriers antibiotic use
Barriers – Antibiotic Use
  • Timing
    • Consistency
    • Sustainability (constant monitor)
  • Selection
    • Resistance (surgeons and organism)
    • Availability; national consensus issues
  • Duration
    • Knowledge gap
    • If it’s not broke, don't change it
nniss benchmark 2 11
NNISS Benchmark = 2-11 %

Surgical Infection Rate

1.13 %

duration of antibiotic prophylaxis what is best for our patients
Duration of Antibiotic Prophylaxis:What is Best for Our Patients?
  • Antibiotic prophylaxis is one of many methods for reducing the incidence of SSI
  • There is a lack of evidence that antibiotics given after the end of the operation prevent SSIs
  • There is evidence that increased use of antibiotics promotes antibiotic resistance
diabetes glucose control and si
Diabetes, Glucose, Control and SI

Infections (%)

Latham,ICHE 2001; 22:607-12


Glucose Control and Deep Sternal Wound Infections

Furnary et al. Ann Thorac Surg 1999:67:352

Survival increased with intensive insulin therapy ( nondiabetic patients included ) targeting BG 80-110 mg/dL

Van den Berghe et al. NEJM 2001; 345:1359-1367

glycemic control
Glycemic Control
  • Established IV insulin protocol for cardiac surgery patients with known diabetes (Pre-op BG > 75 mg/dl) and all others (Pre-op BG >150 mg/dl)
  • The protocol was developed by surgeons, anesthesiologists, endocrinologists, and nursing
  • Insulin infusions to be initiated in OR
  • Insulin infusion to be used for the duration of post-op period while the patient is in cardiac intensive care unit (CICU)
  • Endocrine referral if insulin infusion is utilized
  • Conversion protocol (IV infusion to sliding scale)
diabetes glucose control sis iche 2001 22 607 12
Diabetes, Glucose Control, & SIsICHE 2001; 22: 607-12


  • Peri-operative hyperglycemia and diabetes are associated with increased risk of SIs
  • Early diagnosis of diabetes among high-risk patients may have short and long-term benefits
hair removal pre operative shaving
Hair RemovalPre-operative Shaving
  • Shaving the surgical site with a razor induces small skin lacerations:
    • Potential sites for infection
    • Disturbs hair follicles which are often colonized with S. aureus
    • Risk greatest when done the night before
    • Patient education
      • be sure patients know that they should not do you a favor and shave before they come to the hospital!
shaving clipping si
Shaving, Clipping & SI

Infections (%)

Alexander. Arch Surg 1983; 118:347

cochrane database syst rev 2006 apr 19 2
Cochrane Database Syst Rev. 2006 Apr 19;(2)
  • Three trials involving 3193 patients
  • Compared shaving with clipping
  • Statistically significantly more SSIs when people were shaved rather than clipped (RR 2.02, 95%CI 1.21 to 3.36)
  • Razors removed from OR’s
  • Razors removed from most clinical areas
  • Patients may use razors for personal hygiene
  • Increased myocardial ischemia & VT
  • Bleeding and increased transfusion requirements
  • Surgical wound infections & prolonged hospitalizations
  • Lower pain threshold
  • Drug metabolism decreased
  • Standardization
    • Pre warm
    • Removed “random number generators”
    • One device and one measure (first PACU temp)
  • Review by patient populations
  • Education/communication
    • Room set point pre-op
    • Increased temperature upon pt arrival to room until draped
    • Staff comfort balanced against patient centered care
  • Products
    • Forced hot air
    • Warm fluids
    • Cooling vests
    • Temporal thermometers
Potentially PreventableThis complication may not have occurred with the application of every indicated prevention measure

Apparently Unavoidable

Despite the application of every indicated prevention measure the complication occurred anyway

A mystery………

  • List of patients sent to each surgeon, 30 days post procedure
    • 97% return rate (SASE, interoffice mailing)
    • Self report: any post operative infection/ comments
  • Daily admissions with wound infection
    • Review for surgical date and s/s infection
  • Daily microbiology reports of all + cultures reviewed for wound, fluid cultures, e.g joint aspirates
    • Charts reviewed for NNIS criteria, surgical date and s/s infection
potentially preventable review
Potentially Preventable Review
  • All infections reviewed for potential preventability using SCIP guidelines
  • Reviewed using other criteria as well
  • Review done by IC dept and fed back to multiple cmts (COI, SCIP, SPIT, SAQI)
  • System level changes made when applicable
  • Consistently, 50% of infections have a SCIP miss!!
improvement tools
Improvement Tools
  • Systems
  • Populations
  • Cycles of Change
    • PDSA, Six Sigma, LEAN
  • Process Analysis
  • Failure Mode Identification
  • BH PI Tool Kit
keys to success
Keys to Success
  • Persistence and reinforcement/high visibility
  • Senior leader support
  • Multidisciplinary cooperation & collaboration
    • Accurate, timely and relevant data
    • Right people
  • Willing to try changes and take a risk
  • Develop reliable systems (strive for 10-2 > 90%)
  • Incorporate into workflow
    • Make changes easy and transparent
  • Stress importance of impact on patient and practitioner
  • Make The Right Thing The Easy Thing
lessons learned
Lessons Learned
  • Involve all stakeholders
  • Leave your stripes at the door
  • Must have physician champions- credible
  • Be humble
  • Take more blame and give more credit
  • BROAD shoulders
  • Must work as team
  • Small tests of change with frequent tempo
  • Small pilot population
  • Work within your culture
  • Steal shamelessly
  • Make the right thing the easy thing
Medicine used to be simple, ineffective, and relatively safe…….

Now it is complex, effective, and potentially dangerous.

Sir Cyril Chantler

1999 Hollister Lecture atNorthwestern University, Illinois

James, B. 16th IHI Conference

for more information
Gary Kanter, M.D.

Department of Anesthesiology

Baystate Medical Center

Springfield MA 01199

413 794 3520

For More Information: