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Building your SSI Prevention Bundle. Armstrong Institute for Patient Safety and Quality Presented by: Elizabeth C. Wick, M.D. / Brad Winters, M.D. DRAFT – final pending AHRQ approval. Learning Objectives.

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slide1
Building your SSI Prevention Bundle

Armstrong Institute for Patient Safety and Quality

Presented by: Elizabeth C. Wick, M.D. /Brad Winters, M.D.

DRAFT – final pending AHRQ approval

learning objectives
Learning Objectives
  • Develop and implement an SSI reduction goal and prevention bundle that addresses up to three surgical care processes that your team feels needs to be improved to address SSIs
  • Understand how to use the results of your staff safety assessment to build a bundle
  • Review how to initiate audits of your processes
  • Create a performance goal (improvement in outcome) for your team
  • Learn how to proceed with improvements that do not have a strong evidence base
  • Locate SUSP resources on the project website

DRAFT – final pending AHRQ approval

background
Background
  • SSI is the most common nosocomial infection in the surgical patient
  • SSI is the most common complication after colorectal abdominal surgery (3-30%)
  • SSI is associated with increased mortality, length of stay, and re-admission
  • An SSI costs between $6,200-$15,000/per patient (superficial-organ space)

DRAFT – final pending AHRQ approval

ssi definitions
SSI Definitions
  • Superficial

-Purulent drainage from wound

-Positive wound culture

-Pain, redness swelling

-Diagnosis by Surgeon

  • Deep

-Purulent drainage from deep aspect of the wound

-Dehiscence

-Abscess on exam or CT scan

  • Organ Space

-Infection in the surgical cavity (abdomen)

DRAFT – final pending AHRQ approval

colorectal surgery readmissions johns hopkins hospital
Colorectal Surgery Readmissions/Johns Hopkins Hospital

Readmission rate 17.6% (2009-12)

DRAFT – final pending AHRQ approval

pathogenesis of ssi
Pathogenesis of SSI

Host

Bacteria

Procedure

DRAFT – final pending AHRQ approval

no single ssi prevention bundle
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

DRAFT – final pending AHRQ approval

slide9

Johns Hopkins Hospital

May 2010 SCIP

Hospital Compare

www.medicare.gov

Does SCIP give us enough information?

DRAFT – final pending AHRQ approval

slide10
NSQIP Report 2009

DRAFT – final pending AHRQ approval

peri operative antibiotic compliance michigan surgical quality collaborative 2
Peri-operative Antibiotic Compliance:Michigan Surgical Quality Collaborative2

DRAFT – final pending AHRQ approval

auditing your practice
Auditing Your Practice
  • Evaluate a sample of patients undergoing your procedure of interest for compliance with processes your team identified as potential areas to improve
    • (i.e: the next 10-20 patients)
  • Adapt tool from SUSP website or develop new tool
  • Practical and feasible strategy to evaluate performance and surface defects
  • Empowers frontline staff

DRAFT – final pending AHRQ approval

how do we conduct audits
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

DRAFT – final pending AHRQ approval

gentamicin
Gentamicin

Interventions-

  • Increased amount of gentamicin available in room
  • Added dose calculator in anesthesia record
  • Educated surgery, anesthesia, and nursing

Despite a 95% compliance on SCIP

DRAFT – final pending AHRQ approval

susp antibiotic audit tool
SUSP Antibiotic Audit Tool

DRAFT – final pending AHRQ approval

normothermia
Normothermia

Interventions-

  • Confirmed that temperature probes were accurate (trial comparing foley and esophageal sensors)
  • Initiated forced air warming in the pre-operative area

DRAFT – final pending AHRQ approval

susp normothermia audit tool
SUSP Normothermia Audit Tool

DRAFT – final pending AHRQ approval

slide19
What about interventions with no data to support them?

DRAFT – final pending AHRQ approval

separation of dirty and clean instruments
Separation of “Dirty” and “Clean” Instruments

Intervention-

  • Built separate tray of instruments used for bowel anastomosis
  • Extra suction and bovie tip and gloves opened and changed after anastomosis
  • Educational sessions with scrub techs and nurses about instrument separation
  • Audits and education on the spot

DRAFT – final pending AHRQ approval

slide21
Bringing Emerging Evidence for SSI Prevention to Your Patients

DRAFT – final pending AHRQ approval

emerging evidence for ssi prevention
Emerging Evidence for SSI Prevention
  • Antibiotic Usage

-Redosing

-Weight based dosing of cephalosporins

  • Utilization of mechanical bowel preparation with oral antibiotics
  • Normoglycemia/Prevention of hyperglycemia
  • Standardization of skin preparation

DRAFT – final pending AHRQ approval

slide23

Available on SUSP website

https://armstrongresearch.hopkinsmedicine.org/susp/ssi/resources.aspx

DRAFT – final pending AHRQ approval

jhu antibiotic poster
JHU Antibiotic Poster

Entire document available on SUSP website

https://armstrongresearch.hopkinsmedicine.org/susp/ssi/resources.aspx

DRAFT – final pending AHRQ approval

additional interventions to improve antibiotic efficacy
Additional Interventions to Improve Antibiotic Efficacy
  • Weight-based dosing of cephalosporins
  • Antiobiotic Re-Dosing

- Maintain therapeutic antibiotic serum levels during the entire procedure

  • If using cefoxitin consider changing because of short redosing interval
  • Audit your practice!!
  • Develop standard selections for based on procedure for your hospital
  • Engage surgery, nursing and anesthesia to implement standard protocol
  • Consider integrating into EMR if available
  • Audit your results and share success

DRAFT – final pending AHRQ approval

hyperglycemia and infection
Hyperglycemia and Infection
  • Background-

-Hyperglycemia is common in hospitalized patients

-38% of medical and surgical patients had hyperglycemia (26% diabetic and 12% non-diabetic)

-In cardiac surgery, degree of post operative hyperglycemia correlates with SSI, adopted as SCIP measures

  • Goal-

Glucose <180mg/dl in all hospitalized patients

DRAFT – final pending AHRQ approval

johns hopkins glucose control
Johns Hopkins Glucose Control

DRAFT – final pending AHRQ approval

could you do better with glycemic management
Could you do better with glycemic management?
  • Audit your current practice
  • Do you have a policy?

Consider gathering a multidisciplinary team (endocrinology, surgery, anesthesiology, nursing (ward and pre-op)) to develop a protocol for your hospital

Look at SUSP website for examples from other hospitals

https://armstrongresearch.hopkinsmedicine.org/susp/ssi/resources.aspx

DRAFT – final pending AHRQ approval

preparation of the surgical site
Preparation of the Surgical Site
  • Background-

-1012 bacteria reside on the skin

-Staphlococcus and streptococcus species among others

  • Goal of skin preparation-

-Reduce bacterial burden on skin prior to incision

  • Best practice-

-Dual agent skin preparation (Chlorhexidine + alcohol +, providone- iodine + alcohol)

-Skin prep should include alcohol to increase durability of sterilization

-Prep should be applied to specification (duration and amount)

-Prep must be dry before incision

DRAFT – final pending AHRQ approval

slide32

Chloraprep better than Betadine

Chloraprep and Duraprep better than Betadine

DRAFT – final pending AHRQ approval

is skin prep an area you could improve
Is Skin Prep an Area You Could Improve?

Audit your practices

- what is being used for what cases?

- who is doing the prep?

-how long are they taking for the prep?

Develop an educational plan, engaging frontline providers, for standardization

-? In-services

-? Video education

-? Change doctor preference cards

Audit again after your interventions…. How well did you do? Share the results!

DRAFT – final pending AHRQ approval

summary
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
  • The CUSP method empowers frontline staff

DRAFT – final pending AHRQ approval

resources to find the information that you need for susp
Resources to find the information that you need for SUSP
  • Armstrong Institute for Patient Safety and Quality

https://armstrongresearch.hopkinsmedicine.org/susp.asp

DRAFT – final pending AHRQ approval

action items
Action Items
  • Review staff safety assessment results
  • Pick 2-3 audit tools based on frontline feedback, SCIP measures and emerging evidence

Find tools on our website-

https://armstrongresearch.hopkinsmedicine.org/susp/ssi/resources.aspx

  • Audit 5-10 patients with each tool
  • Create a performance goal for each intervention for your team
  • Develop your bundle
  • Develop system changes to implement interventions
  • Share your tools and ideas for new tools

DRAFT – final pending AHRQ approval

references
References
  • Merriam-Webster Dictionary. “Auditing.” Merriam-Webster Dictionary web site. http://www.merriam-webster.com/dictionary/auditing. Accessed September 1, 2013.
  • Hendren S, Englesbe MJ, Brooks L, et al. Prophylactic antibiotic practices for colectomy in Michigan. Am J Surg. 2011;201(3):290-293.
  • Hospital Compare. Medicare: the official U.S. government site for medicare.  Medicare.gov Website.

http://www.medicare.gov/hospitalcompare/profile.html#profTab=2&ID=210009&loc=21287&lat=39.2962372&lng=-76.5928888&name=johns%20hopkins%20hospital. Accessed May 30, 2010

4. Wick EC, Hobson DB, Bennett JL, et al. Implementation of a Surgical Comprehensive Unit-Based Safety Program to Reduce Surgical Site Infections. JACS. 2012; 215(2):193-200.

DRAFT – final pending AHRQ approval

content call evaluation
Content Call Evaluation

We want to ensure that the content calls provide useful and pertinent information for the SUSP teams. For this reason we request that you complete a brief evaluation following each call. The evaluation may be found at the following link:

https://www.surveymonkey.com/s/SUSP_Cohort4

DRAFT – final pending AHRQ approval