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Surgical Infection Prevention In Washington State Where we started and where we’re going…. Nancy West, RN, MPH, CPHQ Qualis Health With Many Thanks to Dale W. Bratzler, DO, MPH and E. Patchen Dellinger, MD. Why focus on surgical quality?. ~30 million major operations each year in the US

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surgical infection prevention in washington state where we started and where we re going

Surgical Infection PreventionIn Washington StateWhere we started and where we’re going…

Nancy West, RN, MPH, CPHQ

Qualis Health

With Many Thanks to Dale W. Bratzler, DO, MPH and E. Patchen Dellinger, MD

why focus on surgical quality
Why focus on surgical quality?
  • ~30 million major operations each year in the US
    • Despite advances in surgical and anesthesia technique and improvements in perioperative care, variations in outcomes for patients having surgery are well known
consequences of surgical complications
Consequences of Surgical Complications
  • Dimick and colleagues demonstrated increased costs:
    • infectious complications was $1,398
    • cardiovascular complications $7,789
    • respiratory complications $52,466
    • thromboembolic complications $18,310.
  • Khuri and colleagues demonstrated that, independent of preoperative patient risk, the occurrence of a 30-day complication reduced median patient survival by 69%.

Dimick JB, et al. J Am Coll Surg 2004;199:531-7.

Khuri SF, et al. Ann Surg 2005;242:326-41.

who pays for surgical complications
Who Pays for Surgical Complications?

Complications were always associated with an increase in costs to healthcare payors: complications were associated with an average increase in payment of $7645 (54%) per patient.

Dimick JB, et al. Who pays for poor surgical quality? Building a business case for quality improvement. J Am Coll Surg. 2006;202:933-7.

medicare surgical infection prevention sip project objective
Medicare Surgical Infection Prevention (SIP) Project Objective

To decrease the morbidity and mortality associated with postoperative infection in the Medicare patient population

selected surgical procedures
Selected Surgical Procedures
  • Cardiac
  • Coronary Artery Bypass Graft (CABG)
  • Colon
  • Hip & Knee Arthroplasty
  • Abdominal & Vaginal Hysterectomy
  • 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.

slide8

Antibiotic Timing Related to Incision

Where we started in 2001

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

perioperative prophylactic antibiotics timing of administration
Perioperative Prophylactic AntibioticsTiming of Administration

14/369

15/441

1/41

1/47

Infections (%)

1/81

2/180

5/699

5/1009

Hours From Incision

Classen. NEJM. 1992;328:281.

infection antibiotic indicators national surgical care improvement project
Infection antibiotic IndicatorsNational Surgical Care Improvement Project
  • SCIP INF – 1: Proportion of patients with antibiotic initiated within 1 hour before surgical incision
  • SCIP INF – 2: Proportion of patients who receive prophylactic antibiotics consistent with current recommendations
  • SCIP INF – 3: Proportion of patients whose prophylactic antibiotics were discontinued within 24 hours of surgery end time
surgical care improvement project performance measures process
Surgical Care Improvement ProjectPerformance measures - Process
  • Surgical infection prevention
      • Antibiotics
          • Administration within one hour before incision
          • Use of antimicrobial recommended in guideline
          • Discontinuation within 24 hours of surgery end
  • Other Process Improvement
      • Glucose control in cardiac surgery patients
      • Proper hair removal
      • Normothermia in colorectal surgery patients
inf 1 the questions
INF – 1: the questions
  • Antibiotic administered within 60 minutes prior to incision time
    • “On call” to OR?
    • Give in pre-op?
    • What about ED surgical admissions?
    • Who is responsible?
    • Where is the time documented?
inf 1 what works
INF-1: What works!
  • Anesthesiology takes responsibility for administration of abx; time is included in anesthesia record
  • Keep abx in pre-op Pyxis
  • Utilize a visual/physical cue: push the abx when you hit the button to open the OR door!
  • Utilize a forcing function: have abx hanging and plugged into the port so that it must be given before the anesthesiologist can run the sedation
  • Use the preop “pause” to check for administration time for abx.
  • If over 60 mins, redose!
scip inf 2 selection antibiotic recommendation sources
SCIP INF – 2: SelectionAntibiotic 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
  • The Johns Hopkins Guide
  • Society of Thoracic Surgeons
1 currently published guidelines
#1 – Currently published guidelines…
  • ….. favor the use of 1st or 2nd generation cephalosporins for prophylaxis because of numerous published randomized trials that have demonstrated their effectiveness for prophylaxis
    • Safe and inexpensive
2 be cautious about wanting to use vancomycin for prophylaxis
#2 – Be cautious about wanting to use vancomycin for prophylaxis
  • Vancomycin resistance remains a public health problem
  • Vancomycin is not a particularly good antibiotic for prophylaxis
    • Challenges with administration and slower tissue perfusion
    • May result in higher infection rates
inf 2 selection the questions
INF - 2: Selection: the questions
  • What about allergy?
  • What about formularies?
  • Who made up the approved list?
  • What about ertapenem?
  • What about bowel preps?
inf 2 what works
INF – 2: What works!
  • See www.medqic.org for list of approved abx
  • Abx selection list comes from a group including major specialty societies, IDSA, CDC, etc.
  • Ertapenem will be allowed for colon cases x 1 dose starting 10/07
  • Vancomycin use is still a problem: education for physicians seems to help!
  • Keep up with what’s new by joining the national SCIP email list
scip inf 3 discontinuation of prophylaxis
SCIP INF – 3: Discontinuation of Prophylaxis
  • Numerous clinical trials have compared short-term to long-term antimicrobial prophylaxis
    • Infection rates are the same regardless of duration of prophylaxis
      • Prolonged prophylaxis has been associated with higher rates of infections with resistant organisms (when infection occurs). Prolonged prophylaxis only changes the flora – it does not lower infection rates.

Prolonged prophylaxis is a patient safety issue.

slide20

SCIP #3: Discontinuationof 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.

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 SSI’s
  • There is evidence that increased use of antibiotics promotes antibiotic resistance (CDAD)
antibiotic prophylaxis duration
Antibiotic ProphylaxisDuration
  • Most studies have confirmed efficacy of 12 hrs.
  • Many studies have shown efficacy of a single dose.
  • Whenever compared, the shorter course has been as effective as the longer course.
slide23
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.

http://www.aaos.org/wordhtml/papers/advistmt/1027.htm

inf 3 what works
INF – 3: What works!
  • We are working on having the first postop dose given in PACU by standardizing the postop orders as much as possible.
  • Postop orders Q8hrs X3=24 hours?
inf 3 what works25
INF – 3: What works!
  • Have an automatic stop order for PROPHYLACTIC antibiotics.
  • Nursing has signage at patients bedside that tells when the last dose must be in.
  • Send MD's their data along with overall data for their service area. As being competitive by nature no one wants to be lagging behind.
protocols protocols protocols
Protocols, protocols, protocols
  • Design protocols based on surgery type
  • Initiate protocol as a standard

– Nursing and/or pharmacy drives protocol

– No reliance on individual physician memory

  • Include guidance for exceptions

– Beta Lactam allergy

• Use your own formulary to narrow choices

– Makes protocol easier and saves costs

surgical care improvement project performance measures process27
Surgical Care Improvement ProjectPerformance measures - Process
  • Surgical infection prevention
      • Antibiotics
          • Administration within one hour before incision
          • Use of antimicrobial recommended in guideline
          • Discontinuation within 24 hours of surgery end
      • INF – 4: Glucose control in cardiac surgery patients
      • INF – 6: Proper hair removal
      • INF – 7: Normothermia in colorectal surgery patients
slide28

Glucose Control Lowers the Risk of Wound Infection in Diabetics After Open Heart OperationsZerr et al Portland, OR 1997

7

6

5

4

3

2

1

0

1585 Diabetic Patients

Infection

Rate

%

100 -150151-200201-250 251-300

Mean DMG Range POD # 1

inf 4 glucose control the questions
INF – 4: Glucose Control: the questions
  • What about patients who are not in the ICU? We only run insulin drips in the ICU
  • What glucose level needs to be maintained?
  • Why only cardiac surgery patients?
    • Corollary: we don’t do cardiac surgery but want to pursue glucose control
  • What is the glucose level that will have the best results for patients?
  • What about sliding scale insulin?
inf 4 what works
INF – 4: What works!
  • Implement Insulin Protocol for tighter glycemic control: BG target goal 80-110
  • Baseline measurement of BG Ranges prior to institution of new protocol
  • Use BG level by fingerstick on DAY OF surgery
  • Mandatory Staff Education
  • Weekly Data Collection
  • Data Reporting/Presentation
inf 6 hair removal
INF – 6: Hair removal
  • 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!
influence of shaving on ssi
Influence of Shaving on SSI
  • No Hair GroupRemoval Depilatory Shaved
  • Number 155 153 246
  • Infection rate 0.6% 0.6% 5.6%

Seropian. Am J Surg 1971; 121: 251

inf 6 the questions
INF – 6: the questions
  • What about neurosurgery?
  • What about “delicate” areas?
  • Why do the razors keep coming back?
  • Is the literature too old?
  • Others?
inf 6 what works
INF – 6: What works!
  • Remove all razors from OR and entire hospital!
  • Provide packs allowing for “wet” hair removal with clipper
  • Re-educate, re-check for razors: early and often!
  • Post data and have a competition
  • Visual reminders (“Shave Free Zone” poster)
scip inf 7 temperature control
SCIP INF – 7: 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)

inf 7 temp control the questions
INF – 7: Temp control: the questions
  • Why only colorectal surgery patients?
  • What kind of thermometer do you use?
  • What about OR temp/humidity?
  • Don’t the Bair huggers get in the way?
  • When should we warm up the patients?
  • What about core temperature?
inf 7 what works
INF – 7: What works!
  • Bair huggers for all patients preoperatively/intraoperatively
  • In winter, educate scheduled patients to stay warm on the way in to the hospital
  • Use of temporal arterial thermometers
  • Warmed IV fluids
  • Increasing OR temperatures
  • Involving technicians in OR temp maintenance
  • Caps, booties for patients
surgical care improvement project scip
Surgical Care Improvement Project (SCIP)
  • Preventable Complication Modules
    • Surgical infection prevention
    • Cardiovascular complication prevention
    • Venous thromboembolism prevention
    • Respiratory complication prevention
prevention of cardiac events introduction
Prevention of Cardiac EventsIntroduction
  • As many as 7 to 8 million Americans that undergo major noncardiac surgery have multiple cardiac risk factors or established coronary artery disease
    • More than 1 million cardiac events annually
  • Myocardial ischemia either clinically occult or overt confers a 9 - fold increase in risk of unstable angina, nonfatal myocardial infarction, and cardiac death

Schmidt M, et al. Arch Intern Med. 2002;162:63-69.

Mangano DT, et al. N Engl J Med. 1996;335:1713-1720.

Selzman CH, et al. Arch Surg. 2001;136:286-290.

surgical care improvement project performance measure process
Surgical Care Improvement ProjectPerformance measure - Process
  • SCIP CARD – 2: Perioperative cardiac events
      • Perioperative beta blockers in patients who are on beta blockers prior to admission
slide42

http://www.acc.org/clinical/guidelines/perio/periobetablocker.pdfhttp://www.acc.org/clinical/guidelines/perio/periobetablocker.pdf

prevention of venous thromboembolism
Prevention of Venous Thromboembolism
  • Recent estimates show that
    • more than 900,000 Americans suffer VTE each year
      • about 400,000 of these being DVT
      • About 500,000 being manifest as PE
    • In about 300,000 cases, PE proves fatal; it is the third most common cause of hospital-related deaths in the United States.

Heit JA, Cohen AT, Anderson FA on behalf of the VTE Impact Assessment Group. [Abstract] American Society of Hematology Annual Meeting, 2005.

risk factors for vte
Risk Factors for VTE
  • Previous venous thromboembolism
  • Increased age
  • Surgery
  • Trauma - major, local leg
  • Immobilization - ? bedrest, stroke, paralysis
  • Malignancy & its Rx (CTX, RTX, hormonal)
  • Heart or respiratory failure
  • Estrogen use, pregnancy, postpartum, SERMs
  • Central venous lines
  • Thrombophilic abnormalities

Most hospitalized patients have at least one additional risk factor for VTE

surgical care improvement project performance measures process45
Surgical Care Improvement ProjectPerformance measures - Process
  • Prevention of venous thromboembolism
      • SCIP VTE 1: Proportion who have recommended VTE prophylaxis ordered
      • SCIP VTE 2: Proportion who receive appropriate form of VTE prophylaxis (based on ACCP Consensus Recommendations) within 24 hours before or after surgery
what s next
What’s Next?
  • MRSA
  • VTE assessment and tracking
  • HCAHPS
  • Outpatient measures 2008
    • Timing of antibiotics
    • Antibiotic selection
    • (pediatric asthma)
vbp design assumptions
VBP Design Assumptions

Would build on infrastructure of the Reporting Hospital Quality Data for Annual Payment Update Program (RHQDAPU) – “pay-for-reporting” program

  • Would not include additional funding
  • – 2-5% withhold of base DRG funding for all Medicare patients
  • VBP payments based on the quality of care provided – not the fact that data were reported.
  • If you don’t report data, you can’t play!
what s new on the scip web site
What’s New on the SCIP Web Site!
  • Here are some of the latest additions to the SCIP web site at www.medqic.org/scip. Feel free to visit the SCIP site often as we post new tools, interventions and more weekly.
slide50
Nancy West, RN, MPH, CPHQ

nancyw@qualishealth.org

206364-9700 ext 2007