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Today’s Webinar will begin at noon. 3/27/12. Welcome from Barb DeBaun, RN, MSN, CIC. Introduction. Introduction. Please do not put your phone on hold; use the mute function or *6 Please type questions or comments into text box

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    Presentation Transcript
    1. Today’s Webinar will begin at noon 3/27/12

    2. Welcome from Barb DeBaun, RN, MSN, CIC

    3. Introduction

    4. Introduction • Please do not put your phone on hold; use the mute function or *6 • Please type questions or comments into text box • If time permits, we will open up the phone lines at the conclusion of the presentation

    5. Heather Young, MD

    6. Surgical Site Infection after Hysterectomy in Colorado • Heather Young MD • March 27, 2012 WHY WHY WHAT HOW

    7. Objectives • WHY • Public reporting in CA, CO and nationwide • Our SSI problem • WHAT • Pilot and statewide study • HOW • Transfusion and outcomes • Transfusion and immunity • Transfusion at our hospital

    8. Why we started this project WHY WHY WHAT HOW

    9. Public Reporting of HAI Committee to Reduce Infection Deaths 2010

    10. Public Reporting Agencies State CMS NHSN > = < Pay for performance Online hospital comparisons

    11. All orthopedic, cardiac, and GI surgeries including: Colon surgery Rectal surgery Small bowel surgery Gallbladder surgery Appendectomy Gastric surgery Biliary, liver, pancreatic surgeries Hip prosthesis Knee prosthesis Open fracture fixation Laminectomy Spinal fusion Spinal refusion Coronary bypass grafting Cardiac surgery Pacemaker surgery Backer 2011

    12. AUGUST 2007 Coronary artery bypass grafting Partial & total knee replacement Partial & total hip replacement AUGUST 2008 Herniorrhaphy AUGUST 2009 Vaginal hysterectomy Abdominal hysterectomy JANUARY 2012 Colon surgery Breast surgery Reese 2011

    13. Why we started this project WHY What we did and What we found WHAT HOW

    14. Preparation for Reporting Jul-Dec 2006 Jan-Jun 2007 Jul-Dec 2007 Jan-Jun 2008 Jul-Dec 2008 Jan-Jun 2009 NationalRate

    15. Why we started this project WHY What we did and What we found WHAT HOW

    16. Pilot Data, Study Design Single center, retrospective chart review Inclusion: • All patients who had total abdominal hysterectomy (TAH) • Dec 30, 2005, to Mar 9, 2010 • Age ≥ 18 y.o. Exclusion: • Emergent surgery • Surgery for known infection (tubo-ovarian abscess) • No follow-up documented in 30 days after TAH Young 2011

    17. Hypotheses • Do our surgeons adhere to evidence-based guidelines? • Are there other published variables that we should consider for intervention?

    18. Inclusion/Exclusion Young 2011

    19. Patient & Hospital Variables PMHx, PSHx Indication for TAH Length of time in OR Estimated blood loss (EBL) Blood transfusion Concomitant OR procedures Type of skin incision Surgeon ASA score Wound class SCIP measures compliance Olsen 2009; Ahmed 2001; Taylor 1998; Shapiro 1982; Meltomaa 2000; Molina-Cabrillana 2008; Ghezi 2009; Leung 2007; Persson 1996

    20. Appropriate antibiotics PACU arrival temperature ≥36 degrees Antibiotics within 60 minutes of incision Adherence to SSI Bundle Green = SSI Blue = No SSI Composite Young 2011

    21. Selected Variables and SSI Young 2011

    22. Selected Variables and SSI Young 2011

    23. Laboratory Variables Pre-operative creatinine Pre-operative complete blood count Post-operative hemoglobin / hematocrit Microbiology, if applicable Meltomaa 2000

    24. Lab Values and SSI Young 2011

    25. Multivariate Analysis Young 2011

    26. Reasons for Blood Transfusion Young 2011

    27. Discussion • Obesity trends toward significance • Blood transfusion associated with SSI after TAH, especially if EBL <500 mL • Most indications for blood transfusion are subjective and potentially modifiable Young 2011

    28. Strengths & Weaknesses Excellent post-discharge follow-up (99%) Use of standard definitions Single center Relatively small number of infections and transfusions Young 2011

    29. Next Steps • Expand to multicenter • State of Colorado • Survey of infection control nurses • IRB approved at 35 / 51 hospitals that perform TAH 8 still pending at publication 8 declined participation • Colorado Hospitals Association (CHA)

    30. Methods • Survey designed • Website developed, supported by CHA • Emails sent to all infection control nurses at participating facilities • Stipend offered for participation Young 2012

    31. Participants • 6 facilities • 567 subjects entered into database • 20 excluded • 547 subjects analyzed • 10 (1.8%) developed SSI • 35 (6.5%) had blood transfusion Young 2012

    32. Associations with SSI Young 2012

    33. Associations with SSI Young 2012

    34. Stratification Analyses Young 2012

    35. Discussion • Blood transfusion and EBL ≥500 mL continue to be risk factors for SSI across several diverse institutions • Biggest contribution of blood transfusion to SSI was in cases of EBL <500 mL Young 2012

    36. Who is more likely to have SSI? EBL 1200 mL EBL 300 mL pRBC pRBC

    37. How blood transfusions relate to patient outcomes How blood transfusions relate to immune functionHow we changed transfusions in hospital practice (sort of!) WHY WHAT HOW

    38. Beneficial effects Detrimental effects Transfusion-Related Immunomodulation (TRIM) ↑ renal transplant survival ↓ Crohn’s disease flares ↓ miscarriage rate ↑ cancer recurrence ↑ post-operative bacterial infection ↑ mortality Vamvakas 2007

    39. TRIM and Hospital Outcomes Blood transfusions are associated with worse hospital outcomes Especially in patients who are not severely ill or profoundly anemic

    40. Hebert et al 1999 ICU Mortality • 838 patients, multicenter, Canada • Randomized controlled trial • Blood transfusion threshold of Hg 7-9 vs 10-12 in community ICU patients • Outcome: 30-day death

    41. Hebert et al 1999 Received less blood Received more blood

    42. Hebert et al 1999 Received less blood Received more blood

    43. Hebert et al 1999 Received less blood Received more blood

    44. Rao et al 2004 Acute Coronary Syndrome • 24,112 patients, multicenter, international • Observational study • Impact of blood transfusion in patients with ACS • Outcome: 30-day death

    45. Rao et al 2004 OR for 30-day death (by Hct)in patients w/ vs w/o blood transfusion • 24,112 patients, international • Impact of blood transfusion on 30-day death in patients with ACS

    46. Rao et al 2004 OR for 30-day death (by Hct)in patients w/ vs w/o blood transfusion • 24,112 patients, international • Impact of blood transfusion on 30-day death in patients with ACS

    47. Blood Transfusion & Surgical Site Infection

    48. Koch et al 2008 Cardiac surgery • Newer vs older blood (<14 vs ≥14 days) • Outcomes: “serious adverse events” and long term survival • Older blood associated with more serious complications and deaths

    49. Koch et al 2008 Death Ventilation Renal failure Sepsis Multiorgan failure Limb ischemia Composite