Surgical Site Infections

1

• Surgical Site Infections
• The Medicare Quality Improvement Organization for
  Arizona

2
What is SCIP?

• Surgical Care Improvement Project
• Evolved from SIP
• Encompasses additional aspects of surgical care
• Reduce/prevent Cardiac events, emboli, and
  ventilator-associated pneumonia

3
Opportunities to Improve Care

• SSI occurs in 1416 surgical patients
• 4060 of SSIs are preventable
• Cardiac 25 noncardiac surgery, 34 in
  vascular, AMI mortality rate as high as 70
• DVT/PE without prophylaxis general surgery
  cases 25, 7 orthopedic cases, gt 50 DVT, 30 PE
• VAP occurs 940, with associated mortality
  rates of 3046

4
SCIP Goals

• Reduce postoperative mortality and
• morbidity by 25 over 5 years

5
A Closer Look at SSI

• SSI in a 51-case day
• 7.65 patients at risk for infection
• 4.59 of those infections are preventable

6
Insert Organizational Data
7
SCIP in the News

• Newsweek, December 12, 2005
• 6 Keys to Safer Hospitals
• USA Today
• ABC News 20/20
• More Killed Annually Than by Auto Accidents and
  Homicides (10-14-2005)

8
SCIP Support

• American College of Surgeons
• American Society of Anesthesiology
• American Hospital Association
• CDC
• JCAHO
• AORN
• Veterans Administration
• AHRQ

9
Evidence Based

• Evidence-based medicine is the process of
  systematically finding, appraising, and using
  contemporaneous research findings as the basis
  for clinical decisions.
• Evidence-based medicine is about asking
  questions, finding and appraising the relevant
  data, and harnessing that information for
  everyday clinical practice.
• BMJ 19953101122-1126 (29 April)
• William Rosenberg, Anna Donald
• Evidence-based Medicine An Approach to Clinical
  Problem-solving

10
SSI Quality Measures

• 1 Prophylactic antibiotic received within 1 hour
  prior to surgical incision
• 2 Prophylactic antibiotic selection for surgical
  patients
• 3 Prophylactic antibiotics discontinued within
  24 hours after surgery end time (48 hours for
  cardiac patients)
• 4 Cardiac surgery patients with controlled 6
  a.m. postoperative serum glucose

11
SSI Quality Measures

• 5 Postoperative wound infection diagnosed during
  index hospitalization
• 6 Surgery patients with appropriate surgical
  site hair removal
• 7 Colorectal surgery patients with immediate
  postoperative normothermia

12
VTE Quality Measures

• 1 Surgery patients with recommended venous
  thromboembolism prophylaxis ordered
• 2 Surgery patients who received appropriate
  venous thromboembolism prophylaxis, within 24
  hours prior to surgery to 24 hours after surgery 
• 3 Intra- or postoperative pulmonary embolism
  (PE) diagnosed during index hospitalization and
  within 30 days of surgery
• 4 Intra- or postoperative deep vein thrombosis
  (DVT) diagnosed during index hospitalization and
  within 30 days of surgery

13
VAP Quality Measures

• 1 Number of days ventilated surgery patients had
  documentation of the head of the bed (HOB) being
  elevated, from recovery end date (day zero)
  through postoperative day seven.
• 2 Patients diagnosed with postoperative
  ventilator-associated pneumonia (VAP) during
  index hospitalization
• 3 Number of days ventilated surgery patients had
  documentation of stress ulcer disease (SUD)
  prophylaxis, from recovery end date (day zero)
  through postoperative day seven.
• 4 Surgery patients whose medical record
  contained an order for a ventilator-weaning
  program (protocol or clinical pathway)

14
Cardiac Quality Measures

•  2 Surgery patients on a beta-blocker prior to
  arrival that received a beta-blocker during the
  perioperative period
•  3 Intra- or postoperative acute myocardial
  infarction (AMI) diagnosed during index
  hospitalization and within 30 days of surgery.

15
Arizonas Ranking
16
Before SCIP

• Alcohol scrubs
• Most rapid reduction of bacteria counts
• 1 minute 47 minutes of other agents
• Transfer of 1,000 organisms
• Bacterial survival 20150 minutes
• Virus survival 2030 minutes
• Chapters from ACS Surgery
• Prevention of Postoperative Infection
• Jonathan L. Meakins, M.D., D. Sc., F.A.C.S.

17
Impact
Pairs matched for procedure, NNIS index,
age General inpatient surgical population 22,
742 procedures included Kirkland. Infect Control
Hosp Epidemiol. 199920725. Prospective,
case-controlled study of 22,742 patients
undergoing inpatient surgical procedures between
19911995.
Information adapted from the Institute for
Healthcare Improvement (www.ihi.org).
18
Opportunity

• Decreasing the rate of SSI is an opportunity to
• Improve care
• Promote improved outcomes
• Increase patient satisfaction
• Reduce costs

19
Components of SSI

• Antibiotic Administration
• Hair Removal
• Glucose Control
• Normothermia

20
CATS

• Clipping (Hair Removal)
• Antibiotic Administration
• Thermia (Normothermia)
• Sugar (Glucose Control)

21
Antibiotics

• Timely administration
• Selection
• Timely discontinuation

22
Timely Administration

• Most studies indicate that optimum timing for
  prophylactic antibiotic is within 1 hour of
  incision time. (Cephalosporins)
• When cuff is used, make sure all antibiotic is
  infused prior to inflation of cuff.
• Note Because of the longer required infusion
  time, vancomycin, when indicated for beta-lactam
  allergy, should be started within 2 hours before
  the incision.

Information adapted from the Institute for
Healthcare Improvement (www.ihi.org).
23
Timing of Abx. Prophylaxis
Classen, et al. N Engl J Med. 1992328281.
Information adapted from the Institute for
Healthcare Improvement (www.ihi.org).
24
Insert Organizational Data
25
Antibiotic Selection

• Choose prophylactic antibiotics consistent with
  national guidelines
• Special cases
• Allergy (anaphylactoid) to ?-lactam antibiotics
• High rate of MRSA wound infections locally
• Recent prolonged course of antibiotics or ICU stay

Information adapted from the Institute for
Healthcare Improvement (www.ihi.org).
26
Ancef

• Cefazolin
• Effective against gram positive and negative
• Low rate of allergic responses
• Easy to administer
• Inexpensive

27
Prophylaxis Dosing

• Always give at least a full therapeutic dose of
  antibiotic.
• Consider the upper range of doses for large
  patients and/or long operations.
• Repeat doses for long operations (gt 4 hours)

Information adapted from the Institute for
Healthcare Improvement (www.ihi.org).
28
Prophylaxis Duration

• 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.
• There is no need to continue coverage beyond 24
  hours.

Information adapted from the Institute for
Healthcare Improvement (www.ihi.org).
29
Duration Concerns

• 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 unnecessary or prolonged
  use of antibiotics promotes antibiotic resistance.

Information adapted from the Institute for
Healthcare Improvement (www.ihi.org).
30
Tubes, Lines, and Drains

• 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.
• Advisory Statement
• Recommendations for the Use of Intravenous
  Antibiotic
• Prophylaxis in Primary Total Joint Arthroplasty
• American Association of Orthopedic Surgeons
  (AAOS)

31
Duration in Cardiac Surgery

• Our findings confirm that continuing ABP beyond
  48 hours after CABG surgery is still widespread
  however, this practice is ineffective in reducing
  SSI, increases antimicrobial resistance, and
  should therefore be avoided.
• Prolonged Antibiotic Prophylaxis After
  Cardiovascular Surgery and Its
• Effect on Surgical Site Infections and
  Antimicrobial Resistance
• Stephan Harbarth, MD, MS Matthew H. Samore, MD
• Debi Lichtenberg, RN Yehuda Carmeli, MD, MPH
• Circulation. 20001012916-2921

32
Insert Organizational Data
33
Hair Removal Quality Measure

• Surgery patients with appropriate surgical site h
  hair removal.

34
Hair Removal

• Appropriate
• No hair removal at all
• Clipping
• Depilatory use
• Inappropriate
• Razors

Information adapted from the Institute for
Healthcare Improvement (www.ihi.org).
35
Shaving Influence

• No Hair Group Removal Depilatory Shaved
• Number 155 153 246
• Infection rate 0.6 0.6 5.6
• Seropian. Am J Surg. 1971 121 251.

Information adapted from the Institute for
Healthcare Improvement (www.ihi.org).
36
Glucose Control

• Cardiac surgery patients with controlled 600
  a.m. postoperative serum glucose. The measure
  looks at the glucose result for postoperative day
  1 and day 2.

37
Risk, Glucose Control, Cardiac Surgery

• Increased riskDiagnosed diabetesUndiagnosed
  diabetesPost-op glucose gt 200 mg within 48h
• Latham. Inf Contr Hosp Epidemiol. 200122607.
• Dellinger. Inf Contr Hosp Epidemiol. 200122604.

38
SSI Related to Glucose Control
Cardiac Surgery after Median Sternotomy Latham.
ICHE. 2001 22 607-612.
Information adapted from the Institute for
Healthcare Improvement (www.ihi.org).
39
Additional Benefits of Glucose Control

• Decreased
• Acute renal failure
• Red cell transfusions
• Ventilator support
• Time spent in intensive care
• van den Berghe G, Wouters P, Weekers F, et al.
  Intensive insulin therapy in the critically ill
  patients. N Engl J Med. 2001 Nov. 8
  345(19)1359-1367. PMID 11794168

40
Normothermia Quality Measure

• Colorectal surgery patients with immediate
  normothermia (96.8100.4 F) within the first
  hour after leaving the operating room.

41
Normothermia

• Patients who had a decrease of only 1.9C in core
  temperature were three times as likely to develop
  surgical wound infections as were those in whom a
  normal body temperature of 37C was maintained.
• Kurz A, Sessler DI, Lenhardt RA. Perioperative
  normothermia to reduce the incidence of
  surgical-wound infection and shorten
  hospitalization. N Engl J Med 1996 334120915.
  

42
Be An Advocate

• Advocate to reduce the risk of surgical site
  infections by using evidence-based care. Your
  patients will thank you.

43
Be Aware

• Be aware of evidence-based measures to reduce
  surgical site infection
• Hair Removal (Clipping)
• Antibiotic Usage (Antibiotic)
• Normothermia (Thermia)
• Glucose Control (Sugar)

44
Be Alert

• Be alert to the care your surgical patient is
  receiving. Is the care evidence-based or
  something else?

45
Be Active

• Ask the surgeon if he or she wants an antibiotic
  administered.
• Throw every razor away.
• Check the glucose on cardiac patients.
• Keep your patients warm.
• Work with a team to improve surgical care,
  increase patient satisfaction, improve patient
  outcomes, and decrease costs.

46
Insert Organizational Interventions
47
Be Active

• WASH
• YOUR
• HANDS

48
www.hsag.com This material was prepared by
Health Services Advisory Group, the Medicare
Quality Improvement Organization for Arizona,
under contract with the Centers for Medicare
Medicaid Services (CMS), an agency of the U.S.
Department of Health and Human Services. The
contents presented do not necessarily reflect CMS
policy. Publication No. AZ-8SOW-1C-021506-06