Surgical Site Infection Prevention Collaborative MCIC March 2006

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Surgical Site Infection Prevention
CollaborativeMCIC March 2006
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Background NNIS

• National Nosocomial Infection Surveillance (NNIS)
  System
• CDC program that reports aggregated surveillance
  data from 300 US hospitals
• Standard case-finding (by ICD-9 code),
  definitions for infection, and risk-stratification
  methodology
• Pooled mean and standard deviation reported for
  surgical procedures, including craniotomy,
  laminectomy, spinal fusion, C-section, and CABG

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Background Methodology

• HEIC surveillance methodology
• Monthly denominator data from case-mix data base
  (all NNIS procedures by ICD-9 code)
• Complete chart review of all procedures performed
  to assess for infection
• Risk stratification
• Length of procedure (1 point)
• ASA score (1 point)
• Wound class (assuming all procedures are clean
  because CANNOT get wound class)
• Generation and distribution of standardized rates
  quarterly or semi-annually (if denominator lt
  50/quarter)

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Background Reporting

• HEIC reporting strategies
• Rates with NNIS benchmarking
• Weekly evaluation of numbers of infections
  (includes non-NNIS procedures)

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Present your local NNIS infection data here
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Surgical Site Infections GOALS

• Define and identify risk factors for SSI
• Discuss strategies for prevention
• Discuss antibiotic prophylaxis principles

Pamela A. Lipsett, MD Professor Departments of
Surgery,Anesthesiology, Critical Care Medicine,
Nursing Johns Hopkins University Schools of
Medicine and Nursing
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Proportion of Adverse EventsMost Frequent
Categories
Non-surgical
Surgical
Brennan. N Engl J Med. 1991324370-376
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INTRODUCTION

• 40 million operations annually
• 20 experience infection
• Surgical site infections (SSI) prolong hospital
  stay by 6.5 to 7.4 days and comprise 42 of extra
  charges

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SSIRISK FACTORSINTRINSIC-PATIENT RELATED

• Age
• Nutritional status
• Diabetes
• Smoking
• Obesity
• Remote infections

• Endogenous mucosal microorganisms
• Altered immune system
• Preoperative stay-severity of illness

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SSIRISK FACTORSEXTRINSIC-OPERATION RELATED

• Duration of operation
• Prophylaxis
• Ventilation
• Sterilization of equipment
• Wound class
• Drains

• Duration of surgical scrub
• Skin antisepsis
• Preop shaving
• Preop skin prep
• Surgical attire
• Sterile draping
• Surgical technique

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NON-ANTIBIOTIC FACTORS

• Length of pre-operative stay
• Pre-operative shaving
• Length of operation
• Use of abdominal drains

• Pre-operative showering
• Presence of remote infections
• Normothermia
• Increased oxygenation
• Glucose control

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Temperature and SSI Following Colectomy

• Mechanical bowel prep
• Parenteral antibiotics at induction x 4 d
• Standard anesthetic-isoflurane
• Randomized after inductionTgt36.5 º or Tgt34.5 º
• Supplemental O2 in PACU x 3h
• Aggressive fluid resuscitation

Kurz. NEJM 19963341209
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Temperature and SSI Following Colectomy

• Normo (104) Hypo(96) P
• SSI 6 18 .009
• Collagen 328 254 .04
• Time to eat 5.6d 6.5d lt.006

Kurz. NEJM 19963341209
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Hyperglycemia and Infection RiskAbdominal and
Cardiovascular Operations

• Glucose POD1
• lt220 mg gt220 mg
• Any Infection 12 31
• Serious Infection 5.7-fold increase for any
  glucose gt 220 mg
• Pomposelli. JPEN 19982277

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Diabetes, Glucose Control, and SSIsAfter Median
Sternotomy
Latham. ICHE 2001 22 607-12
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Insulin Treatment in SICU Patients

• 
  Treatment Group
• 
  Conventional Intensive
• Death in ICU 63/783 (8) 35/765
  (5)

Van den Berghe. NEJM 20013451359
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Preoperative Recommendations Category 1A

• If hair is removed, remove immediately before the
  operation, preferably with electric clippers

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Influence of Shaving on SSI

• 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
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Shaving, Clipping and SSI
Cruse. Arch Surg 1973 107 206
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Hair Removal Techniques and SSI
Alexander. Arch Surg 1983 118 347
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GUIDELINES FOR ANTIBIOTIC PROPHYLAXIS

• 1. The procedure should carry a significant risk
  of infection and/or cause significant bacterial
  contamination.

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Relative Benefit from Antibiotic Surgical
Prophylaxis

• Operation Prophylaxis () Placebo () NNT
• Colon 4-12 24-48 3-5
• Other (mixed) GI 4-6 15-29 4-9
• Vascular 1-4 7-17 10-17
• Cardiac 3-9 44-49 2-3
• Hysterectomy 1-16 18-38 3-6
• Craniotomy 0.5-3 4-12 9-29
• Total joint 0.5-1 2-9 12-100
• Breast hernia ops 3.5 5.2 58

Number Needed to Treat
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GUIDELINES FOR ANTIBIOTIC PROPHYLAXIS

• 2.The antibiotic selected must be active against
  the major contaminating organisms and should have
  previously been shown to be effective
  prophylaxis.
• It is NOT necessary to cover ALL organisms
  present.

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GUIDELINES FOR ANTIBIOTIC PROPHYLAXIS

• 3. The antibiotic chosen must achieve
  concentrations higher than the minimal inhibitory
  concentration (MIC) of the suspected pathogens in
  the wound site at the time of incision.

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GUIDELINES FOR ANTIBIOTIC PROPHYLAXIS

• 4. The shortest possible course of the most
  effective least toxic antibiotic must be used for
  prophylaxis. Must consider distribution and
  half-life of individual agents.

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GUIDELINES FOR ANTIBIOTIC PROPHYLAXIS

• 5. The newer broader spectrum agents must be
  saved for therapy of resistant organisms and
  should not be used for prophylaxis.

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Antimicrobial Prophylaxis Category IB

• Do not routinely use vancomycin for antimicrobial
  prophylaxis

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WHEN (TIMING) OF PROPHYLACTIC AGENTS

• Antibiotic levels of the individual agents must
  be higher than the MIC at the time of incision
• Individual agents must be considered
• Cefazolin has a Vd of 10-12 L can can be pushed
  within minutes of incision
• Additional doses dependent on half-life and
  blood loss

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Timing Analysis
Burke JP. CID. 200133s78-s82
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Appropriate UseLDS
Year Operations SSI () Inappropriate Prophylaxis ()
1996 976 17 (1.7) 6 (35)
1997 1035 30 (2.9) 6 (20)
1998 963 12 (1.2) 1 (8)
1999 932 16 (1.7) 0
Burke JP. CID. 200133s78-s82
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Antibiotic Timing Related to Incision
Bratzler DW, Houck PM, et al. Arch Surg
2005140174-182
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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
205140174-182
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SPECIAL CONSIDERATION MORBID OBESITY

• Cefazolin 1 gram is not the correct dose for
  everyone
• At incision and closure 1g , blood and tissue
  levels all lower than normal weight
• Below MIC for gram pos cocci and gram neg rods

• Cefazolin 2gm good blood and tissue levels
• Wound infection rates from 16.5 to 5.1
• Forse et alsurgery 1989106,751-767

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CONCLUSIONS

• Must be familiar with principles of prophylaxis
  and CDC recommendations
• Morbidly obese patients should receive larger
  doses of antibiotics

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CONCLUSIONSBeyond CDC

• Maintenance of normothermia maybe important
  (Level II)
• Glucose control perioperatively

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Improving Safety and QualityFive Step Model for
Improvement
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Why do we need to improve care?

• In U.S. Healthcare system
• 44,000- 98,000 preventable deaths
• 50 billion in total costs

IOM report To err is human
Similar results in UK and Australia
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Why do we need to improve care?

• Patients Do the right thing!
• Purchasers
• Leapfrog group
• Insurers
• Regulators
• JCAHO ICU measurement set
• CMS surgical care improvement project

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Outline

• Review 5 step model for improvement
• Provide practical examples
• How will we prevent SSI?

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Model to Improve

• Pick an important clinical area
• Identify what should we do?
• principles of evidence-based medicine
• Measure if you are doing it
• Ensure patients get what they should
• education
• create redundancy
• reduce complexity
• Evaluate whether outcomes are improved

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Important Clinical Areas

• Eliminating CR-BSIs
• Ventilator Associated Pneumonia
• Sepsis Bundle
• Perioperative Beta Blockers
• VTE Prophylaxis
• Decreasing SSI

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Model to Improve

• Pick an important clinical area
• Identify what should we do?
• principles of evidence-based medicine
• Measure if you are doing it
• Ensure patients get what they should
• education
• create redundancy
• reduce complexity
• Evaluate whether outcomes are improved

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Model to Improve

• Pick an important clinical area
• Identify what should we do?
• principles of evidence-based medicine
• Measure if you are doing it
• Ensure patients get what they should
• education
• create redundancy
• reduce complexity
• Evaluate whether outcomes are improved

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Outcome vs. Process Measures

• Process
• full barrier precautions
• DVT and PUD prophylaxis
• Appropriate abx timing
• Adv/Disadvantages
• short cycle
• feedback meaningful
• no risk-adjustment

• Outcome
• mortality
• catheter-related BSI
• SSI
• Adv/Disadvantages
• long cycle
• feedback difficult
• important to patients

McGlynn, Jt Comm J Qual Improv 1988
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Model to Improve

• Pick an important clinical area
• Identify what should we do?
• principles of evidence-based medicine
• Measure if you are doing it
• Ensure patients get what they should
• education
• create redundancy
• reduce complexity
• Evaluate whether outcomes are improved

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Systems Approach

• Every system is perfectly designed to get the
  results that it gets
• Berwick
• If you want to change performance you need to
  change the system

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All improvement is local we can provide
concepts you need to design interventions
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Science of Safety

• Accept that we will make mistakes
• Focus on systems, including interpersonal
  communication, rather than people
• Largest barrier is lack of awareness evidence
  exists
• Standardize to reduce complexity
• Create independent checks

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Model to Improve

• Pick an important clinical area
• Identify what should we do?
• principles of evidence-based medicine
• Measure if you are doing it
• Ensure patients get what they should
• education
• create redundancy
• reduce complexity
• Evaluate whether outcomes are improved

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Eliminating SSI

• Apply best practices
• If hair is removed, use clippers
• Appropriate antibiotics
• Choice
• Timing
• Discontinuation
• Perioperative normothermia
• Glycemic control
• Decrease complexity
• Create redundancy

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Tips for success

• Engage
• Make the problem real
• Publicly commit that harm is untenable
• Educate
• Execute
• Culture, complexity and redundancy
• Regular team meetings
• Evaluate
• Measurement and feedback
• Recognition and visibility
• CELEBRATE SUCCESS !

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Engage

• Make the problem real
• Share local infection rates
• Share local compliance with process measures
• Share a story of a patient with SSI
• (????) Have the patient share their story
• Publicly commit that harm is untenable
• Institutional commitment
• Champions within the OR, within the teams, within
  the departments involved

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Tips for success

• Engage
• Make the problem real
• Publicly commit that harm is untenable
• Educate
• Execute
• Culture, complexity and redundancy
• Regular team meetings
• Evaluate
• Measurement and feedback
• Recognition and visibility
• CELEBRATE SUCCESS !

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Educate

• Develop an educational plan to reach ALL members
  of the caregiver team
• Use this power point or use you own local experts
  
• Educate on the evidence based practices AND the
  data collection plan and other steps of the
  process.
• Use posters to educate the teams about the
  evidence-based process measures

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Perioperative SSI Process Measures
Quality Indicator Numerator Denominator
Appropriate antibiotic choice Number of patients who received the appropriate prophylactic antibiotic All patients for whom prophylactic antibiotics are indicated
Appropriate timing of prophylactic antibiotics Number of patients who received the prophylactic antibiotic within 60 minutes prior to incision All patients for whom prophylactic antibiotics are indicated
Appropriate discontinuation of antibiotics Number of patients who received prophylactic antibiotics and had them discontinued in 24 hours All patients who received prophylactic antibiotics
Appropriate hair removal Number of patients who did not have hair removed or who had hair removed with clippers All surgical patients
Perioperative normothermia Number of patients with postoperative temperature 36.0oC Patients undergoing colon surgery (Optional All patients)
Perioperative glycemic control Number of cardiac surgery patients with glucose control at 6AM pod 1 Patients undergoing cardiac surgery
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Perioperative SSI Process Measures Data
collection plan

• How the process measures will be collected on ALL
  patients at the time of the surgical procedure
• The responsibility of all of the team members

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BSI poster
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Tips for success

• Engage
• Make the problem real
• Publicly commit that harm is untenable
• Educate
• Execute
• Culture, complexity and redundancy
• Regular team meetings
• Evaluate
• Measurement and feedback
• Recognition and visibility
• CELEBRATE SUCCESS !

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Execute

• Culture
• Develop a culture of intolerance for infection
• Reduce complexity of the process
• Checklists
• Local antibiotic guidelines posted in ORs
• Redundancy
• Add to briefing/debriefing checklist
• Post reminders in the OR (White board)
• Regular team meetings
• Develop a project plan
• One or two tasks a week
• Identify who owns the steps of the process that
  works in your environment

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Catheter Related Blood Stream Infection Checklist

• Before the procedure, did they
• Wash hands
• Sterilize procedure site
• Drape entire patient in a sterile fashion
• During the procedure, did they
• Use sterile gloves, mask and sterile gown
• Maintain a sterile field
• Did all personnel assisting with procedure follow
  the above precautions
• Empowered nursing to stop the procedure if
  violation occurred

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Tips for success

• Engage
• Make the problem real
• Publicly commit that harm is untenable
• Educate
• Execute
• Culture, complexity and redundancy
• Regular team meetings
• Evaluate
• Measurement and feedback
• Recognition and visibility
• CELEBRATE SUCCESS !

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Sample ReportsSSI Process Measures Over Time
Compared to Cohort
Quality Measure Your Team Other Teams in Collaborative
Composite 84 85
Appropriate Abx Selection 87 95
Appropriate Abx Timing 98 96
Appropriate Hair Removal 96 95
Prevention of Hypothermia 61 57
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Sample ReportsSSI Process Measures Over Time
Compared to Cohort
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Sample ReportsSSI rates Over Time Compared to
Cohort
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Sample ReportsSSI rates Over Time Compared to
Cohort
Your Team Your Team Your Team Your Team
Reporting Period SSI Cases Median SSI rate / 100 cases
Baseline 16 2533 6.32
Jan 05 - March 05 6 744 8.06
April 05 - June 05 2 637 3.14
July 05 - Sept 05 1 744 1.34
Oct 05 - Dec 05 1 546 1.83
All Teams in Cohort All Teams in Cohort All Teams in Cohort All Teams in Cohort
Reporting Period SSI Cases Median SSI rate / 100 cases
Baseline 45 8900 5.06
Jan 05 - March 05 4 650 6.15
April 05 - June 05 8 1250 6.40
July 05 - Sept 05 6 1500 4.00
Oct 05 - Dec 05 3 1100 2.73
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Tips for success

• Engage
• Make the problem real
• Publicly commit that harm is untenable
• Educate
• Execute
• Culture, complexity and redundancy
• Regular team meetings
• Evaluate
• Measurement and feedback
• Recognition and visibility
• CELEBRATE SUCCESS !

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QI Process
Process hospitals Baseline 4th quarter Difference
lt 1hour 44 72 95 15
Selection 44 90 95 3.4
Normothermia 29 57 74 12
NOT Shaving 14 59 95 27
Oxygenation 8 75 94 18
Glucose control 5 46 54 18
Dellinger P et al. Am J Surg 20051909-15
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QI Efforts
Dellinger P et al. Am J Surg 20051909-15
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Will You Commit to Improve Quality?

• If not now, then when?
• If not this, then what?
• If not you, then who?