Surgical Site Infection Prevention The Cardiovascular Surgical Translational Study (

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Surgical Site Infection Prevention The
Cardiovascular Surgical Translational Study
(CSTS)

• Armstrong Institute for Patient Safety and
  Quality
• Elizabeth Martinez, MD, MHS
• martinez.elizabeth_at_mgh.harvard.edu

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Learning Objectives

• To understand the evidence based practices for
  SSI reduction
• To understand the model for translating evidence
  into practice
• To explore how to implement evidence-based
  behaviors to prevent SSI
• To understand strategies to engage, educate,
  execute and evaluate

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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

• Over 300,000 CABG annually
• SSI rates 3.51 (10,500 annually)
• 25 mediastinitis
• 33 saphenous vein site
• 6.8 multiple sites
• Increased mortality17.3 v. 3.0 (plt0.0001)
• Increased LOS 47 v 5.9 with LOSgt14days
  (plt0.0001)
• Increased cost 20,000 to 60,000

Fowler et al.Circ, 2005112(S), 358.
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CABG SSI Risk Model

• Preop
• Age
• Obesity
• Diabetes
• Cardiogenic shock
• Hemodialysis
• Immunosuppression

• Intraop
• Perfusion time
• Placement of IABP
• 3 anastomoses

Did not include known best practices (e.g. SCIP)
Fowler et al.Circ, 2005112(S), 358.
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Traditional SSI Risk FactorsIntrinsic-Patient
Related

• Age
• Nutritional status
• Diabetes
• Smoking
• Obesity
• Remote infections
• Endogenous mucosal microorganisms
• Altered immune system
• Preoperative stay-severity of illness
• Wound class

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Preventive Measures

• Appropriate hair removal
• Appropriate prophylactic antibiotic use
• Selection, timing, redosing, discontinuation
• Perioperative normothermia
• Perioperative normoglycemia

Surgical Care Improvement Metrics Proposed
SCIP measure
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CDC Guidelines for Antibiotic Prophylaxis

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

Mangram. Infect.Control Hosp.Epidemiol.
199920(4)250
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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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CDC 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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WOUND INFECTIONORGANISMS 1990-1996
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CDC 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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Give antibiotics within 60 minutes prior to
incision.
Relative Risk
Classen. NEJM. 1992328281.
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Cardiac surgery prophylaxiseffect of serum levels
Serum Levelat Wound Closure
Infection
None Present
3/11 (27) 2/175 (1)
P .002
Goldmann. J Thorac Cardiovasc Surg.
197773470-479.
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Cefazolin Half-life
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CDC 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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Does prolonged peri-op abx prophylaxis have
consequences?

• Prospective surveillance
• 2641 patients undergoing cardiac surgery
• Exposure outcome
• cephalosporin resistant enterobacteriaceae and
  VRE
• Prolonged antibiotic prophylaxis (gt48 h)
• increase the risk of acquired resistance
• (OR 1.6, CI 1.1-2.6)

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CDC 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 Evidence

• Do not routinely use vancomycin for antimicrobial
  prophylaxis
• IT IS NOT THE BEST AGENT FOR SKIN FLORA!
• If Vancomycin is used
• it is recommended that an aminoglycoside be
  considered for one preoperative and at most one
  additional postoperative dose to act as a
  specific gram-negative agent when vancomycin is
  indicated to be the primary prophylactic agent.1
• This may not be commonly used but should be
  considered if you have a problem with gram
  negative infections.

1Ann Thorac Surg 200783156976
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Hyperglycemia and Infection RiskAbdominal and
Cardiovascular Operations
Glucose POD1 Glucose POD1
lt220 mg gt220 mg
Any Infection 12 31
Serious Infection 5.7-fold increase for any glucose gt 220 mg 5.7-fold increase for any glucose gt 220 mg
Pomposelli. JPEN 19982277
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Portland Diabetes Project Mortality
Furnary AP, et al. J Thorac Cardiovasc Surg.
2003125
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ADDITIONAL CONSIDERATIONS FOR REDUCING SSI
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Chlorhexidine is Beneficial asSurgical Skin Prep
Br J Surg. 2010 Nov97(11)1614-20
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Selective Nasal Decolonization
Bode. N Engl J Med 20103629-17
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Nasal Decolonization

• Selective decolonization
• Rapid PCR
• Patients with S. aureus
• Protocol used Mupirocin PLUS chlorhexidine baths
• The duration of the study treatment was 5 days,
  irrespective of the timing of any interventions.
  Patients who were still hospitalized after 3
  weeks and those still hospitalized after 6 weeks
  received a second and third course of the same
  trial medication, respectively.

Bode. N Engl J Med 20103629-17
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Mupirocin Recommendations

• STS recommendations
• beginning at least the day before operation
  (sooner, if elective operation) and continuing
  for 2 to 5 days after surgery. 1
• CSTS recommendations
• Selective decolonization

1Ann Thorac Surg 200783156976
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Preoperative Chlorhexidine Baths

• Mixed data
• Do demonstrate decrease in skin colony count
• Little data including cardiac surgical patients
• Consider as part of a comprehensive program

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Estimated Overall Benefits1
Process Relative Risk Reduction NNT
Clipping vs. Shaving 70 21
Normothermia 68 8
Appropriate Abx timing 80 42
Glycemic control 63 31
Number Needed to Treat Post op cardiac and Abd
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Summary Recommendations

• First line antibiotic Cefazolin 2 grams to be
  given within 60 minutes prior to incision
• Cefazolin to be redosed within 4 hours
• Consider 2-3 hours
• Perioperative antibiotics to be discontinued
  prior to 48 hours
• Use a clipper to remove hair remove the least
  area as possible
• Maintain glucoses in the 140-180 range and
  prevent hyperglycemia gt200mg/dL
• Chlorhexidine for skin prep
• Selective decolonization

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Learning Objectives

• To understand the evidence based practices for
  SSI reduction
• To understand the model for translating evidence
  into practice
• To explore how to implement evidence-based
  behaviors to prevent SSI
• To understand strategies to engage, educate,
  execute and evaluate

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Translating Evidenceinto Practice
Pronovost, Berenholtz, Needham. BMJ 2008
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Your Hospitals Performance
summarized (estimate) data for all surgical
procedures from all participating Institutions
as of 3/31/2011
www.hospitalcompare.hhs.gov Accessed 3/5/2011
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Ensure Patients ReliablyReceive Evidence
  Senior Team Staff
  leaders leaders Staff
Engage How does this make the world a better place? How does this make the world a better place? How does this make the world a better place?
Educate What do we need to do? What do we need to do? What do we need to do?
Execute What keeps me from doing it? What keeps me from doing it? What keeps me from doing it?
Execute How can we do it with my resources and culture? How can we do it with my resources and culture? How can we do it with my resources and culture?
Evaluate How do we know we improved safety? How do we know we improved safety? How do we know we improved safety?
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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 and the ICU and floor
  teams
• Partnership with Infection Preventionist

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Educate

• Develop an educational plan to reach ALL members
  of the caregiver team
• Educate on the evidence based practices AND the
  data collection plan and other steps of the
  process.
• Use multiple methods to educate
• Posters to educate the teams about the
  evidence-based process measure
• Presentations at staff/faculty meetings, MM

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Six Steps to Prevent SSI
Avoid Razors
1.

• Avoid Hypothermia

2.
gt36 degrees
Give Correct Antibiotics
3.
Give Antibiotics at the Right Time
4.
Within 60 minutes prior to incision
5.
Redose Antibiotics Appropriately
Antibiotics at 24 Hours
6.
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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 surgery without CPB/planned hypothermia
Perioperative glycemic control Number of cardiac surgery patients with glucose control at 6AM pod 1 and 2 Patients undergoing cardiac surgery
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Execute

• Culture
• Develop a culture of intolerance for infection
• Standardize/Reduce complexity of the process
• Checklists -Confirm abx administration during
  briefing
• Utilize a glycemic control protocol
• Local antibiotic guidelines posted in ORs
• Standardize surgical skin prep
• Redundancy
• Add best practices to briefing/debriefing
  checklist
• Post reminders in the OR (White board)
• Antibiotic timer program for redosing
• Regular team meetings
• Develop a project plan
• Identify barriers

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Evaluate

• Track compliance with SCIP measures
• Performance measures already being tracked by
  hospitals as part of SCIP participation
• Post performance on monthly basis
• Post in the OR, ICU and floor
• Investigate non-compliant cases on a monthly
  basis
• Use Learning from Defect (LFD) tool
• Post SSI rates on a monthly/quarterly basis
• Investigate each SSI with the CUSP team to
  identify areas for improvement using the LFD tool
• Audit performance with skin prep methodology (at
  a minimum) and goal is conversion to
  chlorhexidine

based on data availability on Hospital compare
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Share Results
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Acknowledgements

• Deborah Hobson, BSN
• Pamela Lipsett, MD
• Sara Cosgrove, MD
• Lisa Maragakis, MD
• Trish Perl, MD
• Matthew Huddle, BS
• Nicole Errett, BS
• Justin Henneman, BS
• Joyce Wahr, MD
• The Johns Hopkins SSI Prevention Collaborative
  teams

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QUESTIONS?

• Thank you!
• Elizabeth Martinez, MD, MHS
• Massachusetts General Hospital, Harvard Medical
  School
• martinez.elizabeth_at_mgh.harvard.edu