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SCIP: Preventing Surgical Site Infections

SCIP: Preventing Surgical Site Infections . Gary Kanter, M.D. Betsy Lehman Center December 4, 2007. www.medqic.org/sip. S urgical C are I mprovement P roject . National Quality Partnership CMS,CDC Reduce nationally the incidence of surgical complications by 25% by 2010

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SCIP: Preventing Surgical Site Infections

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  1. SCIP:Preventing Surgical Site Infections Gary Kanter, M.D. Betsy Lehman Center December 4, 2007

  2. www.medqic.org/sip

  3. Surgical Care Improvement Project • National Quality Partnership • CMS,CDC • Reduce nationally the incidence of surgical complications by 25% by 2010 • (13,027 deaths, 271,055 complications)/yr • Focus on • Surgical infection prevention • Adverse cardiac events • Prevention of DVT • Post operative pneumonia • Using evidence based medicine

  4. How often do patients receive “scientifically indicated care” in this country? • Near 100%- we are doing a great job • 75%- not too shabby • 55%- flip a coin • What does science have to do with medicine? McGlynn, et al: The quality of health care delivered to adults in the United States. NEJM 2003; 348: 2635-2645 (June 26, 2003)

  5. How often do patients receive “scientifically indicated care” in this country? • Near 100%- we are doing a great job • 75%- not too shabby • 55%- flip a coin • What does science have to do with medicine? McGlynn, et al: The quality of health care delivered to adults in the United States. NEJM 2003; 348: 2635-2645 (June 26, 2003)

  6. Surgical Infection (SI): Epidemiology & Impact • Account for 14-16 % of all Hospital Acquired Infections (HAI) • 2-5% of operative patients will develop SI • 0.8-2 million infections a year • SI increase LOS • Average 7.5 additional days • Excess costs • $130-$845 million per year • Adds $2,734 - $26,019 per pt (average $3,000) • Pain and suffering

  7. SI: Epidemiology & Impact Patients who develop infection are: • 60% more likely to spend time in an ICU • 5 times as likely to be readmitted • Have a mortality rate twice that of noninfected patients An estimated 40-60% of these infections are preventable

  8. Business Case for SCIP APU increased to 2%

  9. Business Case for SCIP

  10. Baystate Medical Center • 700 bed tertiary care referral center (population of ~1M) • Flagship of Baystate Health • 41 k admissions/year • Annual surgical volume: 29,043 • Western Campus of TUFTS • Member CoTH, 9 residency programs, 244 residents • 1200 member medical staff, 206 faculty MDs • Level 1 Trauma Center • IHI Mentor Hospital Surgical Infection Prevention

  11. Use of antimicrobial prophylaxis for major surgery: baseline results from the National Surgical Infection Prevention Project Arch Surg. 2005 Feb;140(2):174-82.

  12. Quality Improvement Process • Benchmarking, measurement, and feedback • Work with key physician champions • Disseminate recommendations to educate • Use physician order entry • Enlist help of case managers as quality safety net • Use PDSA cycles to test and improve

  13. Prophylactic Antibiotics Antibiotics given for the purpose of preventing infection when infection is not present but the risk of post-operative infection is present

  14. Prophylactic AntibioticsQuestions • Which cases benefit? • When should you start? • Which drug should you use? • How much should you give? • How long should antibiotics be continued?

  15. Recently Updated Antibiotic Recommendations * For the purposes of national performance measurement a case will pass the antibiotic selection performance measure if vancomycin is used for prophylaxis (in the absence of a documented beta-lactam allergy) if there is physician documentation of the rationale for vancomycin use (effective for July 2006 discharges).

  16. Recently Updated Antibiotic Recommendations (continued) * Ciprofloxacin, levofloxacin, gatifloxacin, or moxifloxacin (effective for July 2006 discharges). † For the purposes of national performance measurement, a case will pass the antibiotic selection indicator if the patient receives oral prophylaxis alone, parenteral prophylaxis alone, or oral prophylaxis combined with parenteral prophylaxis.

  17. Prophylactic AntibioticsQuestions • Which cases benefit? • When should you start? • Which drug should you use? • How much should you give? • How long should antibiotics be continued?

  18. Timing of Antibiotic ProphylaxisGI Operations Stone HH et al. Ann Surg. 1976;184:443-452.

  19. 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.

  20. Antibiotic Timing Related to Incision Bratzler DW, Houck PM, et al. Arch Surg. 2005;140:174-182.0

  21. Visual Prompt and data collection

  22. Never Underestimate the Power of Competition BMC AB Timing by Anesthesiologist

  23. Memorandum DIVISION OF HEALT H CARE QUALITY TO: , MD FROM: Associate Medical Director DATE: , 2006 SUBJECT: SCIP (Surgical Care Improvement Program) As part of the SCIP process, the medical record of PATIENT was reviewed. As eviden ced by the attached documentation , it appears that the patient’s prophylactic pre - operative antibiotic w as : _____ given greater than 1 hour prior to th e initial incision time , _____ not re - dosed. _____given after the initial surgical incision. _ X __not g iven at all ( no time of administration was documented) Please remember that current standard of practice is · prophylactic pre - operative an tibiotic administration within 60 minutes p rior to the incision (Levaq uin and Vancomycin are within 120 minutes pri or to the incision ). · Re - dosing of antibiotics if the case extends beyond 3 hours when cefazolins are used Please contact me at 4 4326 if you have any questions. Thank you .

  24. Quality IndicatorsNational Surgical Infection Prevention Project Quality Indicator #2: Proportion of patients who receive prophylactic antibiotics consistent with current recommendations

  25. Antibiotic 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 2003

  26. Antibiotic Selection - Successful Interventions • Distribution of guidelines to perioperative staff (standardize practice) • Antibiotic selection and ordering (standardize process, opt out for selection) • Decision aids in the system (active prompt ) • Use of cephalosporins and vancomycin/gentamicin in penicillin allergic patients • Reviewed and revised AB selections in computer order sets (opt out, forcing function)

  27. Clin Infect Dis. 2004;38:1706-1715.

  28. Expanded pt populations

  29. Quality Indicator #3 Proportion of patients whose prophylactic antibiotics were discontinued within 24 hours of surgery end time

  30. 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. 2005;140:174-182.

  31. Antibiotic Prophylaxis Duration • Most studies have confirmed efficacy of  12 hours • Many studies have shown efficacy of a single dose • Whenever compared, the shorter course has been as effective as the longer course

  32. Papers Comparing Duration of Peri-op Antibiotic Prophylaxis • Colorectal 3 • Mixed GI 4 • Hysterectomy 3 • Gyn & GI 1 • Head & Neck 3 • Orthopedic 4 • Vascular 3 • Cardiac __7__ • Total 28 Papers supporting longer duration 1

  33. 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

  34. Consequences of Prolonged AB Use • Increased antibiotic and drug administration costs • Increased antibiotic-associated complications • Increased patterns of antibiotic resistance • Clostridium difficile Enterocolitis • Colonization with MRSA

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