The Joint Commission Center for Transforming Healthcare (CTH) Surgical Site Infections in Colorectal Surgeries Project

1. The Joint Commission Center for Transforming Healthcare (CTH) Surgical Site Infections in Colorectal Surgeries Project: 2012 Sasha Madison, MPH, CIC Director Infection Prevention & Control Dept. May 14, 2014

2. Collaborate with American College of Surgeons & NSQIP measurement system leveraged. • Seven participating hospitals: • Mayo Clinic, MN • Cleveland Clinic, OH • Stanford Hospital & Clinics, CA • OSF Saint Francis, IL • Northwestern Memorial Hospital, IL • North Shore LIJ, NY • Cedars-Sinai Medical Center, CA Project #4: Surgical Site Infection

3. Systematic Approach to Problem Solving – Surgical Site Infections (1) • The Center worked with the American College of Surgeons to determine the scope of the SSI project, since there is a wide range of surgeries and procedures that can develop SSIs – each with its own unique set of complications and challenges. • To help narrow the scope of the project, the following criteria were used to identify a specific procedure that: • Is common across different types of hospitals • Has significant complications with an adverse clinical impact • Hospitals have significant opportunities to improve performance • Has high variability in performance across hospitals

4. Collaborative Project Definition DMAIC Problem Statement: • The incidence of Surgical Site Infections in colorectal surgery is high, variable, and represents opportunity for improvement. Goal: • Reduce colorectal surgical site infections by 50% (Observed and Observed/Expected) Scope: • Process Begins: Pre-Operative Processes (Pre-Op Clinic with Surgeon) • Process Ends: 30 Days Post-Surgery • Includes:All emergent & elective surgical procedures • Excludes: Trauma and Transplant patients & Patients under 18 years of age Timeline: August 2010 – March 2012

5. 2009 Metrics:Observed & O/E Baseline Performance DMAIC Metric 1- Observed Colorectal SSIs Baseline: 18.5% Target: 9.3% (50% reduction) Metric 2- O/E* Ratio for Colorectal SSIs Baseline: 1.49 Target: 0.74 (50% reduction) Average SSI Cases / Month = 3 Note: Observed/Expected / Index Value Expected Value is Dependent on “Expected” influence/calculation

6. DMAIC SHC SSI Project Phases & Elements Note: Above variables found to be statistically significant, however not entirely modifiable. - No Interventions Made

7. Project Interventions & Monitoring DMAIC

8. DMAIC NHSN Publicly Reported Cases- MIDAS Focus Study • MIDAS Focus Objectives: • Detailed abstraction of elements with identified areas of opportunity • Data will be analyzed for any potential trends and to serve as a guide for further interventions • Surgeon specific SSI rates • Surgical Quality Council Dashboard will include SSI outcomes

9. Antibiotic Stewardship Program DMAIC • Dosing of Ertapenem for patients with BMI greater than 30 • Assessment of empiric therapy recommendations for contaminated and dirty cases • Measuring timing of prophylactic antibiotics prior to incision: • 0-15 minutes • 16-30 “ ” • 31-45 “ ” • 46-60 “ ”

10. DMAIC

11. Improvement ‘Bundle’ • Interventions across the episode of care • Multi-disciplinary • Engage staff, patient, and families • Standardize as many processes as possible • Ensure high compliance with elements • Quick audits • Build the elements into the system • Frequent feedback and communication

12. Pre-operative Interventions • Pre-operative Chlorhexidine packets • Provided to all patients preoperatively with instructions • Use monitored morning of admission • If not reported as not being used, SAGE wipes used on the entire body • Patients with BMI > 30 (Mayo) • SAGE wipes applied even if preoperative bath performed • Procedure listing software automatically identifies patients with BMI > 30 • Pre-op antibiotic ordering (Mayo) • Procedure scheduling software automatically provides SCIP appropriate choices • Weight-based dosing • Software automatically orders intra-operative re-dosing dose if historical data for the specific procedure and surgeon demonstrated an average case duration >3 hours

13. Pre-Operative Interventions (cont’d) • Hair removal by electric clipper • Outside of the operating room • Standardized to Chlorhexidine-Alcohol (Chloraprep™) skin preparation for all abdominal cases • Surgical assistant applies skin preparation • All in-serviced on appropriate application • Must dry for 3 minutes before drapes applied

14. Intra-Operative Interventions • Pre-procedural pause includes confirming appropriate antibiotics administered and documented • Re-dosing of cefazolin for cases longer than 3 hours. (Mayo) • Circulating nurse has the preop order and pulls medication at the beginning of the case • Reminder window on anesthesia provider’s computer screen Triggered off time of first dose administration • Appropriate weight-based dosing

15. Intra-Operative Interventions (cont’d) • “Closing” Process • At the time of fascia closure • All staff change gloves • Gowns if soiled • Field re-blocked with sterile towels • Instruments used during case removed and “closing tray” brought onto the field

16. Post-Operative Interventions • All order-sets discontinue SCIP compliant antibiotics after two postop doses or single dose when appropriate (Mayo) • Pharmacist part of team and queries service • Hand hygiene essential on floor • Physician/Nursing initiative • Patient and Family initiative • Sterile dressing on until morning of POD 2 • Document removal • Chlorhexidine shower/wipes daily after dressing removal (Mayo) • Standard postop order-sets orders urinary catheter removal at 8am the morning after surgery (Mayo) • Dismiss with chlorhexidine soap bottle for use at home (Mayo)

17. Important Lessons: • Multidisciplinary approach is essential • Physicians, nursing (pre, intrao-p, floor), pharmacy, CST, SA, administration, supply chain, quality, S&P, IT, Patient Education, Infection Control, WOCN, NSQIP team • Address the entire surgical episode of care • Pre, intra, and postoperative elements may influence SSI rates • Interventions designed for each phase • Introduce elements of change and audit compliance • Build ‘clues’ into the process to ensure better compliance: convenient hand hygiene supplies (Purell wipes, Hibiclens bottles), signage, Hibiclens packets, etc. • Build process improvements into the system to ensure task completion • No evidence for which of element(s) makes a difference in the “bundle”: the outcome is all that matters

18. Challenges Encountered DMAIC Learnings: • Reduction of our SSI rates continue to be challenging. Questions 2012: • Could we learn more by studying the elements of the National Healthcare Safety Network(NHSN) colorectal SSI cases? • Could we focus our efforts on the ‘bulk’ of our infections; Organ Space (asked in 2012) • Focused our efforts on organ space infections beginning after this collaborative – later part of 2102 • Decrease seen in 2013 (decrease seen in colo-rectal SIR) • Found part of the issue was appropriate classification of cases: major educational focus later part 2012/2013 Experienced & Foreseeable Challenges: • Strategies for preventing infections are different based on culture, environment, surgeon practice, patient pre-existing conditions • Lag time in collection and receipt of data to assess improvements • Nursing time for documentation of audits takes away from patient care • Insufficient and incomplete audits • Resources needed for this improvement project Best Practice: • Standardization of approach was sequential and we may not see full term change yet (glove changing, closing trays, etc. occurred in sequence not parallel) • Best practices identified elsewhere may not have same level of impact in our organization

19. Next Steps & Opportunities DMAIC • Based on best practice learnings through collaborative, continue glove changes & separate/clean closing instruments • MIDAS Focus Study on Publicly Reported Cases • Infection Control SSI surveillance in July/Aug 2011 identified an opportunity in colorectal surgery • Data collection focused on elements which are not captured elsewhere • Need for individual physician communication of infections identified • Opportunity for Physician review of case with abstracted data elements • Antibiotic Stewardship • Instituted February 2012 • Review of current prophylaxis guidelines and empiric therapy • SSIDeep/Organ Space and Sepsis commonalities • Drill down on each Organ/Space and Deep SSI • Leaks (i.e. CT scans, physician documentation, abscessogram results) • Antibiotic prophylaxis dosing for patients with BMI greater than 30 • Empiric therapy and treatment protocols • Pursue Pre-Operative Warming Improvements • Preoperative strategies for surgery admission unit • Potential partnership with vendors to pilot new interventions