Reducing Colon Surgical Site Infections: A Quality Improvement Initiative of Two Hospitals

1. Reducing Colon Surgical Site Infections: A Quality Improvement Initiative of Two Hospitals Angela Gabasan, RN, MSN,CIC Barbara A. Smith, RN, MPA, CIC Eloisa Santos, RN, MA, CIC Emilia Mia Sordillo, MD, PhD Raymond Wedderburn, MD Lester Gottesman, MD Richard Whelan, MD Bruce Polsky, MD St. Luke’s-Roosevelt Hospital Center, NY, NY Financial Disclosure: None

2. 2008 NYS Hospital-Acquired Infection Report (NYS HAIR) published in June 2009 -PHL 2819 mandatory reporting of select HAI -use NHSN for reporting Colon SSI rate exceeded state and national rates Issue: We’re in the RED

3. The Project: Reduce Colon SSI • Multidisciplinary team • surgical team • OR team • infection control team • Review of the Hospital’s Guidelines for Antimicrobial Prophylaxis in Surgery • colon pre-op antibiotic current, no need to change • Retrospective review of cases • 2008 cases n=225 • 2009 1st and 2nd Qtr cases n=98 • Communicate strategy to the stake holders

4. Retrospective Review: Analysis of 2008 and 2009 Cases • No change in practice or deviations in operating room or surgical techniques • Good compliance with post-op temperature and clipping of the surgical site • Betadine skin prep is used in majority of cases and found adequate • No unusual pathogens • Operating Room environment not implicated

5. Retrospective Review: Analysis of 2008 and 2009 Cases Room for Improvement: Pre-op antibiotics • Selection and timing • Weight-based dosing: obese>100Kg/130% IBW • SL site 33% given increased dose • RH site 44% given increased dose • Redosing for procedure >4h duration • SL site 44% redosed • RH site 23% redosed

6. Plan of Action • Re-emphasize adherence to Hospital Guidelines for Antimicrobial Prophylaxis in Surgery • Focus on 4 indicators covered in the Guidelines 1. antibiotic selection 2. timing of antibiotic administration 3. weight-based dosing 4. redosing for procedures >4 hours

7. Plan of Action • Designate a point surgeon at each facility to: • communicate recommendations to the surgical team • assist in SSI case review • White board in each OR suite • reminder to the OR and surgical team • time of procedure • time antibiotic is administered • surgeon orders, anesthesiologist administer

8. Results: Colon procedure SSI rates and Antimicrobial Prophylaxis Guideline Adherence

9. NHSN 5.6

10. Results: Colon procedure SSI rates and Antimicrobial Prophylaxis Guideline Adherence

11. NHSN 5.6

12. Results: Summary • Colon SSI rates decreased as adherence to Antibiotic Prophylaxis Guidelines improved • 2008 to 2010 SSI rate reduction • 48% @ St. Luke’s site • 40% @ Roosevelt site • Combined cost avoidance • >$400,000.00* * APIC Dispelling the Myths: The true cost of Healthcare Associated Infections

13. Lessons Learned • Compliance was gradual, and depended on the cooperation of the surgeons • Increased accountability of the surgical team led to better adherence with all 4 indicators • Designation of a point surgeon at each hospital facilitated cooperation and communication among stakeholders • Our Goal: continue to reduce SSI rates to at or below the State and National level

14. Thank You! Angela Gabasan, RN Nurse Epidemiologist, St. Luke’s-Roosevelt Hospital 1111 Amsterdam Avenue New York, NY 10025 (212) 523-4563 or (212) 523-2106 agabasan@chpnet.org

15. OR White Board

16. GUIDELINES FOR ANTIMICROBIAL PROPHYLAXIS IN SURGERYST. LUKE’S-ROOSEVELT REVISED February 2010