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The Cardiac Surgery Translational Study (“CSTS”) The Quality And Safety Research Group

The Cardiac Surgery Translational Study (“CSTS”) The Quality And Safety Research Group. Surgical Site Infection Prevention. Elizabeth Martinez, MD, MHS emartinez10@partners.org March 18, 2011 Immersion Calls. Immersion call Schedule. CSTS Timeline. Planned Roll-out

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The Cardiac Surgery Translational Study (“CSTS”) The Quality And Safety Research Group

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  1. The Cardiac Surgery Translational Study (“CSTS”) The Quality And Safety Research Group Surgical Site Infection Prevention Elizabeth Martinez, MD, MHS emartinez10@partners.org March 18, 2011 Immersion Calls

  2. Immersion call Schedule

  3. CSTS Timeline • Planned Roll-out • CLABSI Prevention interventions and monthly data collection: June, 2011 • SSI Prevention interventions and monthly data collection: Approximately September 2011 • VAP Prevention and monthly data collection: After December 2011

  4. Learning Objectives • 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

  5. Proportion of Adverse EventsMost Frequent Categories Non-surgical Surgical Brennan. N Engl J Med. 1991;324:370-376

  6. Introduction Over 300,000 CABG annually SSI rates 3.51% (10,500 annually) 25% mediastinitis 33% saphenous vein site 6.8% multiple sites Increased mortality:17.3% v. 3.0% (p<0.0001) Increased LOS: 47% v 5.9% with LOS>14days (p<0.0001) Increased cost: $20,000 to $60,000 Fowler et al..Circ, 2005:112(S), 358.

  7. Background: An Example of Surveillance Methodology National Healthcare Safety Network (NHSN) Formerly NNIS National Healthcare Safety Network surveillance CDC program that reports aggregated surveillance data from ~thousands of US hospitals hospitals/mandated for certain infections in order to receive full Medicare payment Standard case-finding (by ICD-9 code), definitions for infection, and risk-stratification methodology Pooled mean and standard deviation reported for surgical procedures SSIs can develop up to 1-year postop ‘hardware’ = sternal wires

  8. 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, 2005:112(S), 358.

  9. 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

  10. Translating Evidenceinto Practice Pronovost, Berenholtz, Needham. BMJ 2008

  11. Evidence Based Practices that Reduce risk of SSIs* • Appropriate prophylactic antibiotics • Selection • Timing (and redosing) • Discontinuation • Appropriate hair removal as close to time of surgery as possible: • Don’t remove hair unless necessary; If you remove hair -Don’t shave. Can use clipper/depilatory (AVOID razors) • Normothermia in non CPB cases • Appropriate glycemic control ************************************************************* • Chlorhexidine surgical skin prep (used appropriately) *SCIP measures

  12. 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

  13. Ensure Patients ReliablyReceive Evidence

  14. TRiP: 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/standardize • Evaluate whether outcomes are improved

  15. Systems Approach • Every system is perfectly designed to get the results that it gets. - Bataldan • If you want to change performance you need to change the system.

  16. 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

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

  18. 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 your successes

  19. 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

  20. 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 posters to educate the teams about the evidence-based process measures

  21. Six Steps to Prevent SSI 1. Avoid Razors 2. >36 degrees 3. Give Correct Antibiotics Avoid Hypothermia 4. Give Antibiotics at the Right Time *Within 60 minutes prior to incision 5. Redose Antibiotics Appropriately 6. Antibiotics at 24 Hours

  22. Perioperative SSI Process Measures

  23. Execute • Culture • Develop a culture of intolerance for infection • Standardize/Reduce complexity of the process • Checklists -Confirm abx administration during briefing • Utilize 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

  24. 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

  25. Share Results

  26. Acknowledgements Deborah Hobson, BSN Pamela Lipsett, MD Sara Cosgrove, MD Lisa Maragakis, MD Trish Perl, MS Matthew Huddle, BS Nicole Errett, BS Justin Henneman, BS The Johns Hopkins SSI Prevention Collaborative teams

  27. QUESTIONS? Thank You! Elizabeth Martinez, MD, MHS Massachusetts General Hospital, Harvard University emartinez10@partners.org

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