Armstrong Institute for Patient Safety and Quality

1. Building your SSI Prevention Bundle Armstrong Institute for Patient Safety and Quality Presented by: Elizabeth C. Wick, M.D. /Brad Winters, M.D. DRAFT – final pending AHRQ approval

2. Learning Objectives • Develop and implement an SSI reduction goal and prevention bundle that addresses up to three surgical care processes that your team feels needs to be improved to address SSIs • Understand how to use the results of your staff safety assessment to build a bundle • Review how to initiate audits of your processes • Create a performance goal (improvement in outcome) for your team • Learn how to proceed with improvements that do not have a strong evidence base • Locate SUSP resources on the project website DRAFT – final pending AHRQ approval

3. Background • SSI is the most common nosocomial infection in the surgical patient • SSI is the most common complication after colorectal abdominal surgery (3-30%) • SSI is associated with increased mortality, length of stay, and re-admission • An SSI costs between $6,200-$15,000/per patient (superficial-organ space) DRAFT – final pending AHRQ approval

4. SSI Definitions • Superficial -Purulent drainage from wound -Positive wound culture -Pain, redness swelling -Diagnosis by Surgeon • Deep -Purulent drainage from deep aspect of the wound -Dehiscence -Abscess on exam or CT scan • Organ Space -Infection in the surgical cavity (abdomen) DRAFT – final pending AHRQ approval

5. Colorectal Surgery Readmissions/Johns Hopkins Hospital Readmission rate 17.6% (2009-12) DRAFT – final pending AHRQ approval

6. Pathogenesis of SSI Host Bacteria Procedure DRAFT – final pending AHRQ approval

7. No single SSI prevention bundle • Deeper dive into SCIP measures to identify local defects • Emerging evidence • Abx redosing and weight based dosing • Maintenance of normogylcemia • Mechanical bowel preparation with oral abx • Standardization of skin preparation • Capitalize on frontline wisdom • CUSP/Staff Safety Assessment DRAFT – final pending AHRQ approval

8. Deeper Dive Into SCIP Measures to Identify Local Defects DRAFT – final pending AHRQ approval

9. Johns Hopkins Hospital May 2010 SCIP Hospital Compare www.medicare.gov Does SCIP give us enough information? DRAFT – final pending AHRQ approval

10. NSQIP Report 2009 DRAFT – final pending AHRQ approval

11. Identifying Safety Issues and Opportunities for Improvement Wick, et al. 2012.

12. Peri-operative Antibiotic Compliance:Michigan Surgical Quality Collaborative2 DRAFT – final pending AHRQ approval

13. Auditing Your Practice • Evaluate a sample of patients undergoing your procedure of interest for compliance with processes your team identified as potential areas to improve • (i.e: the next 10-20 patients) • Adapt tool from SUSP website or develop new tool • Practical and feasible strategy to evaluate performance and surface defects • Empowers frontline staff DRAFT – final pending AHRQ approval

14. How do we conduct audits? • Retrospective chart review • Concurrent review • Place audit tool on chart • Complete over continuum of care • We recommend auditing 5-10 patients • Larger samples yield better estimates of performance • Your data does not need to be submitted DRAFT – final pending AHRQ approval

15. Gentamicin Interventions- • Increased amount of gentamicin available in room • Added dose calculator in anesthesia record • Educated surgery, anesthesia, and nursing Despite a 95% compliance on SCIP DRAFT – final pending AHRQ approval

16. SUSP Antibiotic Audit Tool DRAFT – final pending AHRQ approval

17. Normothermia Interventions- • Confirmed that temperature probes were accurate (trial comparing foley and esophageal sensors) • Initiated forced air warming in the pre-operative area DRAFT – final pending AHRQ approval

18. SUSP Normothermia Audit Tool DRAFT – final pending AHRQ approval

19. What about interventions with no data to support them? DRAFT – final pending AHRQ approval

20. Separation of “Dirty” and “Clean” Instruments Intervention- • Built separate tray of instruments used for bowel anastomosis • Extra suction and bovie tip and gloves opened and changed after anastomosis • Educational sessions with scrub techs and nurses about instrument separation • Audits and education on the spot DRAFT – final pending AHRQ approval

21. Bringing Emerging Evidence for SSI Prevention to Your Patients DRAFT – final pending AHRQ approval

22. Emerging Evidence for SSI Prevention • Antibiotic Usage -Redosing -Weight based dosing of cephalosporins • Utilization of mechanical bowel preparation with oral antibiotics • Normoglycemia/Prevention of hyperglycemia • Standardization of skin preparation DRAFT – final pending AHRQ approval

23. Available on SUSP website https://armstrongresearch.hopkinsmedicine.org/susp/ssi/resources.aspx DRAFT – final pending AHRQ approval

24. Redosing and Weight Based Dosing Bowel Prep

25. JHU Antibiotic Poster Entire document available on SUSP website https://armstrongresearch.hopkinsmedicine.org/susp/ssi/resources.aspx DRAFT – final pending AHRQ approval

26. Additional Interventions to Improve Antibiotic Efficacy • Weight-based dosing of cephalosporins • Antiobiotic Re-Dosing - Maintain therapeutic antibiotic serum levels during the entire procedure • If using cefoxitin consider changing because of short redosing interval • Audit your practice!! • Develop standard selections for based on procedure for your hospital • Engage surgery, nursing and anesthesia to implement standard protocol • Consider integrating into EMR if available • Audit your results and share success DRAFT – final pending AHRQ approval

27. Hyperglycemia and Infection • Background- -Hyperglycemia is common in hospitalized patients -38% of medical and surgical patients had hyperglycemia (26% diabetic and 12% non-diabetic) -In cardiac surgery, degree of post operative hyperglycemia correlates with SSI, adopted as SCIP measures • Goal- Glucose <180mg/dl in all hospitalized patients DRAFT – final pending AHRQ approval

28. University of Washington/Glucose Control

29. Johns Hopkins Glucose Control DRAFT – final pending AHRQ approval

30. Could you do better with glycemic management? • Audit your current practice • Do you have a policy? Consider gathering a multidisciplinary team (endocrinology, surgery, anesthesiology, nursing (ward and pre-op)) to develop a protocol for your hospital Look at SUSP website for examples from other hospitals https://armstrongresearch.hopkinsmedicine.org/susp/ssi/resources.aspx DRAFT – final pending AHRQ approval

31. Preparation of the Surgical Site • Background- -1012 bacteria reside on the skin -Staphlococcus and streptococcus species among others • Goal of skin preparation- -Reduce bacterial burden on skin prior to incision • Best practice- -Dual agent skin preparation (Chlorhexidine + alcohol +, providone- iodine + alcohol) -Skin prep should include alcohol to increase durability of sterilization -Prep should be applied to specification (duration and amount) -Prep must be dry before incision DRAFT – final pending AHRQ approval

32. Chloraprep better than Betadine Chloraprep and Duraprep better than Betadine DRAFT – final pending AHRQ approval

33. Is Skin Prep an Area You Could Improve? Audit your practices - what is being used for what cases? - who is doing the prep? -how long are they taking for the prep? Develop an educational plan, engaging frontline providers, for standardization -? In-services -? Video education -? Change doctor preference cards Audit again after your interventions…. How well did you do? Share the results! DRAFT – final pending AHRQ approval

34. Summary • No single SSI prevention bundle • Need to identify local defects • Auditing is a practical and feasible strategy to evaluate performance and surface defects • Tools are adaptable to local environment • The CUSP method empowers frontline staff DRAFT – final pending AHRQ approval

35. Resources to find the information that you need for SUSP • Armstrong Institute for Patient Safety and Quality https://armstrongresearch.hopkinsmedicine.org/susp.asp DRAFT – final pending AHRQ approval

36. Action Items • Review staff safety assessment results • Pick 2-3 audit tools based on frontline feedback, SCIP measures and emerging evidence Find tools on our website- https://armstrongresearch.hopkinsmedicine.org/susp/ssi/resources.aspx • Audit 5-10 patients with each tool • Create a performance goal for each intervention for your team • Develop your bundle • Develop system changes to implement interventions • Share your tools and ideas for new tools DRAFT – final pending AHRQ approval

37. References • Merriam-Webster Dictionary. “Auditing.” Merriam-Webster Dictionary web site. http://www.merriam-webster.com/dictionary/auditing. Accessed September 1, 2013. • Hendren S, Englesbe MJ, Brooks L, et al. Prophylactic antibiotic practices for colectomy in Michigan. Am J Surg. 2011;201(3):290-293. • Hospital Compare. Medicare: the official U.S. government site for medicare.  Medicare.gov Website. http://www.medicare.gov/hospitalcompare/profile.html#profTab=2&ID=210009&loc=21287&lat=39.2962372&lng=-76.5928888&name=johns%20hopkins%20hospital. Accessed May 30, 2010 4. Wick EC, Hobson DB, Bennett JL, et al. Implementation of a Surgical Comprehensive Unit-Based Safety Program to Reduce Surgical Site Infections. JACS. 2012; 215(2):193-200. DRAFT – final pending AHRQ approval

38. Content Call Evaluation We want to ensure that the content calls provide useful and pertinent information for the SUSP teams. For this reason we request that you complete a brief evaluation following each call. The evaluation may be found at the following link: https://www.surveymonkey.com/s/SUSP_Cohort4 DRAFT – final pending AHRQ approval