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Surgical Infection Prevention In Washington State Where we started and where we’re going…

Surgical Infection Prevention In Washington State Where we started and where we’re going…. Nancy West, RN, MPH, CPHQ Qualis Health With Many Thanks to Dale W. Bratzler, DO, MPH and E. Patchen Dellinger, MD. Why focus on surgical quality?. ~30 million major operations each year in the US

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Surgical Infection Prevention In Washington State Where we started and where we’re going…

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  1. Surgical Infection PreventionIn Washington StateWhere we started and where we’re going… Nancy West, RN, MPH, CPHQ Qualis Health With Many Thanks to Dale W. Bratzler, DO, MPH and E. Patchen Dellinger, MD

  2. Why focus on surgical quality? • ~30 million major operations each year in the US • Despite advances in surgical and anesthesia technique and improvements in perioperative care, variations in outcomes for patients having surgery are well known

  3. Consequences of Surgical Complications • Dimick and colleagues demonstrated increased costs: • infectious complications was $1,398 • cardiovascular complications $7,789 • respiratory complications $52,466 • thromboembolic complications $18,310. • Khuri and colleagues demonstrated that, independent of preoperative patient risk, the occurrence of a 30-day complication reduced median patient survival by 69%. Dimick JB, et al. J Am Coll Surg 2004;199:531-7. Khuri SF, et al. Ann Surg 2005;242:326-41.

  4. Who Pays for Surgical Complications? Complications were always associated with an increase in costs to healthcare payors: complications were associated with an average increase in payment of $7645 (54%) per patient. Dimick JB, et al. Who pays for poor surgical quality? Building a business case for quality improvement. J Am Coll Surg. 2006;202:933-7.

  5. CMS

  6. Medicare Surgical Infection Prevention (SIP) Project Objective To decrease the morbidity and mortality associated with postoperative infection in the Medicare patient population

  7. Selected Surgical Procedures • Cardiac • Coronary Artery Bypass Graft (CABG) • Colon • Hip & Knee Arthroplasty • Abdominal & Vaginal Hysterectomy • Vascular Surgery: • Aneurysm repair • Thromboendarterectomy • Vein Bypass These procedures are being evaluated in the Medicare project because there is no controversy over the use of antibiotics for these operations. This does not imply that antibiotic prophylaxis should not be used for other procedures.

  8. Antibiotic Timing Related to Incision Where we started in 2001 Bratzler DW, Houck PM, et al. Arch Surg. 2005;140:174-182.

  9. 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.

  10. Infection antibiotic IndicatorsNational Surgical Care Improvement Project • SCIP INF – 1: Proportion of patients with antibiotic initiated within 1 hour before surgical incision • SCIP INF – 2: Proportion of patients who receive prophylactic antibiotics consistent with current recommendations • SCIP INF – 3: Proportion of patients whose prophylactic antibiotics were discontinued within 24 hours of surgery end time

  11. Surgical Care Improvement ProjectPerformance measures - Process • Surgical infection prevention • Antibiotics • Administration within one hour before incision • Use of antimicrobial recommended in guideline • Discontinuation within 24 hours of surgery end • Other Process Improvement • Glucose control in cardiac surgery patients • Proper hair removal • Normothermia in colorectal surgery patients

  12. INF – 1: the questions • Antibiotic administered within 60 minutes prior to incision time • “On call” to OR? • Give in pre-op? • What about ED surgical admissions? • Who is responsible? • Where is the time documented?

  13. INF-1: What works! • Anesthesiology takes responsibility for administration of abx; time is included in anesthesia record • Keep abx in pre-op Pyxis • Utilize a visual/physical cue: push the abx when you hit the button to open the OR door! • Utilize a forcing function: have abx hanging and plugged into the port so that it must be given before the anesthesiologist can run the sedation • Use the preop “pause” to check for administration time for abx. • If over 60 mins, redose!

  14. SCIP INF – 2: SelectionAntibiotic 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 • The Johns Hopkins Guide • Society of Thoracic Surgeons

  15. #1 – Currently published guidelines… • ….. favor the use of 1st or 2nd generation cephalosporins for prophylaxis because of numerous published randomized trials that have demonstrated their effectiveness for prophylaxis • Safe and inexpensive

  16. #2 – Be cautious about wanting to use vancomycin for prophylaxis • Vancomycin resistance remains a public health problem • Vancomycin is not a particularly good antibiotic for prophylaxis • Challenges with administration and slower tissue perfusion • May result in higher infection rates

  17. INF - 2: Selection: the questions • What about allergy? • What about formularies? • Who made up the approved list? • What about ertapenem? • What about bowel preps?

  18. INF – 2: What works! • See www.medqic.org for list of approved abx • Abx selection list comes from a group including major specialty societies, IDSA, CDC, etc. • Ertapenem will be allowed for colon cases x 1 dose starting 10/07 • Vancomycin use is still a problem: education for physicians seems to help! • Keep up with what’s new by joining the national SCIP email list

  19. SCIP INF – 3: Discontinuation of Prophylaxis • Numerous clinical trials have compared short-term to long-term antimicrobial prophylaxis • Infection rates are the same regardless of duration of prophylaxis • Prolonged prophylaxis has been associated with higher rates of infections with resistant organisms (when infection occurs). Prolonged prophylaxis only changes the flora – it does not lower infection rates. Prolonged prophylaxis is a patient safety issue.

  20. SCIP #3: Discontinuationof 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.

  21. Duration of Antibiotic Prophylaxis:What is Best for Our Patients? • Antibiotic prophylaxis is one of many methods for reducing the incidence of SSI • There is a lack of evidence that antibiotics given after the end of the operation prevent SSI’s • There is evidence that increased use of antibiotics promotes antibiotic resistance (CDAD)

  22. Antibiotic ProphylaxisDuration • Most studies have confirmed efficacy of 12 hrs. • Many studies have shown efficacy of a single dose. • Whenever compared, the shorter course has been as effective as the longer course.

  23. 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

  24. INF – 3: What works! • We are working on having the first postop dose given in PACU by standardizing the postop orders as much as possible. • Postop orders Q8hrs X3=24 hours?

  25. INF – 3: What works! • Have an automatic stop order for PROPHYLACTIC antibiotics. • Nursing has signage at patients bedside that tells when the last dose must be in. • Send MD's their data along with overall data for their service area. As being competitive by nature no one wants to be lagging behind.

  26. Protocols, protocols, protocols • Design protocols based on surgery type • Initiate protocol as a standard – Nursing and/or pharmacy drives protocol – No reliance on individual physician memory • Include guidance for exceptions – Beta Lactam allergy • Use your own formulary to narrow choices – Makes protocol easier and saves costs

  27. Surgical Care Improvement ProjectPerformance measures - Process • Surgical infection prevention • Antibiotics • Administration within one hour before incision • Use of antimicrobial recommended in guideline • Discontinuation within 24 hours of surgery end • INF – 4: Glucose control in cardiac surgery patients • INF – 6: Proper hair removal • INF – 7: Normothermia in colorectal surgery patients

  28. Glucose Control Lowers the Risk of Wound Infection in Diabetics After Open Heart OperationsZerr et al Portland, OR 1997 7 6 5 4 3 2 1 0 1585 Diabetic Patients Infection Rate % 100 -150151-200201-250 251-300 Mean DMG Range POD # 1

  29. INF – 4: Glucose Control: the questions • What about patients who are not in the ICU? We only run insulin drips in the ICU • What glucose level needs to be maintained? • Why only cardiac surgery patients? • Corollary: we don’t do cardiac surgery but want to pursue glucose control • What is the glucose level that will have the best results for patients? • What about sliding scale insulin?

  30. INF – 4: What works! • Implement Insulin Protocol for tighter glycemic control: BG target goal 80-110 • Baseline measurement of BG Ranges prior to institution of new protocol • Use BG level by fingerstick on DAY OF surgery • Mandatory Staff Education • Weekly Data Collection • Data Reporting/Presentation

  31. INF – 6: Hair removal • Shaving the surgical site with a razor induces small skin lacerations • potential sites for infection • disturbs hair follicles which are often colonized with S. aureus • Risk greatest when done the night before • Patient education • be sure patients know that they should not do you a favor and shave before they come to the hospital!

  32. Influence of Shaving on SSI • No Hair GroupRemoval Depilatory Shaved • Number 155 153 246 • Infection rate 0.6% 0.6% 5.6% Seropian. Am J Surg 1971; 121: 251

  33. INF – 6: the questions • What about neurosurgery? • What about “delicate” areas? • Why do the razors keep coming back? • Is the literature too old? • Others?

  34. INF – 6: What works! • Remove all razors from OR and entire hospital! • Provide packs allowing for “wet” hair removal with clipper • Re-educate, re-check for razors: early and often! • Post data and have a competition • Visual reminders (“Shave Free Zone” poster)

  35. SCIP INF – 7: Temperature Control • 200 colorectal surgery patients • control - routine intraoperative thermal care (mean temp 34.7°C) • treatment - active warming (mean temp on arrival to recovery 36.6°C) • Results • control - 19% SSI (18/96) • treatment - 6% SSI (6/104), P=0.009 Kurz A, et al. N Engl J Med. 1996. Also: Melling AC, et al. Lancet. 2001. (preop warming)

  36. INF – 7: Temp control: the questions • Why only colorectal surgery patients? • What kind of thermometer do you use? • What about OR temp/humidity? • Don’t the Bair huggers get in the way? • When should we warm up the patients? • What about core temperature?

  37. INF – 7: What works! • Bair huggers for all patients preoperatively/intraoperatively • In winter, educate scheduled patients to stay warm on the way in to the hospital • Use of temporal arterial thermometers • Warmed IV fluids • Increasing OR temperatures • Involving technicians in OR temp maintenance • Caps, booties for patients

  38. Surgical Care Improvement Project (SCIP) • Preventable Complication Modules • Surgical infection prevention • Cardiovascular complication prevention • Venous thromboembolism prevention • Respiratory complication prevention

  39. Prevention of Cardiac EventsIntroduction • As many as 7 to 8 million Americans that undergo major noncardiac surgery have multiple cardiac risk factors or established coronary artery disease • More than 1 million cardiac events annually • Myocardial ischemia either clinically occult or overt confers a 9 - fold increase in risk of unstable angina, nonfatal myocardial infarction, and cardiac death Schmidt M, et al. Arch Intern Med. 2002;162:63-69. Mangano DT, et al. N Engl J Med. 1996;335:1713-1720. Selzman CH, et al. Arch Surg. 2001;136:286-290.

  40. Surgical Care Improvement ProjectPerformance measure - Process • SCIP CARD – 2: Perioperative cardiac events • Perioperative beta blockers in patients who are on beta blockers prior to admission

  41. http://www.acc.org/clinical/guidelines/perio/periobetablocker.pdfhttp://www.acc.org/clinical/guidelines/perio/periobetablocker.pdf

  42. Prevention of Venous Thromboembolism • Recent estimates show that • more than 900,000 Americans suffer VTE each year • about 400,000 of these being DVT • About 500,000 being manifest as PE • In about 300,000 cases, PE proves fatal; it is the third most common cause of hospital-related deaths in the United States. Heit JA, Cohen AT, Anderson FA on behalf of the VTE Impact Assessment Group. [Abstract] American Society of Hematology Annual Meeting, 2005.

  43. Risk Factors for VTE • Previous venous thromboembolism • Increased age • Surgery • Trauma - major, local leg • Immobilization - ? bedrest, stroke, paralysis • Malignancy & its Rx (CTX, RTX, hormonal) • Heart or respiratory failure • Estrogen use, pregnancy, postpartum, SERMs • Central venous lines • Thrombophilic abnormalities Most hospitalized patients have at least one additional risk factor for VTE

  44. Surgical Care Improvement ProjectPerformance measures - Process • Prevention of venous thromboembolism • SCIP VTE 1: Proportion who have recommended VTE prophylaxis ordered • SCIP VTE 2: Proportion who receive appropriate form of VTE prophylaxis (based on ACCP Consensus Recommendations) within 24 hours before or after surgery

  45. What’s Next? • MRSA • VTE assessment and tracking • HCAHPS • Outpatient measures 2008 • Timing of antibiotics • Antibiotic selection • (pediatric asthma)

  46. VBP Design Assumptions Would build on infrastructure of the Reporting Hospital Quality Data for Annual Payment Update Program (RHQDAPU) – “pay-for-reporting” program • Would not include additional funding • – 2-5% withhold of base DRG funding for all Medicare patients • VBP payments based on the quality of care provided – not the fact that data were reported. • If you don’t report data, you can’t play!

  47. What’s New on the SCIP Web Site! • Here are some of the latest additions to the SCIP web site at www.medqic.org/scip. Feel free to visit the SCIP site often as we post new tools, interventions and more weekly.

  48. Nancy West, RN, MPH, CPHQ nancyw@qualishealth.org 206364-9700 ext 2007

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