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Surgical Site Infection Prevention The Cardiovascular Surgical Translational Study (“CSTS”)

Surgical Site Infection Prevention The Cardiovascular Surgical Translational Study (“CSTS”). Armstrong Institute for Patient Safety and Quality Elizabeth Martinez, MD, MHS martinez.elizabeth@mgh.harvard.edu. Learning Objectives. To understand the evidence based practices for SSI reduction

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Surgical Site Infection Prevention The Cardiovascular Surgical Translational Study (“CSTS”)

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  1. Surgical Site Infection Prevention The Cardiovascular Surgical Translational Study (“CSTS”) Armstrong Institute for Patient Safety and Quality Elizabeth Martinez, MD, MHS martinez.elizabeth@mgh.harvard.edu

  2. Learning Objectives • To understand the evidence based practices for SSI reduction • 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 Armstrong Institute for Patient Safety and Quality

  3. Proportion of Adverse EventsMost Frequent Categories Non-surgical Surgical Brennan. N Engl J Med. 1991;324:370-376 Armstrong Institute for Patient Safety and Quality

  4. 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. Armstrong Institute for Patient Safety and Quality

  5. 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. Armstrong Institute for Patient Safety and Quality

  6. 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 Armstrong Institute for Patient Safety and Quality

  7. Preventive Measures* • Appropriate hair removal • Appropriate prophylactic antibiotic use • Selection, timing, redosing**, discontinuation • Perioperative normothermia • Perioperative normoglycemia *Surgical Care Improvement Metrics **Proposed SCIP measure Armstrong Institute for Patient Safety and Quality

  8. CDC Guidelines for Antibiotic Prophylaxis 1. The procedure should carry a significant risk of infection and/or cause significant bacterial contamination. Mangram. Infect.ControlHosp.Epidemiol. 1999;20(4):250 Armstrong Institute for Patient Safety and Quality

  9. Relative Benefit from Antibiotic Surgical Prophylaxis * Number Needed to Treat Armstrong Institute for Patient Safety and Quality

  10. CDC Guidelines for Antibiotic Prophylaxis 2. The antibiotic selected must be active against the major contaminating organisms and should have previously been shown to be effective prophylaxis. It is NOT necessary to cover ALL organisms present. Armstrong Institute for Patient Safety and Quality

  11. WOUND INFECTION:ORGANISMS 1990-1996 Armstrong Institute for Patient Safety and Quality

  12. CDC Guidelines for Antibiotic Prophylaxis 3. The antibiotic chosen must achieve concentrations higher than the minimal inhibitory concentration (MIC) of the suspected pathogens in the wound siteat the time of incision. Armstrong Institute for Patient Safety and Quality

  13. Give antibiotics within 60 minutes prior to incision. Relative Risk Classen. NEJM. 1992;328:281. Armstrong Institute for Patient Safety and Quality

  14. Cardiac surgery prophylaxiseffect of serum levels Serum Levelat Wound Closure Infection None Present 3/11 (27%) 2/175 (1%) P = .002 Goldmann. J Thorac Cardiovasc Surg. 1977;73:470-479. Armstrong Institute for Patient Safety and Quality

  15. Cefazolin Half-life Armstrong Institute for Patient Safety and Quality

  16. CDC Guidelines for Antibiotic Prophylaxis 4. The shortest possible course of the most effective least toxic antibiotic must be used for prophylaxis. Must consider distribution and half-life of individual agents. Armstrong Institute for Patient Safety and Quality

  17. Does prolonged peri-op abx prophylaxis have consequences? • Prospective surveillance • 2641 patients undergoing cardiac surgery • Exposure outcome: • cephalosporin resistant enterobacteriaceae and VRE • Prolonged antibiotic prophylaxis (>48 h) • increase the risk of acquired resistance • (OR 1.6, CI 1.1-2.6) Armstrong Institute for Patient Safety and Quality

  18. CDC Guidelines for Antibiotic Prophylaxis 5. The newer broader spectrum agents must be saved for therapy of resistant organisms and should not be used for prophylaxis. Armstrong Institute for Patient Safety and Quality

  19. Antimicrobial Prophylaxis: Category IB Evidence • Do not routinely use vancomycin for antimicrobial prophylaxis • IT IS NOT THE BEST AGENT FOR SKIN FLORA! • If Vancomycin is used • “it is recommended that an aminoglycoside be considered for one preoperative and at most one additional postoperative dose to act as a specific gram-negative agent when vancomycin is indicated to be the primary prophylactic agent.”1 • This may not be commonly used but should be considered if you have a problem with gram negative infections. 1Ann Thorac Surg 2007;83:1569–76 Armstrong Institute for Patient Safety and Quality

  20. Hyperglycemia and Infection Risk:Abdominal and Cardiovascular Operations Pomposelli. JPEN 1998;22:77 Armstrong Institute for Patient Safety and Quality

  21. Portland Diabetes Project: Mortality 10 CII 8 Patients with diabetes 6 Mortality(%) Patients without 4 diabetes 2 0 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 Furnary AP, et al. J Thorac Cardiovasc Surg. 2003;125 Year Armstrong Institute for Patient Safety and Quality

  22. ADDITIONAL CONSIDERATIONS FOR REDUCING SSI Armstrong Institute for Patient Safety and Quality

  23. Chlorhexidine is Beneficial asSurgical Skin Prep Br J Surg. 2010 Nov;97(11):1614-20 Armstrong Institute for Patient Safety and Quality

  24. Selective Nasal Decolonization Bode. N Engl J Med 2010;362:9-17 Armstrong Institute for Patient Safety and Quality

  25. Nasal Decolonization • Selective decolonization • Rapid PCR • Patients with S. aureus • Protocol used Mupirocin PLUS chlorhexidine baths • The duration of the study treatment was 5 days, irrespective of the timing of any interventions. Patients who were still hospitalized after 3 weeks and those still hospitalized after 6 weeks received a second and third course of the same trial medication, respectively. Bode. N Engl J Med 2010;362:9-17 Armstrong Institute for Patient Safety and Quality

  26. Mupirocin Recommendations • STS recommendations • “beginning at least the day before operation (sooner, if elective operation) and continuing for 2 to 5 days after surgery.” 1 • CSTS recommendations • Selective decolonization 1Ann Thorac Surg 2007;83:1569–76 Armstrong Institute for Patient Safety and Quality

  27. Preoperative Chlorhexidine Baths • Mixed data • Do demonstrate decrease in skin colony count • Little data including cardiac surgical patients • Consider as part of a comprehensive program Armstrong Institute for Patient Safety and Quality

  28. Estimated Overall Benefits1 *Number Needed to Treat **Post op cardiac and Abd Armstrong Institute for Patient Safety and Quality

  29. Summary Recommendations • First line antibiotic Cefazolin 2 grams to be given within 60 minutes prior to incision • Cefazolin to be redosed within 4 hours • Consider 2-3 hours • Perioperative antibiotics to be discontinued prior to 48 hours • Use a clipper to remove hair; remove the least area as possible • Maintain glucoses in the 140-180 range and prevent hyperglycemia >200mg/dL • Chlorhexidine for skin prep • Selective decolonization Armstrong Institute for Patient Safety and Quality

  30. Learning Objectives • To understand the evidence based practices for SSI reduction • 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 Armstrong Institute for Patient Safety and Quality

  31. Translating Evidenceinto Practice Pronovost, Berenholtz, Needham. BMJ 2008 Armstrong Institute for Patient Safety and Quality

  32. 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 Armstrong Institute for Patient Safety and Quality

  33. Ensure Patients ReliablyReceive Evidence Armstrong Institute for Patient Safety and Quality

  34. 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 Armstrong Institute for Patient Safety and Quality

  35. 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 multiple methods to educate • Posters to educate the teams about the evidence-based process measure • Presentations at staff/faculty meetings, M&M Armstrong Institute for Patient Safety and Quality

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

  37. Perioperative SSI Process Measures Armstrong Institute for Patient Safety and Quality

  38. Execute • Culture • Develop a culture of intolerance for infection • Standardize/Reduce complexity of the process • Checklists -Confirm abx administration during briefing • Utilize a 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 Armstrong Institute for Patient Safety and Quality

  39. 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 Armstrong Institute for Patient Safety and Quality

  40. Share Results Armstrong Institute for Patient Safety and Quality

  41. Acknowledgements Deborah Hobson, BSN Pamela Lipsett, MD Sara Cosgrove, MD Lisa Maragakis, MD Trish Perl, MD Matthew Huddle, BS Nicole Errett, BS Justin Henneman, BS Joyce Wahr, MD The Johns Hopkins SSI Prevention Collaborative teams Armstrong Institute for Patient Safety and Quality

  42. QUESTIONS? Thank you! Elizabeth Martinez, MD, MHS Massachusetts General Hospital, Harvard Medical School martinez.elizabeth@mgh.harvard.edu

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