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Dale W. Bratzler, DO, MPH QIOSC Medical Director Oklahoma Foundation for Medical Quality

The Surgical Infection Prevention and Surgical Care Improvement Projects Where we started and where we’re going…. Dale W. Bratzler, DO, MPH QIOSC Medical Director Oklahoma Foundation for Medical Quality. Why focus on surgical quality?. ~30 million major operations each year in the US

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Dale W. Bratzler, DO, MPH QIOSC Medical Director Oklahoma Foundation for Medical Quality

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  1. The Surgical Infection Preventionand Surgical Care Improvement ProjectsWhere we started and where we’re going… Dale W. Bratzler, DO, MPH QIOSC Medical Director Oklahoma Foundation for Medical Quality

  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. Why focus on surgical quality • Patients who experience a postoperative complication have dramatically increased hospital length of stay, hospital costs, and mortality • On average, the length of stay for patients who have a postoperative complication is 3 to 11 days longer

  4. 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. Dimick JB, et al. J Am Coll Surg 2004;199:531-7.

  5. Impact of Complications on Survival Khuri and colleagues demonstrated that, independent of preoperative patient risk, the occurrence of a 30-day complication reduced median patient survival by 69%. Khuri SF, et al. Ann Surg 2005;242:326-41.

  6. 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.

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

  8. Quality IndicatorsNational Surgical Infection Prevention Project • Proportion of patients with antibiotic initiated within 1 hour before surgical incision • Proportion of patients who receive prophylactic antibiotics consistent with current recommendations • Proportion of patients whose prophylactic antibiotics were discontinued within 24 hours of surgery end time

  9. 10 10 10 10 5 5 5 5 0 0 0 0 -2 -2 0 0 2 2 4 4 6 6 Efficacy Of Prophylaxis Is Independent Of The Specific Antibiotic Penicillin, 40,000 U Erythromycin, 0.1 mg/Kg Control Control Staph + Penicillin Staph + Erythromycin Chloramphenicol, 0.1 mg/Kg Tetracycline, 0.1 mg/Kg Lesion Size, mm (24 Hours) Control Control Staph + Chloramphenicol Staph + Tetracycline Age of Lesion at Antibiotic Injection (Hours) Burke JF. Surgery. 1961;50:161.

  10. Clin Infect Dis. 2007; 44:921–7.

  11. Clin Infect Dis. 2007; 44:921–7.

  12. Discontinuation of Prophylaxis • Numerous clinical trials have compared short-term to long-term antimicrobial prophylaxis • Many compared single-dose prophylaxis to multiple dose prophylaxis • Wide variety of operations using a wide variety of antimicrobial agents • 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.

  13. Conclusions: One-dose antibiotic prophylaxis did not lead to an increase in rates of surgical site infection and brought a monthly savings of $1980 considering cephazolin alone. High compliance to 1-dose prophylaxis was achieved through an educational intervention encouraged by the hospital director and administrative measures that reduced access to extra doses. Arch Surg. 2006;141:1109-1113.

  14. “Although it did not reach statistical significance, the timing of the administration of the first dose of an antibiotic after incision seems to be the most important prophylaxis parameter. Multiple postoperative dosing did not contribute to reduction of the incidence of SSI. We strongly recommend that intervention programs on surgical prophylaxis focus on timely administration of the prophylactic antibiotic.” Clin Infect Dis. 2007; 44:921–7.

  15. http://www.aaos.org/about/papers/advistmt/1027.asp Recommendation 3Duration 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.

  16. http://www.sts.org/sections/aboutthesociety/practiceguidelines/antibioticguideline/http://www.sts.org/sections/aboutthesociety/practiceguidelines/antibioticguideline/ Conclusions: The duration of antibiotic prophylaxis should not be dependent on indwelling catheters of any type. There is evidence indicating that antibiotic prophylaxis of 48 hours duration is effective. There is some evidence that single-dose prophylaxis or 24-hour prophylaxis may be as effective as 48-hour prophylaxis, but additional studies are necessary before confirming the effectiveness of prophylaxis lasting less than 48 hours. There is no evidence that prophylaxis administered for longer than 48 hours is more effective than a 48-hour regimen.

  17. Antibiotic 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

  18. Recent Guidelines

  19. Recent Guidelines

  20. Recently Updated Antibiotic Recommendations * For the purposes of national performance measurement a case will pass the antibiotic selection performance measure if vancomycin is used for prophylaxis (in the absence of a documented beta-lactam allergy) if there is physician documentation of the rationale for vancomycin use (effective for July 2006 discharges). Bratzler DW, Hunt DR. The Surgical Infection Prevention and Surgical Care Improvement Projects: national initiatives to improve outcomes for patients having surgery. Clin Infect Dis. 2006;43:322-30.

  21. Recently Updated Antibiotic Recommendations (continued) * Ciprofloxacin, levofloxacin, gatifloxacin, or moxifloxacin (effective for July 2006 discharges). † For the purposes of national performance measurement, a case will pass the antibiotic selection indicator if the patient receives oral prophylaxis alone, parenteral prophylaxis alone, or oral prophylaxis combined with parenteral prophylaxis. Bratzler DW, Hunt DR. The Surgical Infection Prevention and Surgical Care Improvement Projects: national initiatives to improve outcomes for patients having surgery. Clin Infect Dis. 2006;43:322-30.

  22. Antibiotics for Colorectal Surgery • Ertapenem will be added to the acceptable antibiotics for October discharges • Oral antibiotic prophylaxis alone will no longer pass the performance measure

  23. National SurveillanceAntimicrobial Prophylaxis

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

  25. Discontinuation of 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.

  26. Reporting Hospitals (Voluntary)Surgical Infection Prevention Project

  27. Surgical Infection PreventionHospital Voluntary Self-Reporting, Qtr. 1, 2006 Based on medical record abstraction from the charts of patients discharged in the 1st quarter of 2006. Benchmark rates were calculated for all HQA reporting hospitals in the US (N=3247) based on discharges during the 1st quarter of 2006 using the Achievable Benchmarks of CareTM methodology (http://main.uab.edu/show.asp?durki=14527). 243 Texas hospitals voluntarily reporting (Qtr 1, 2006).

  28. Antibiotic practices that have been shown to reduce the risk of SSI. • Administration of the antibiotic dose just before incision • Antibiotic selection for the common organisms to be encountered • Appropriate dose adjustment based on patient weight • Redosing the patient in the operating room for long cases

  29. Surgical Care Improvement ProjectNational Goal • To reduce preventable surgical morbidity and mortality by 25% by 2010

  30. American College of Surgeons American Hospital Association American Society of Anesthesiologists Association of peri-Operative Registered Nurses Agency for Healthcare Research and Quality Centers for Medicare & Medicaid Services Centers for Disease Control and Prevention Department of Veteran’s Affairs Institute for Healthcare Improvement Joint Commission on Accreditation of Healthcare Organizations SCIP Steering Committee

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

  32. 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 • Glucose control in cardiac surgery patients • Proper hair removal • Normothermia in colorectal surgery patients

  33. Furnary et al. Ann Thorac Surg 1999:67:352

  34. Pre-operative shaving • 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!

  35. 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. Cardiovascular Complication Prevention

  37. 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.

  38. Surgical Care Improvement ProjectPerformance measure - Process • Perioperative cardiac events • Perioperative beta blockers in patients who are on beta blockers prior to admission

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

  40. Venous Thromboembolism Prevention

  41. 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.

  42. National Body Position Statements • Leapfrog1: • PE is “the most common preventable cause of hospital • death in the United States” • Agency for Healthcare Research and Quality (AHRQ)2: • Thromboprophylaxis is the number 1 patient safety practice • American Public Health Association (APHA)3: • “The disconnect between evidence and execution as it • relates to DVT prevention amounts to a public health crisis.” • The Leapfrog Group Hospital Quality and Safety Survey. Available at: www.leapfrog.medstat.com/pdf/Final/doc • Shojania KG, et al. Making Healthcare Safer: A Critical Analysis of Patient Safety Practices. AHRQ, 2001. Available at: www.ahrq.gov/clinic/ptsafety/ • White Paper. Deep-vein thrombosis: Advancing awareness to protect patient lives. 2003. Available at: www.alpha.org/ppp/DVT_White_Paper.pdf

  43. Acquired Risk Factors

  44. Thromboprophylaxis Use in Practice 1992-2002 Prophylaxis Patient Group Studies Patients Use (any) Orthopedic surgery 4 20,216 90 % (57-98) General surgery 7 2,473 73 % (38-98) Critical care 14 3,654 69 % (33-100) Gynecology 1 456 66 % Medical patients 5 1,010 23 % (14-62)

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

  46. ACCP Guidelines for VTE Prevention Geerts WH, et al. CHEST. 2004;126:338S-400S.

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