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Surgical Site Infection Prevention
The Cardiac Surgery Translational Study (“CSTS”)
The Quality And Safety Research Group
Elizabeth Martinez, MD, MHS
[email protected]
March 18, 2011 Immersion Calls
Immersion call Schedule
Title
Date /Time
13:00 EST
Presented by
Program Overview
Feb 18, 2011
Peter Pronovost MD PhD
Science Of Safety
February 25, 2011 Jill Marsteller, PhD, MPP
Comprehensive Unit-Based Safety
Program CUSP
Central Line Blood Stream Infection
Elimination
Surgical Site Infection Elimination
Ventilator-Associated Pneumonia
Reduction
Hand-Offs: Transitions in Care
March 4, 2011
Christine Goeschel MPA MPS ScD RN
March 11, 2011
David Thompson DNSC, MS
March 18, 2011
Elizabeth Martinez, MD, MHS
March 25, 2011
Sean Berenholtz, MD
April 1, 2011
Ayse Gurses, PhD
Data we Can Count on
Team Building
April 8, 2011
Lisa Lubomski, PhD.
April 15, 2011
Jill Marsteller, PhD, MPP
Physician Engagement
April 22, 2011
Peter Pronovost, MD, PhD
Slide 2
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
Slide 3
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
Slide 4
Proportion of Adverse Events
Most Frequent Categories
Non-surgical
Surgical
Brennan. N Engl J Med. 1991;324:370-376
Slide 5
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.
Slide 6
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
Slide 7
CABG SSI Risk Model*
Preop
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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.
Traditional SSI Risk Factors
Intrinsic-Patient Related
•
•
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•
•
•
•
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Age
Nutritional status
Diabetes
Smoking
Obesity
Remote infections
Endogenous mucosal microorganisms
Altered immune system
Preoperative stay-severity of illness
Wound class
Slide 9
Translating Evidence
into Practice
Pronovost, Berenholtz, Needham. BMJ 2008
Slide 10
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)
Slide 11
*SCIP measures
Your Hospitals’ Performance*
100
99
Performance (%)
98
97
96
95
94
93
92
91
90
Antibiotic at Right
right time
kind
Antibiotic
of antibiotic
stoppedGlucose
at right time
Controlled
Proper hair removal
*summarized (estimate) data for all surgical procedures
from all participating Institutions as of 3/31/2011
www.hospitalcompare.hhs.gov;
Accessed 3/5/2011
Slide 12
Ensure Patients Reliably
Receive Evidence
Senior
leaders
Team
leaders
Staff
Engage
How does this make the world a better place?
Educate
What do we need to do?
Execute
What keeps me from doing it?
How can we do it with my resources and
culture?
Evaluate
How do we know we improved safety?
Slide 13
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
Slide 14
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.
Slide 15
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
Slide 16
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
Slide 17
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
Slide 18
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
Slide 19
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
Slide 20
Avoid Razors
Avoid Hypothermia
Give Correct Antibiotics
Give Antibiotics at the Right Time
*Within 60 minutes prior to incision
Redose Antibiotics Appropriately
Antibiotics at 24 Hours
Perioperative SSI Process Measures
Quality Indicator
Numerator
Denominator
Appropriate antibiotic choice
Number of patients who received
the appropriate prophylactic
antibiotic
All patients for whom prophylactic
antibiotics are indicated
Appropriate timing of prophylactic
antibiotics
Number of patients who received
the prophylactic antibiotic within
60 minutes prior to incision
All patients for whom prophylactic
antibiotics are indicated
Appropriate discontinuation of
antibiotics
Number of patients who received
prophylactic antibiotics and had
them discontinued in 24 hours
All patients who received
prophylactic antibiotics
Appropriate hair removal
Number of patients who did not
have hair removed or who had hair
removed with clippers
All surgical patients
Perioperative normothermia
Number of patients with
postoperative temperature ≥36.0oC
Patients undergoing surgery
without CPB/planned hypothermia
Perioperative glycemic control
Number of cardiac surgery patients
with glucose control at 6AM pod 1
and 2
Patients undergoing cardiac surgery
Slide 22
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
Slide 23
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
Slide 24
Share Results
Slide 25
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
Slide 26
QUESTIONS?
Thank You!
Elizabeth Martinez, MD, MHS
Massachusetts General Hospital, Harvard University
[email protected]