Surgical Site Infection Prevention Collaborative MCIC March 2006

Background: NNIS

• National Nosocomial Infection Surveillance (NNIS) System – CDC program that reports aggregated surveillance data from ~300 US hospitals – Standard case-finding (by ICD-9 code), definitions for infection, and risk-stratification methodology – Pooled mean and standard deviation reported for surgical procedures, including craniotomy, laminectomy, spinal fusion, C-section, and CABG

Background: Methodology

• HEIC surveillance methodology – Monthly denominator data from case-mix data base (all NNIS procedures by ICD-9 code) – Complete chart review of all procedures performed to assess for infection – Risk stratification • Length of procedure (1 point) • ASA score (1 point) • Wound class ( assuming all procedures are clean because CANNOT get wound class) – Generation and distribution of standardized rates quarterly or semi-annually (if denominator < 50/quarter)

Background: Reporting

• HEIC reporting strategies – Rates with NNIS benchmarking – Weekly evaluation of numbers of infections (includes non-NNIS procedures)

Present your local NNIS infection data here

Surgical Site Infections

GOALS • Define and identify risk factors for SSI • Discuss strategies for prevention • Discuss antibiotic prophylaxis principles Pamela A. Lipsett, MD Professor Departments of Surgery,Anesthesiology, Critical Care Medicine, Nursing Johns Hopkins University Schools of Medicine and Nursing

Proportion of Adverse Events Most Frequent Categories

25% 20% Non-surgical Surgical 15% 10% 5% 0% Drug related Wound infect.

Tech.

comp.

Late comp.

Diag.

mishap Therap.

mishap Nontech.

comp.

Proc.

related

Brennan. N Engl J Med. 1991;324:370-376

INTRODUCTION

• 40 million operations annually • 20% experience infection • Surgical site infections (SSI) prolong hospital stay by 6.5 to 7.4 days and comprise 42% of extra charges

SSI:RISK FACTORS INTRINSIC-PATIENT RELATED • Age • Nutritional status • Diabetes • Smoking • Obesity • Remote infections • Endogenous mucosal microorganisms • Altered immune system • Preoperative stay severity of illness

SSI:RISK FACTORS EXTRINSIC OPERATION RELATED • Duration of surgical scrub • Skin antisepsis • Preop shaving • Preop skin prep • Surgical attire • Sterile draping • Surgical technique • Duration of operation • Prophylaxis • Ventilation • Sterilization of equipment • Wound class • Drains

NON-ANTIBIOTIC FACTORS

• Length of pre operative stay • Pre-operative shaving • Length of operation • Use of abdominal drains • Pre-operative showering • Presence of remote infections • Normothermia • Increased oxygenation • Glucose control

Temperature and SSI Following Colectomy

• Mechanical bowel prep • Parenteral antibiotics at induction x 4 d • Standard anesthetic-isoflurane • Randomized after induction T>36.5 º or T>34.5 º • Supplemental O 2 in PACU x 3h • Aggressive fluid resuscitation

Kurz. NEJM 1996;334:1209

Temperature and SSI Following Colectomy

SSI Collagen Time to eat Normo (104) 6 328 5.6d

Hypo(96) 18 254 6.5d

P .009

.04

<.006

Kurz. NEJM 1996;334:1209

Hyperglycemia and Infection Risk Abdominal and Cardiovascular Operations Any Infection “Serious” Infection Glucose POD#1 <220 mg% >220 mg% 12% 31% 5.7-fold increase for any glucose > 220 mg% Pomposelli. JPEN 1998;22:77

Diabetes, Glucose Control, and SSIs After Median Sternotomy

20 15 10 5 0 <200 200-249 250-299 >300 Latham. ICHE 2001; 22: 607-12

Insulin Treatment in SICU Patients

Treatment Group Conventional Intensive Death in ICU 63/783 (8%) 35/765 (5%)

Van den Berghe. NEJM 2001;345:1359

Preoperative Recommendations: Category 1A • If hair is removed, remove immediately before the operation, preferably with electric clippers

Influence of Shaving on SSI

Group Number Infection rate No Hair Removal 155 0.6% Depilatory 153 0.6% Shaved 246 5.6%

Seropian. Am J Surg 1971; 121: 251

2.5

2 1.5

1 0.5

0

Shaving, Clipping and SSI

% Infected Shave Clip Neither Cruse. Arch Surg 1973; 107: 206

Hair Removal Techniques and SSI

% Infection 12 8 4 0 Clean Clean-Contam PM Razor AM Razor PM Clipper AM Clipper Alexander. Arch Surg 1983; 118: 347

GUIDELINES FOR ANTIBIOTIC PROPHYLAXIS

1. The procedure should carry a significant risk of infection and/or cause significant bacterial contamination.

Relative Benefit from Antibiotic Surgical Prophylaxis

Operation Colon Other (mixed) GI Vascular Cardiac Hysterectomy Prophylaxis (%) 4-12 4-6 1-4 3-9 1-16 Craniotomy Total joint Breast & hernia ops 0.5-3 0.5-1 3.5

Placebo (%) 24-48 15-29 7-17 44-49 18-38 4-12 2-9 5.2

NNT* 3-5 4-9 10-17 2-3 3-6 9-29 12-100 58

* Number Needed to Treat

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.

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 site at the time of incision.

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.

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.

Antimicrobial Prophylaxis: Category IB

• Do not routinely use vancomycin for antimicrobial prophylaxis

WHEN (TIMING) OF PROPHYLACTIC AGENTS

• Antibiotic levels of the individual agents must be higher than the MIC at the time of incision • Individual agents must be considered – Cefazolin has a Vd of 10-12 L can can be pushed within minutes of incision – Additional doses dependent on half-life and blood loss

Timing Analysis

100 90 80 70 60 50 40 30 20 10 0 Early Optimal Late Never Burke JP. CID. 2001;33;s78-s82 1985 1988 1992 1993 1994-96

Year

Appropriate Use:LDS

# Operations SSI (%) Inappropriate Prophylaxis (%) 1996 1997 1998 1999 976 1035 963 17 (1.7) 30 (2.9) 12 (1.2) 6 (35) 6 (20) 1 (8) 932 16 (1.7)

Burke JP. CID. 2001;33;s78-s82

0

Antibiotic Timing Related to Incision 60 50 40 30 20 10 0 2.7

1.2

4.3

20.3

56 2.8

1.4

0.9

> 24 0 24 0 18 1 18 0 12 1 12 0 61 60 -0 0 60 61 -1 20 Minutes Before or After Incision 12 1 18 0 18 1 24 0 0.9

> 24 0 9.6

Bratzler DW, Houck PM, et al. Arch Surg 2005:140:174 182

Discontinuation of Antibiotics 100 80 73.3

79.5

85.8

88 90.7

100 80 60 50.7

40.7

40 26.2

22.6

20 14.5

10 6.2

6.3

2.2

0 12 o r le ss >1 2-2 4 >2 4-3 6 >3 6-4 8 >4 8-6 0 >6 0-7 2 >7 2-8 4 >8 4-9 6 Hours After Surgery End Time 2.7

> 96 9.3

60 40 20 0 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 205:140:174-182

SPECIAL CONSIDERATION: MORBID OBESITY

• Cefazolin 1 gram is not the correct dose for everyone – At incision and closure 1g , blood and tissue levels all lower than “normal” weight – Below MIC for gram pos cocci and gram neg rods • Cefazolin 2gm good blood and tissue levels • Wound infection rates from 16.5% to 5.1% Forse et al:surgery 1989:106,751-767

CONCLUSIONS

• Must be familiar with principles of prophylaxis and CDC recommendations • Morbidly obese patients should receive larger doses of antibiotics

CONCLUSIONS: Beyond CDC

• Maintenance of normothermia maybe important (Level II) • Glucose control perioperatively

Improving Safety and Quality: Five Step Model for Improvement

Why do we need to improve care?

In U.S. Healthcare system • 44,000- 98,000 preventable deaths • $50 billion in total costs IOM report “To err is human” Similar results in UK and Australia

Why do we need to improve care?

•

Patients – Do the right thing!

• Purchasers – Leapfrog group • Insurers • Regulators – JCAHO ICU measurement set – CMS surgical care improvement project

Outline

• Review 5 step model for improvement • Provide practical examples • How will we prevent SSI?

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 • Evaluate whether outcomes are improved

Important Clinical Areas

• Eliminating CR-BSIs • Ventilator Associated Pneumonia • Sepsis Bundle • Perioperative Beta Blockers • • VTE Prophylaxis

Decreasing SSI

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 • Evaluate whether outcomes are improved

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 • Evaluate whether outcomes are improved

Outcome vs. Process Measures

• Outcome – mortality – catheter-related BSI – SSI • Process – full barrier precautions – DVT and PUD prophylaxis – Appropriate abx timing Adv/Disadvantages – long cycle – feedback difficult – important to patients Adv/Disadvantages – short cycle – feedback meaningful – no risk-adjustment McGlynn, Jt Comm J Qual Improv 1988

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 • Evaluate whether outcomes are improved

Systems Approach

• Every system is perfectly designed to get the results that it gets Berwick • If you want to change performance you need to change the system

All improvement is local: we can provide concepts; you need to design interventions

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

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 • Evaluate whether outcomes are improved

Eliminating SSI

• Apply best practices – If hair is removed, use clippers – Appropriate antibiotics • Choice • Timing • Discontinuation – Perioperative normothermia – Glycemic control • Decrease complexity • Create redundancy

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 SUCCESS !

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, within the teams, within the departments involved

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 SUCCESS !

Educate

• Develop an educational plan to reach ALL members of the caregiver team – Use this power point or use you own local experts – 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

Perioperative SSI Process Measures

Quality Indicator Numerator Denominator Appropriate antibiotic choice Appropriate timing of prophylactic antibiotics Appropriate discontinuation of antibiotics Appropriate hair removal Perioperative normothermia Number of patients who received the appropriate prophylactic antibiotic Number of patients who received the prophylactic antibiotic within 60 minutes prior to incision Number of patients who received prophylactic antibiotics and had them discontinued in 24 hours Number of patients who did not have hair removed or who had hair removed with clippers Number of patients with postoperative temperature ≥36.0

o C All patients for whom prophylactic antibiotics are indicated All patients for whom prophylactic antibiotics are indicated All patients who received prophylactic antibiotics All surgical patients Patients undergoing colon surgery (Optional: All patients) Perioperative glycemic control Number of cardiac surgery patients with glucose control at 6AM pod 1 Patients undergoing cardiac surgery

Perioperative SSI Process Measures Data collection plan

• How the process measures will be collected on ALL patients at the time of the surgical procedure • The responsibility of all of the team members

BSI poster

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 SUCCESS !

Execute

• Culture • Develop a culture of intolerance for infection • Reduce complexity of the process • Checklists • Local antibiotic guidelines posted in ORs • Redundancy • Add to briefing/debriefing checklist • Post reminders in the OR (White board) • Regular team meetings • Develop a project plan – One or two tasks a week • Identify who owns the steps of the process that works in your environment

Catheter Related Blood Stream Infection Checklist

•

Before the procedure,

did they: – Wash hands – Sterilize procedure site – Drape entire patient in a sterile fashion •

During the procedure,

did they: – Use sterile gloves, mask and sterile gown – Maintain a sterile field • Did all personnel assisting with procedure follow the above precautions • Empowered nursing to stop the procedure if violation occurred

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 SUCCESS !

Sample Reports:

SSI Process Measures Over Time Compared to Cohort Quality Measure Composite Appropriate Abx Selection Appropriate Abx Timing Appropriate Hair Removal Prevention of Hypothermia Your Team 84% 87% 98% 96% 61% Other Teams in Collaborative 85% 95% 96% 95% 57%

Sample Reports:

SSI Process Measures Over Time Compared to Cohort

M CIC Pe riope rativ e Collaborativ e Sample Re port for SSI Proce ss M e asure s Pe rformance Compare d to Cohort

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Composite Your Team Other Teams in Collaborative Appropriate Abx Selection Appropriate Abx Timing

Quality Measure

Appropriate Hair Removal Prevention of Hypothermia

Sample Reports:

SSI rates Over Time Compared to Cohort

MCIC Pe riope ra tive Colla bora tive Qua rte rly SSI Ra te Ove r Time Ba se line to Third Qua rte r 2005

10.00

9.00

8.00

7.00

6.00

5.00

4.00

3.00

2.00

1.00

0.00

Ba se lin e Ja n 0 5 M arc h 0 5 Ap ril 05 - J un e 0 5 Ju ly 05 - S ep t 0 5 Oc t 0 5 D ec 05 Cohort Y our Team

Sample Reports:

SSI rates Over Time Compared to Cohort

Your Team

Reporting Period # SSI Cases Median SSI rate / 100 cases Baseline 16 2533 6.32

Jan 05 - March 05 6 744 8.06

April 05 - June 05 July 05 - Sept 05 Oct 05 - Dec 05 2 1 1 637 744 546 3.14

1.34

1.83

All Teams in Cohort

Reporting Period Baseline Jan 05 - March 05 April 05 - June 05 July 05 - Sept 05 Oct 05 - Dec 05 # SSI 45 4 8 6 3 Cases 8900 650 1250 1500 1100 Median SSI rate / 100 cases 5.06

6.15

6.40

4.00

2.73

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 SUCCESS !

Process < 1hour Selection Normothermia NOT Shaving Oxygenation Glucose control

QI Process

# hospitals Baseline 4 th quarter 44 44 29 14 8 5 72 90 57 59 75 46 95 95 74 95 94 54

Dellinger P et al. Am J Surg 2005;190;9-15

Difference 15 3.4

12 27 18 18

QI Efforts

Dellinger P et al. Am J Surg 2005;190;9-15

Will You Commit to Improve Quality?

• If not now, then when? • If not this, then what?

• If not you, then who?