Transcript Document

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
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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
2
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.
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Who Pays for Surgical Complications?
Hospital
Reimbursement
$
Costs of care
$
Profit
$
Profit margin
%
14266
(uncomplicated)
10978
3288
23.0
21911
(complicated)
21156
755
3.4
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.
CMS
Medicare Surgical Infection
Prevention (SIP) Project Objective
To decrease the morbidity and mortality associated
with postoperative infection in the Medicare
patient population
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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.
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Antibiotic Timing Related to Incision
Where we started in 2001
60
56
40
Incision
Percent
50
30
20.3
20
9.6
10
2.7
1.2
4.3
2.8
1.4
0.9
0.9
Minutes Before or After Incision
Bratzler DW, Houck PM, et al. Arch Surg. 2005;140:174-182.
0
24
>
18
124
0
12
118
0
0
61
-1
2
060
60
-0
12
061
18
012
1
24
018
1
>
24
0
0
Perioperative Prophylactic
Antibiotics
Timing of Administration
4
14/369
Infections (%)
15/441
3
1/41
2
1/47
1/81
2/180
1
5/699
5/1009
0
≤-3
-2
-1
0
1
2
3
4
≥5
Hours From Incision
Classen. NEJM.
1992;328:281.
Infection antibiotic Indicators
National 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
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Surgical Care Improvement Project
Performance 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
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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?
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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!
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SCIP INF – 2: Selection
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
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#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
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#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
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INF - 2: Selection: the questions
•
•
•
•
•
What about allergy?
What about formularies?
Who made up the approved list?
What about ertapenem?
What about bowel preps?
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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
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SCIP INF – 3: Discontinuation of
Prophylaxis
• Numerous clinical trials have compared shortterm 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.
100
SCIP #3: Discontinuation of
Antibiotics
90.7
88
85.8
100
79.5
80
73.3
60
60
50.7
40.7
40
40
26.2
22.6
14.5
20
20
10
9.3
6.3
6.2
2.7
2.2
Hours After Surgery End Time
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.
96
>
-9
6
>8
4
-8
4
>7
2
-7
2
>6
0
-6
0
>4
8
-4
8
>3
6
-3
6
>2
4
>1
2
le
12
or
-2
4
0
ss
0
Cumulative Percent
Percent
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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)
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Antibiotic Prophylaxis
Duration
• 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.
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• 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
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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?
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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.
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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
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Surgical Care Improvement Project
Performance 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
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Glucose Control Lowers the Risk of Wound
Infection in Diabetics After Open Heart
Operations
Zerr et al Portland, OR 1997
7
6
1585 Diabetic Patients
5
Infection
Rate
%
4
3
2
1
0
100 -150 151-200 201-250 251300
Mean DMG Range POD # 1 © 2004 Institute for Healthcare Improvement
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?
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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
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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!
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Influence of Shaving on SSI
•
Group
No Hair
Removal
Depilatory
Shaved
•Number
155
153
246
•Infection rate
0.6%
0.6%
5.6%
Seropian. Am J Surg 1971; 121: 251
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INF – 6: the questions
•
•
•
•
•
What about neurosurgery?
What about “delicate” areas?
Why do the razors keep coming back?
Is the literature too old?
Others?
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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)
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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)
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?
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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
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Surgical Care Improvement Project (SCIP)
• Preventable Complication Modules
– Surgical infection prevention
– Cardiovascular complication prevention
– Venous thromboembolism prevention
– Respiratory complication prevention
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Prevention of Cardiac Events
Introduction
• 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.
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Surgical Care Improvement Project
Performance measure - Process
• SCIP CARD – 2: Perioperative cardiac events
• Perioperative beta blockers in patients who are on
beta blockers prior to admission
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http://www.acc.org/clinical/guidelines/perio/periobetablocker.pdf
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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
43
Meeting, 2005.
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
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Surgical Care Improvement Project
Performance 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
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MEET SCIP
The Surgical Care Improvement Puppy!!
BEAGLES SAVE LIVES
It is not just about CATS
Beta Blockers
Environment controls—temperature
Antibiotics
Glucose control
Lovenox
Embolism prevention
Skin preparation—no razor
What’s Next?
•
•
•
•
MRSA
VTE assessment and tracking
HCAHPS
Outpatient measures 2008
– Timing of antibiotics
– Antibiotic selection
– (pediatric asthma)
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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!
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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.
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Nancy West, RN, MPH, CPHQ
[email protected]
206364-9700 ext 2007
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