The Bundle Approach to Reducing Surgical Site Infections

Virginia Lipke, RN, BS, ACRN, CIC Infection Control Practitioner The St. Luke Hospitals Ft. Thomas and Florence, Ky.

September 9, 2008

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Outline

 Introduction to St. Luke Hospitals  Standardizing Care  Bundles in general are evidence based  Impact of IHI 100,000 Lives Campaign  Surgical Site Infection Risks & Considerations  Surgical Volume  Targeted Infection Control Surveillance  MRSA Bundle as an example  Focus on Value of Bundle and Process

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About St. Luke Hospitals

St. Luke Hospitals, Inc. (SLH) consist of two community facilities:  St. Luke Hospital – East: 310 bed facility located in Ft. Thomas, KY  St. Luke Hospital – West: 177 bed facility located in Florence, KY

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Standardizing Care

 General agreement that standardization of care will improve efficiency of care and result in better outcomes  IHI (Institute of Health Improvement) 100,000 Lives Campaign  Directed standardization of care • • • • • • Rapid Response Teams Medication Reconcilliation Ventilator-Associated Pneumonia Bloodstream Infections AMI SSI  Creation and implementation of bundles or care paths facilitated care for these initiatives

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Methodology for Bundle Development

 Identify need and create clinical and business case  Secure administrative support and medical staff buy-in through communication at various clinical committees  Define the process and protocol for the bundle  Complete implementation of the bundle  Continued monitoring and evaluation

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Leveraging Findings for Organizational change

 Present findings to all committees  Suggest protocol and practice changes  Secure physician champions  Bring in local talent to help  Do your own study and share results  Know the community standard

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Sustaining Impact and Results

 Ongoing monitoring  Quantify results clinically and financially  Communication of results to all stakeholders  Reinforce education  Physicians, clinical staff & patients  Revisit community and national data

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Adoption of Protocols and Bundles at St. Luke Hospitals

 Employing a systematic approach and following a set methodology for protocol and bundle implementations resulted in success and credibility  Pneumococcal Vaccination  IHI 100,000 Lives Campaign Initiatives  Mentor status for 4 of the initiatives  Significant decrease in non-ICU codes  No Ventilator Associated Pneumonia in 34 months  IHI 5 Million Lives Campaign  DVT Protocol implementation December 2008

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Surgical Site Infections (SSIs): Magnitude of the Problem

 1996: 28.4M ambulatory surgery procedures in the U.S.(CDC, National Center for Health Statistics)  2003: 30.8M inpatient surgical procedures and 9.7M  (37%) of those performed on patients >65 years (CDC,National Center for Health Statistics)  NNIS: SSIs occur in 2.6%¹ of all surgeries = 1.5M SSIs annually Attributable cost: $25,5246 (range $1,783 $134,602)² 1.Mangram,AJ,et al.,Guidelines for the Prevention of Surgical Site Infections,1999,CDC. 2.Stone,PW et al.,Am J Infect Control,2005 2.Stone,PW, et al.,Am.J.Infect.Control,2005;33(9):501-9

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SSI Risk Factors for the Patient

 Age  Nutritional Status  Diabetes  Nicotine Use  Obesity  Coexisting Infection  Altered Immune Response  Long Preoperative Stay

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Risk Factors for SSI: Pre-and Intraoperative

  Inappropriate use of antibiotic prophylaxis Infection at remote site  Shaving versus clipping or no hair removal  Improper skin preparation  Improper hand antisepsis by operating room team  Long duration of surgery   Surgical attire and drapes Environment of room, (ventilation & sterilization)  Surgical technique: homeostasis, sterile field, O2

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Surgical Care at St. Luke Hospitals

 Routine monitoring and surveillance  Identification of risk associated with MRSA  Business case for MRSA bundle  Implementation of bundle  Evaluating impact of bundle

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Surgical Volume and Infection Control Monitoring

 Total Surgeries  Over 10,000 cases per year  Targeted Surveillance  C-Sections  Total Hips  Total Knees  Gastric By-pass and Bandings  Fusions  Craniotomies  Overall infection rates are low

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SLH SSI Rate

10 8 6 4 18 16 14 12 2 0 SSI Count SSI Rate St. Luke Hospitals Combined - Surgical Site Infection Count and Rate SSI Count SSI Rate

8 SSIs were MRSA-related Gastric Bypasses started

2004 6 0.97

2005 12 1.22

2006 17 1.56

MRSA Bundle initiated 2 SSIs were MRSA-related

2007 7 0.56

1.80

1.60

1.40

1.20

1.00

0.80

0.60

0.40

0.20

0.00

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Internal & External Data

 Lab reports and testing methods  Past years IC report compared to NNIS  Antibiograms for the past years  Literature searches-beware of old data and be open to new data  What is our current practice?  What new surgical services are we adding?

 What are the risks?

S T. L U K E H O S P I T A L S Why Should Hospitals Place Greater Emphasis on How Skin is Prepped?

 When we consider pathogenesis of SSI, it has been accepted for decades that most SSI are

endogenous

in nature.

 Usual Suspects  S. aureus  Co Ag Negative Staph  E.coli

 K.oxytoca

 S.pneumonaie

 P.aeruginosa

 S.marcescens

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Community & Hospital Impact

St. Luke Hospitals Emergency Department visits where MRSA was noted for skin and soft tissue infections:

2003 173 2004 244 2005 504 2006 660  8 MRSA-related Surgical Site Infections (SSIs) in CY2006 (47% of total SSIs); 0 in previous years  Increased awareness by Emergency, Obstetrics, and Surgery Practitioners

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Projected Cost of MRSA Bundle

Site CY2006 Elective Surgical Volume via PAT Lab Test and CHG Costs Mupirocin Costs (based on 5% MRSA(+) rate) Total Annual Projected Costs St. Luke East 3400 $13.83 ($12.00+$1.83) $6,460 $53,482 St. Luke West 3500 $13.83 ($12.00+$1.83) $6,650 $55,055 St. Luke Hospitals 6900 $13.83 ($12.00+$1.83) $13,110 $108,537

Potential SSI Cost Avoidance (based on CY2006 numbers): 5 SSI cases at $40,000 2 = $200,000

2 Engemann, Clin.Inf.Dis 2003;36:592-598.

Nicholson, AJIC 2006;34:44-48.

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SLH MRSA Bundle

 Nasal cultures on all surgical patients in pre-admission testing (PAT) and hospital-based OB patients at 36-week visit  All pre-admission surgical patients given 2% CHG (chlorhexadine) bathing cloths for use the day of surgery; expecting mothers have 2% CHG cloths applied prior to delivery  If patient is MRSA positive, 2% Mupirocin is applied to both nares prior to surgery  MRSA (+) patients are provided with educational brochure – “Living with MRSA” 1 1 Resource created by Washington State Public Health Department

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Implementing the MRSA Bundle

 Nasal swab training for PAT and hospital-based OB staff  Coordination w/ lab  Coordination w/ pharmacy  Communication plan for result notification  Data tracking and monitoring  Patient education  Staff education  Physician education

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Timeline

November December 2006 CA-MRSA is noted to be impacting SSI rates January 2007 Proposed MRSA Bundle presented to various clinical committees MRSA Bundle standing orders approved by Medical Executive Committee March 2007 November 2007 Surgery Committee proposes single dose of Mupirocin for patients whose lab results are not available prior to surgery October 2006 December 2006 January 2007 February 2007 Review of existing best practices; clinical and financial impact analyses completed Letters are sent to Medical Staff proposing MRSA Bundle protocol All pre-admission testing and hospital-based OB patients are screened for MRSA May 2007 1 MRSA-related SSI in initial nine months of program

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SLH MRSA Bundle Process

St. Luke Hospitals MRSA Bundle Process All Elective Surgical Patients

Pt. Arrives to PAT Pt. is nasal swabbed and given 2% CD waschloth pack per MD standing orders Note: Patients whose MRSA lab results are not completed prior to surgery will receive a single dose of Mupirocin prior to surgery.

Lab analyzes culture Yes Lab notifies MD about positive culture Is pt. positive for MRSA?

No Lab results communicated back to MD; pt. uses washcloth prior to arriving for surgery Yes Lab notifies ICP of positive culture MD prescribes Mupirocin ICP flags pt. for contact isolation in LastWord Pt. uses washcloth prior to arriving for surgery Pt. arrives for surgery

Physicians for Women Expecting Mothers

Pt. Arrives at MD office for 36-week visit Nasal swab is performed Lab analyzes culture Is pt. positive for MRSA?

No Yes Lab notifies MD about positive culture Yes Lab notifies ICP of positive culture Lab results communicated back to MD MD prescribes Mupirocin ICP flags pt. for contact isolation in LastWord Pt. arrives to the hospital for delivery Pt. uses washcloth prior to deliery

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Results and Impact

 Screening of all surgery patients who go through pre-admission testing (~ 65 % of all surgeries)  Screening of all OB patients from St. Luke Physicians for Women Service (~ 60% of all deliveries)  Percentage of surgery patients with positive MRSA culture: 3.9%  March – December  Two Surgical Site Infections • One MRSA SSI (C-Section)

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Results and Impact

St. Luke Hospitals Combined Surgical MRSA Culture Activity Month

Mar-07 Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07

Total MRSA (+) Cultures Total Cultures % MRSA (+)

23 20 24 21 21 22 14 20 16 11

192

537 526 457 476 508 506 434 477 487 404

4812

4.3% 3.8% 5.3% 4.4% 4.1% 4.3% 3.2% 4.2% 3.3% 2.7%

3.9%

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Barriers and Challenges

   Timely communication with physician about positive results  Regular cultures have 2 day turn-around time Patients having pre-admission testing less than 48 hours prior to surgery (culture results not available)  Investigation into current lab collection and transport processes Questions about treatment for colonized MRSA   Some physicians wanting to treat all colonization with vancomycin Patient’s reaction to positive culture results

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Where Do We Go From Here?

 Ongoing analysis of impact  Continue to educate physicians about treating their patients with MRSA  Continued education to patients and community about preventing and living with MRSA  Expand scope of program to include inpatient and emergent surgery cases with possible expansion to all new admissions  Consider utilization of a rapid screen test  Evaluation and consideration of protocol revisions

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Our Goal…

Drive to Zero!!

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Questions

Ginny Lipke (859) 572-3688 [email protected]