Transcript Document

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The Surgical Infection Prevention
and Surgical Care Improvement Projects
National Initiatives to Improve Surgical Care
Dale W. Bratzler, DO, MPH
QIOSC Medical Director
Why focus on surgical quality?
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~30 million major operations each
year in the US
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Despite advances in surgical and
anesthesia technique and
improvements in perioperative care,
variations in outcomes for patients
having surgery are well known
Why focus on surgical quality?
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Among the most common
complications
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surgical site infections (SSIs) and
postoperative sepsis
• cardiovascular complications including
myocardial infarction
• respiratory complications including
postoperative pneumonia and failure to
wean
• thromboembolic complications
Cost of Complications
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Attributable costs
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Infectious complications - $1398
• Cardiovascular complications - $7789
• Respiratory complications - $52466
• Thromboembolic complications - $18310
Dimick JB, et al. Hospital costs associated with surgical complications: a report from the privatesector National Surgical Quality Improvement Program. J Am Coll Surg. 2004;199:531-7.
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Surgical Care Improvement Project
National Goal
To reduce preventable
surgical morbidity and
mortality by 25% by 2010
SCIP Steering Committee
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American College of
Surgeons
• American Hospital
Association
• American Society of
Anesthesiologists
• Association of periOperative Registered
Nurses
• Agency for Healthcare
Research and Quality
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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
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Performance Measure
Review
Surgical Site Infections (SSI)
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2-5% of operated patients will develop SSI
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40 million operations annually in the U.S.
• 0.8 - 2 million SSI’s occur annually in the U.S.
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SSI increases LOS in hospital
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average 7.5 days
Excess cost per SSI:
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*$2,734-26,019 (1985, US$)
• US national costs: $130-845 million/year
*Jarvis, Infect Control HospEpidemiol. 1996;17.
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Quality Indicators
National Surgical Infection Prevention Project
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Proportion of patients who have their antibiotic
dose initiated within 1 hour before surgical
incision (2 hours for vancomycin or fluoroquinolones)
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Proportion of patients who receive
prophylactic antibiotics consistent with
current recommendations (published
guidelines)
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Proportion of patients whose prophylactic
antibiotics were discontinued within 24 hours
of surgery end time (48 hours for cardiac surgery)
Revision to SCIP Inf 2
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We will allow for the use of vancomycin
for prophylaxis for cardiac, vascular,
and orthopedic surgery, if…
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There is a physician-documented reason in the
medical record
Beta-lactam allergy
We may do some hospital-specific
audits of vancomycin use in outlier
institutions
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Recently Updated Antibiotic
Recommendations
Surgery Type
Hip or knee
arthroplasty
Antimicrobial recommendations
Preferred: Cefazolin or cefuroxime
If patient high risk for MRSA: Vancomycin*
Beta-lactam allergy:
• Vancomycin or clindamycin
Cardiac or
vascular
Preferred: Cefazolin or cefuroxime
If patient high risk for MRSA: Vancomycin*
Beta-lactam allergy:
• Vancomycin or clindamycin
* 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. Clin Infect Dis. 2006 (in press).
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Recently Updated Antibiotic
Recommendations (continued)
Surgery Type
Hysterectomy
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Antimicrobial recommendations
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Cefotetan, cefazolin, cefoxitin, cefuroxime, or ampicillin-sulbactam
Beta-lactam allergy:
• Clindamycin + gentamicin or fluoroquinolone* or aztreonam
• Metronidazole + gentamicin or fluoroquinolone*
• Clindamycin monotherapy
Colorectal †
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Neomycin + erythromycin base; neomycin + metronidazole
• Cefotetan, cefoxitin, cefazolin + metronidazole, or ampicillin-sulbactam
Beta-lactam allergy:
• Clindamycin + gentamicin or fluoroquinolone* or aztreonam
• Metronidazole + gentamicin or fluoroquinolone*
* 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. Clin Infect Dis. 2006 (in press).
Other Points about the Antibiotic
Measures
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SCIP Inf 2 – May see public reporting on
Hospital Compare of July 2006
discharges
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SCIP Inf 3 – Any antibiotics given in the
first 48 hours after surgery (72 hours for
cardiac surgery) are considered
“prophylactic” in the absence of a
documented infection
Surgical Care Improvement Project
New Performance measures - Process
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Surgical infection prevention
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Glucose control in cardiac surgery
patients (< 200 mg/dL)
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Proper hair removal
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Blood glucose closest to 0600 on PO day 1
and 2 (surgery end date is PO day 0)
No hair removal, clippers, or depilatory
Normothermia in colorectal surgery
patients
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Temperature between 96.8-100.4° F within the
first hour after leaving the OR
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Cardiovascular Complication Prevention
Prevention of Cardiac Events
Introduction
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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
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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
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Perioperative cardiac events
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Perioperative beta blockers in patients
who are on beta blockers prior to
admission
“perioperative” is defined as 24 hours
prior to incision through discharge from
the post-anesthesia care/recovery area
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Venous Thromboembolism Prevention
Prevention of Venous Thromboembolism
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Introduction
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VTE Remains a major health problem
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200,000 new cases annually in US
In addition to the risk of sudden death
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30% of survivors develop recurrent VTE within 10 years
28% of survivors develop venous stasis syndrome within 20
years
The incidence of VTE is more than 100 times greater for
patients who have been hospitalized than among
community dwelling
Incidence increases with age
Goldhaber SZ. N Engl J Med. 1998;339:93-104.
Silverstein MD, et al. Arch Intern Med. 1998;158:585-593.
Heit JA, et al. Thromb Haemost. 2001;86:452-463.
Heit JA. Clin Geriatr Med. 2001;17:71-92.
Heit JA, et al. Mayo Clin Proc. 2001;76:1102-1110.
Surgical Care Improvement Project
Performance measures - Process
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Prevention of venous
thromboembolism
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Surgery patients with recommended
VTE prophylaxis ordered
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Surgery Patients Who Received
Appropriate Venous Thromboembolism
Prophylaxis Within 24 Hours Prior to
Surgery to 24 Hours After Surgery
Based on the 2004 ACCP Consensus Recommendations
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www.medqic.org/scip