Transcript Slide 1
Surgical Infection Prevention
Team Members:
Anesthesia: W. Scott Jellish - chair, Maureen Kawka, Joe Rinehart
Infectious Disease: Paul O’Keefe, Chris Schriever
Surgical Services: Jeri Katsaros, Margaret Vorrier
Labor & Delivery: Maureen Davey
Quality Resource Management: Mary Altier, Carmen Barc, Vada Grant
Infection Control: Jayne Haake
CCE: William Barron, LuAnn Vis, Michael Wall
Opportunity Statement
Surgical site infections are a major complication after surgery,
resulting in considerable morbidity, mortality, and
resource utilization. Proper use of antibiotics – giving
the right drug at the right time – is effective in preventing
infections after surgery
Project Goals: To achieve 100% compliance for the
following measures:
1.
2.
3.
Administer antibiotics within one hour before surgical incision
Administer the appropriate antibiotic
Stop antibiotics within 24 hours after surgery
Targeted Surgeries
Abdominal and Vaginal Hysterectomy
Hip and Knee Replacement
Cardiac Bypass
Other Cardiac Surgery
Vascular Surgery
Colon Surgery
Solutions Implemented in 2005
Data collection processes completely overhauled
Restructured data collection to CMS/JCAHO specifications
Monthly chart audits (50-70/month) by RN Quality Specialists
Forwarded data to UHC for “practice” and benchmarking
Began abstracting additional SIP measures – glucose control, hair
removal, normothermia
Communication with key stakeholders
Overall results available on luhs.org
Department specific results available on internal website
Barriers Addressed
Adjusted post-operative orders for antibiotic
discontinuation
Focused efforts with Orthopaedic NP to improve
SIP-3
Shared patient/MD level data
Forwarded endorsement from American Academy of Orthopaedic
Surgeons
Engaged colon surgery physician leader
OR management team focused on appropriate hair
removal
Improved access to clippers
Removed razors from OR – only available through case carts
LUMC patients who receive prophylactic antibiotics within
60 minutes prior to surgical incision
105
UCL = 103.95
100
Percent
95
LUHS Mean = 93.0%
90
85
LCL = 81.98
UHC Rate: 77%
80
Month
* Preliminary data for quality improvement purposes only
LUMC patients who receive prophylactic antibiotics
consistent with current CMS guidelines
100
UCL = 99.02
95
UHC Rate: 89%
90
Percent
85
LUHS Mean = 82.5%
80
75
70
LCL = 66.05
65
Month
* Preliminary data for quality improvement purposes only
LUMC patients who have prophylactic antibiotics
discontinued within 24 hours after surgery end
90
UCL = 89.94
Percent
80
70
LUHS Mean = 69.8
UHC Rate: 61%
60
Orthopedic NP involvement and order changes
50
LCL = 49.70
Month
* Preliminary data for quality improvement purposes only
Next Steps: Where do we go from here?
SIP-1:
Individual feedback (letters) concerning protocol noncompliance to
Anesthesiologists, Residents, & CRNA’s
Incorporate prompt for antibiotic administration during the timeout
Signage prompts at OR doors and Pharmacy
SIP-2:
Awaiting response for Vancomycin use in CV valve cases
SIP-3:
Collect CV data for 48 hour discontinuation
Brainstorm improvement opportunities with CV Nurse
Practitioners and General surgeons (colon surgeries)
Next Steps: Where do we go from here?
Engage Operating Room staff and OR Pharmacy
in improvement efforts
Initiate use of UHC online tool and sampling
process to assist with data collection of the
extended measure set
Glucose control
Hair removal
Normothermia
SSI rates
Submit SIP-1 measure to CMS