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
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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
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Glucose control
Hair removal
Normothermia
SSI rates
 Submit SIP-1 measure to CMS