Transcript Surgical Care Improvement Project

Surgical Site Infections
The Medicare Quality Improvement Organization for Arizona
What is SCIP?
• Surgical Care Improvement Project
• Evolved from SIP
• Encompasses additional aspects of surgical
care
– Reduce/prevent: Cardiac events, emboli, and
ventilator-associated pneumonia
Opportunities to Improve Care
• SSI: occurs in 14%–16% surgical patients
– 40%–60% of SSIs are preventable
• Cardiac: 2%–5% noncardiac surgery, 34% in
vascular, AMI mortality rate as high as 70%
• DVT/PE: without prophylaxis: general surgery cases
25%, 7% orthopedic cases, > 50% DVT, 30% PE
• VAP: occurs 9%–40%, with associated mortality rates
of 30%–46%
SCIP Goals
Reduce postoperative mortality and
morbidity by 25% over 5 years
A Closer Look at SSI
• SSI in a 51-case day
– 7.65 patients at risk for infection
– 4.59 of those infections are preventable
Insert Organizational Data
SCIP in the News
• Newsweek, December 12, 2005
– 6 Keys to Safer Hospitals
• USA Today
• ABC News 20/20
– More Killed Annually Than by Auto Accidents
and Homicides (10-14-2005)
SCIP Support
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American College of Surgeons
American Society of Anesthesiology
American Hospital Association
CDC
JCAHO
AORN
Veterans Administration
AHRQ
Evidence Based
• “Evidence-based medicine is the process of systematically
finding, appraising, and using contemporaneous research
findings as the basis for clinical decisions.”
• “Evidence-based medicine is about asking questions,
finding and appraising the relevant data, and harnessing
that information for everyday clinical practice.”
BMJ 1995;310:1122-1126 (29 April)
William Rosenberg, Anna Donald
Evidence-based Medicine: An Approach to Clinical Problem-solving
SSI Quality Measures
1: Prophylactic antibiotic received within 1
hour prior to surgical incision
2: Prophylactic antibiotic selection for
surgical patients
3: Prophylactic antibiotics discontinued within
24 hours after surgery end time (48 hours
for cardiac patients)
4: Cardiac surgery patients with controlled 6
a.m. postoperative serum glucose
SSI Quality Measures
5: Postoperative wound infection diagnosed
during index hospitalization
6: Surgery patients with appropriate surgical
site hair removal
7: Colorectal surgery patients with immediate
postoperative normothermia
VTE Quality Measures
1: Surgery patients with recommended venous
thromboembolism prophylaxis ordered
2: Surgery patients who received appropriate venous
thromboembolism prophylaxis, within 24 hours prior to
surgery to 24 hours after surgery
3: Intra- or postoperative pulmonary embolism (PE)
diagnosed during index hospitalization and within 30 days
of surgery
4: Intra- or postoperative deep vein thrombosis (DVT)
diagnosed during index hospitalization and within 30 days
of surgery
VAP Quality Measures
1: Number of days ventilated surgery patients had
documentation of the head of the bed (HOB) being
elevated, from recovery end date (day zero) through
postoperative day seven.
2: Patients diagnosed with postoperative ventilator-associated
pneumonia (VAP) during index hospitalization
3: Number of days ventilated surgery patients had
documentation of stress ulcer disease (SUD) prophylaxis,
from recovery end date (day zero) through postoperative
day seven.
4: Surgery patients whose medical record contained an order
for a ventilator-weaning program (protocol or clinical
pathway)
Cardiac Quality Measures
2: Surgery patients on a beta-blocker prior to arrival
that received a beta-blocker during the
perioperative period
3: Intra- or postoperative acute myocardial
infarction (AMI) diagnosed during index
hospitalization and within 30 days of surgery.
Arizona’s Ranking
100
90
80
70
71
70
66
61
60
National
50
AZ
40
30
20
10
0
Antibiotic Received within 1 Hour Prior to Surgical Incision
Antibiotics Discontinued within 24 Hours After Surgery End
Before SCIP
• Alcohol scrubs
– Most rapid reduction of bacteria counts
– 1 minute = 4–7 minutes of other agents
• Transfer of 1,000 organisms
– Bacterial survival 20–150 minutes
– Virus survival 20–30 minutes
Chapters from ACS Surgery
Prevention of Postoperative Infection
Jonathan L. Meakins, M.D., D. Sc., F.A.C.S.
Impact
Infected
Uninfected
Mortality (in-hospital)
7.8%
3.5%
ICU admission
29%
18%
Readmission
41%
7%
Median initial LOS
11d
6d
Median total LOS
18d
7d
Initial excess cost
+$3,644 (median)
Total excess cost
+$5,038 (median)
*Pairs matched for procedure, NNIS index, age
*General inpatient surgical population; 22, 742 procedures included
Kirkland. Infect Control Hosp Epidemiol. 1999;20:725. Prospective, case-controlled study of
22,742 patients undergoing inpatient surgical procedures between 1991–1995.
Information adapted from the Institute for Healthcare Improvement (www.ihi.org).
Opportunity
• Decreasing the rate of SSI is an opportunity
to:
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Improve care
Promote improved outcomes
Increase patient satisfaction
Reduce costs
Components of SSI
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Antibiotic Administration
Hair Removal
Glucose Control
Normothermia
CATS
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Clipping (Hair Removal)
Antibiotic Administration
Thermia (Normothermia)
Sugar (Glucose Control)
Antibiotics
• Timely administration
• Selection
• Timely discontinuation
Timely Administration
• Most studies indicate that optimum timing
for prophylactic antibiotic is within 1 hour
of incision time. (Cephalosporins)
• When cuff is used, make sure all antibiotic
is infused prior to inflation of cuff.
Note: Because of the longer required infusion time,
vancomycin, when indicated for beta-lactam allergy,
should be started within 2 hours before the incision.
Information adapted from the Institute for Healthcare Improvement (www.ihi.org).
Timing of Abx. Prophylaxis
4
3.8
3.4
3.5
3
2.4
% of SSI
2.5
2.1
2
1.6
1.5
1.1
1
0.7
0.5
0.5
0
0
<-3
-2
-1
0
1
2
3
4
>5
Hours From Surgery
Classen, et al. N Engl J Med. 1992;328:281.
Information adapted from the Institute for Healthcare Improvement (www.ihi.org).
Insert Organizational Data
Antibiotic Selection
• Choose prophylactic antibiotics consistent
with national guidelines
– Special cases:
• Allergy (anaphylactoid) to -lactam antibiotics
• High rate of MRSA wound infections locally
• Recent prolonged course of antibiotics or ICU stay
Information adapted from the Institute for Healthcare Improvement (www.ihi.org).
Ancef
• Cefazolin
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Effective against gram positive and negative
Low rate of allergic responses
Easy to administer
Inexpensive
Prophylaxis Dosing
• Always give at least a full therapeutic dose
of antibiotic.
• Consider the upper range of doses for large
patients and/or long operations.
• Repeat doses for long operations (> 4 hours)
Information adapted from the Institute for Healthcare Improvement (www.ihi.org).
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.
• There is no need to continue coverage beyond 24
hours.
Information adapted from the Institute for Healthcare Improvement (www.ihi.org).
Duration Concerns
• 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
SSIs.
• There is evidence that unnecessary or
prolonged use of antibiotics promotes
antibiotic resistance.
Information adapted from the Institute for Healthcare Improvement (www.ihi.org).
Tubes, Lines, and Drains
“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.”
Advisory Statement:
Recommendations for the Use of Intravenous Antibiotic
Prophylaxis in Primary Total Joint Arthroplasty
American Association of Orthopedic Surgeons (AAOS)
Duration in Cardiac Surgery
“Our findings confirm that continuing ABP
beyond 48 hours after CABG surgery is still
widespread; however, this practice is ineffective
in reducing SSI, increases antimicrobial
resistance, and should therefore be avoided.”
Prolonged Antibiotic Prophylaxis After Cardiovascular Surgery and Its
Effect on Surgical Site Infections and Antimicrobial Resistance
Stephan Harbarth, MD, MS; Matthew H. Samore, MD;
Debi Lichtenberg, RN; Yehuda Carmeli, MD, MPH
Circulation. 2000;101:2916-2921
Insert Organizational Data
Hair Removal Quality Measure
• Surgery patients with appropriate surgical
site h hair removal.
Hair Removal
• Appropriate:
– No hair removal at all
– Clipping
– Depilatory use
• Inappropriate:
– Razors
Information adapted from the Institute for Healthcare Improvement (www.ihi.org).
Shaving Influence
No Hair
Removal
Depilatory
Shaved
• Number
155
153
246
• Infection rate
0.6%
0.6%
5.6%
Group
Seropian. Am J Surg. 1971; 121: 251.
Information adapted from the Institute for Healthcare Improvement (www.ihi.org).
Glucose Control
• Cardiac surgery patients with controlled
6:00 a.m. postoperative serum glucose. The
measure looks at the glucose result for
postoperative day 1 and day 2.
Risk, Glucose Control,
Cardiac Surgery
• Increased risk:
Diagnosed diabetes
Undiagnosed diabetes
Post-op glucose > 200 mg% within 48h
Latham. Inf Contr Hosp Epidemiol. 2001;22:607.
Dellinger. Inf Contr Hosp Epidemiol. 2001;22:604.
SSI Related to Glucose Control
20
15
Infection Rate
15
14
12
10
5.1
5
0
< 200
200 - 249
250 - 299
>300
Glucose Level
Cardiac Surgery after Median Sternotomy
Latham. ICHE. 2001; 22: 607-612.
Information adapted from the Institute for Healthcare Improvement (www.ihi.org).
Additional Benefits
of Glucose Control
• Decreased:
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Acute renal failure
Red cell transfusions
Ventilator support
Time spent in intensive care
van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin
therapy in the critically ill patients. N Engl J Med. 2001 Nov. 8;
345(19):1359-1367. PMID: 11794168
Normothermia Quality Measure
Colorectal surgery patients with immediate
normothermia (96.8–100.4° F) within the
first hour after leaving the operating room.
Normothermia
• Patients who had a decrease of only 1.9°C
in core temperature were three times as
likely to develop surgical wound infections
as were those in whom a normal body
temperature of 37°C was maintained.
Kurz A, Sessler DI, Lenhardt RA. Perioperative normothermia to reduce
the incidence of surgical-wound infection and shorten hospitalization.
N Engl J Med 1996; 334:1209–15.
Be An Advocate
• Advocate to reduce the risk of surgical site
infections by using evidence-based care.
Your patients will thank you.
Be Aware
• Be aware of evidence-based measures to
reduce surgical site infection
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Hair Removal (Clipping)
Antibiotic Usage (Antibiotic)
Normothermia (Thermia)
Glucose Control (Sugar)
Be Alert
• Be alert to the care your surgical patient is
receiving. Is the care evidence-based or
something else?
Be Active
• Ask the surgeon if he or she wants an
antibiotic administered.
• Throw every razor away.
• Check the glucose on cardiac patients.
• Keep your patients warm.
• Work with a team to improve surgical care,
increase patient satisfaction, improve
patient outcomes, and decrease costs.
Insert Organizational
Interventions
Be Active
WASH
YOUR
HANDS
www.hsag.com
This material was prepared by Health Services Advisory Group, the
Medicare Quality Improvement Organization for Arizona, under
contract with the Centers for Medicare & Medicaid Services (CMS),
an agency of the U.S. Department of Health and Human Services.
The contents presented do not necessarily reflect CMS policy.
Publication No. AZ-8SOW-1C-021506-06