Transcript Surgical Infection Prevention

Surgical Infection Prevention
Project Team:
Anesthesia
Infectious Disease
Pharmacy
Surgical Services
Labor & Delivery
Quality Resource Management
Center for Clinical Effectiveness
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 and the
right time – is effective in preventing
infections after surgery.
Project Goals
To achieve 100% compliance for the
following measures:
1. Administer antibiotics within one hour
before surgical incision
2. Administer the appropriate antibiotic
3. Stop antibiotics within 24 hours after
surgery
Defined by the National Surgical Infection Prevention Project (CMS/CDC)
Targeted Surgeries
Abdominal and Vaginal Hysterectomy
Hip and Knee Replacement
Cardiac Bypass
Other Cardiac Surgery
Vascular Surgery
Colon Surgery
Most Likely Causes
Antibiotic not administered within
recommended time intervals
Variation in physician ordering practices
Variation in documentation of antibiotic
administration
Solutions Implemented
Initiated extensive data collection plan
Based on CMS and JCAHO specifications
Monthly chart review
Shared service specific data
Reviewed with Physicians and Nurse
Practitioners
Identified improvement opportunities
Revised pre and post operative standard
order sets to mirror guidelines
Ninety percent of LUMC patients receive prophylactic
National Hospital Quality Measures
Surgical
receiving prophylactic
antibiotics
antibiotics withinwithin
60patients
minutes
prior
to
surgical incision
one hour prior to surgical incision
105
UCL = 102.96
100
95
LUHS Mean = 91.4
Percent
90
85
80
LCL = 79.85
75
JCAHO National Rate Q3 2004: 72.0
70
Month
Definition: Surgical patients who received prophylactic antibiotics within 60 minutes prior to surgical incision / Patients undergoing CABG,
cardiac surgery, hip / knee arthroplasty, colon surgery, hysterectomy, or vascular surgery. Vancomycin and fluoroquinolones timeframe is
extended to 120 minutes prior to incision.
Data source: LUMC medical records abstracted by RNs.
Eighty three percent of LUMC patients receive
National Hospital Quality Measures
Surgical patientsconsistent
receiving prophylactic
antibiotics
prophylactic antibiotics
with
current guidelines
consistent with current guidelines
100
95
UCL = 98.89
JCAHO National Rate Q3 2004: 92.0
90
Percent
85
LUHS Mean = 83.0
80
75
70
LCL = 67.12
65
Month
Definition: Surgical patients receiving prophylactic antibiotics consistent with current guidelines / Patients undergoing CABG, cardiac surgery,
hip / knee arthroplasty, colon surgery, hysterectomy, or vascular surgery.
Data source: LUMC medical records abstracted by RNs.
Two-third of LUMC patients now have prophylactic
National Hospital Quality Measures
Surgical patientswithin
receiving prophylactic
antibiotics
antibiotics discontinued
24 hours
after surgery end
discontinued within 24 hours after surgery end time
90
UCL = 87.00
80
Percent
70
60
LUHS Mean = 67.0
JCAHO National Rate Q3 2004: 63.0
50
LCL = 47.07
Month
Definition: Surgical patients with prophylactic antibiotics discontinued within twenty-four hours after surgery end time / Patients undergoing
CABG, cardiac surgery, hip / knee arthroplasty, colon surgery, hysterectomy, or vascular surgery.
Data source: LUMC medical records abstracted by RNs.
Analysis of Results
Loyola performs better than National JCAHO
comparison hospitals for two of the measures
Antibiotic selection requires ongoing attention
and follow up
Discontinuation of antibiotics within 24 hour
has the greatest improvement potential for
Cardiovascular and Orthopaedic surgeries
Next Steps
Continue comparison with UHC and national
benchmarks
Post results on the LUHS portal and internet
Review surgical site infection data for targeted
class 1 surgeries
Plan for public reporting of data
Consider participation in upcoming National
Surgical Care Improvement Project