Transcript Developing surgical site infection bundle improve patient outcomes

Developing a surgical site infection
bundle to improve patient outcomes
Felix W. Tsai MD1, Kathy Masters RD2, Douglas Maposa MD3, Lillian
S. Kao MD4, Charles Monney MS5, and Galit Holzmann-Pazgal MD6
1. Department of Pediatric Surgery, 3. Department of Anesthesia, 4.
Department of Surgery, 6. Department of Pediatrics, UTHSC; 2.
Department of Healthcare Improvement, 5. Department of Infection
Control, Memorial Hermann Hospital
Background
- 44,000-98,000 preventable
deaths a year
- World Health
Organization (WHO)
Surgical Safety Checklist
demonstrated to decrease
mortality and morbidity
world-wide
- National Health Service
has since advocated
universal usage of the
checklist
N Engl J Med 2009;360:491
Background
- Surgical Site Infections
-
Range between 2-5% for all surgical patients
Can add up to $30,000 additional hospital costs
Patient specific risk factors
Modifiable risk factors
- Our infection rate
- Between July 2007-December 2008, 7%
- Between January 2009-September 2009, 4.8%
Goals
- Decrease overall infection rates to less than 3%
within 12 months
- To develop a Surgical Site Infection (SSI)
bundle, facilitated by an operative checklist, to
decrease morbidity
Methods
- SSI bundle creation
- Preoperative chlorhexidine baths – September 2008
- Routine antibiotic discontinuation within 48 hours –
April 2009
- Standardized prophylactic Vancomycin (targeted
antibiotics) – January 2010
- Antibiotics given 30-120 minutes before skin incision
– March 2010
Methods
- SSI bundle creation
- Preoperative chlorhexidine baths
- Standardized prophylactic Vancomycin (targeted
antibiotics)
- Antibiotics given 30-120 minutes before skin
incision
- Routine antibiotic discontinuation within 48 hours
Methods
- SSI bundle creation
- Preoperative chlorhexidine baths
- Routine antibiotic discontinuation within 48 hours
- Standardized prophylactic Vancomycin (targeted
antibiotics)
- Antibiotics given 30-120 minutes before skin
incision1
1
J Antimicrob Chemother 2006;58(3):645
Methods
- SSI bundle creation
- Preoperative chlorhexidine baths
- Routine antibiotic discontinuation within 48 hours
- Standardized prophylactic Vancomycin (targeted
antibiotics)
- Antibiotics given 30-120 minutes before skin
incision1
1
J Antimicrob Chemother 2006;58(3):645
Methods
- SSI bundle creation
- Preoperative chlorhexidine baths
- Routine antibiotic discontinuation within 48 hours
- Standardized prophylactic Vancomycin (targeted
antibiotics)
- Antibiotics given 30-120 minutes before skin
incision1
1
J Antimicrob Chemother 2006;58(3):645
Methods
- SSI bundle creation
- Preoperative chlorhexidine baths
- Routine antibiotic discontinuation within 48 hours
- Standardized prophylactic Vancomycin (targeted
antibiotics)
- Antibiotics given 30-120 minutes before skin
incision1
1
J Antimicrob Chemother 2006;58(3):645
Methods
- Risk stratification by Risk Adjusted Congenital
Heart Surgery (RACHS) score
- Low risk (RACHS 1, 2)
- Medium risk (RACHS 3, 4)
- High risk (RACHS 5, 6)
Methods
- Retrospective and prospective data collection between August
2007 to August 2010
- Continuous ongoing data collection
- Preoperative baths – September 2008
- Routine antibiotic discontinuation within 48 hours – April 2009
- Standardized antibiotic usage in January 2010
- Implementation of operative checklist began on March 24, 2010
- First cohort (August 2007-March 2010): 349 patients
- Second cohort (March 2010-September 2010): 73 patients
Methods
- Outcomes measured
- Time between antibiotic administration and skin
incision
- SSI rates
Results
- Random audits of preoperative baths: 100%
compliance
- Routine discontinuation of antibiotics on order
form: 100%
- Standardized usage of Vancomycin: >95%
- Before the checklist, appropriate timing and dosing
was only found in 21.4 - 40% of patients
- After the checklist, actual compliance was 97.2% in
all cases requiring cardiopulmonary bypass
Results
Pre-intervention Antibiotic
to Skin Incision Time
Post-intervention
Antibiotic to Skin Incision
Time
p value
Low Risk
(RACHS 1,2)
26 ± 34
Median = 24 minutes
60 ± 29
Median = 59 minutes
0.003
Medium Risk
(RACHS 3,4)
32 ± 27
Median = 22.5 minutes
55 ± 28
Median = 62.5 minutes
0.000
High Risk
(RACHS 5,6)
26 ± 13
Median = 21 minutes
59 ± 23
Median = 57 minutes
0.036
Surgical operations stratified as low risk, medium risk and high risk
Pre- and post-bundle antibiotic dosage timing was analyzed by Student’s t-test
Antibiotic Dosing Interval
90
80
70
60
50
40
30
20
10
0
-10
Pre-intervention
Post-intervention
Low Risk
Medium Risk
High Risk
Results
Results
Results
Conclusions
- A SSI bundle appears to improve antibiotic
delivery to biologically plausible times
- This may help decrease the overall risk of
developing a SSI
- Quality process improvement requires a baseline
commitment and environment
Conclusions
- Checklists are flexible tools that may be effective
in a variety of situations
- Checklist utilization serve as reminders and may
improve teamwork and intraoperative safety
culture
Future Directions
- Continue SSI surveillance
- General pediatric surgery: process compliance
- Pediatric neurosurgery & plastic surgery: nearmisses (implants)
- Laparoscopic surgery: OR efficiency
- Further studies are needed to determine factors
that help and hinder checklist utilization
Acknowledgements
Jannette Gutierrez
Jose Delgado
Raul Guardiola
Betsabe Quezada
Sarah Eshelman
Heather Dunne
Bill Douglas
Mohammed Rafique
Kevin Lally
Kathy Masters
Eric Thomas
This work was supported in part by a training fellowship from the AHRQ
Training Program of the W.M. Keck Center for Interdisciplinary Bioscience
Training of the Gulf Coast Consortia (AHRQ Grant No. T32 HS017586)