Surgical Site Infection Prevention Collaborative MCIC March 2006

Surgical Site Infection Prevention Collaborative

MCIC March 2006

Background: NNIS• National Nosocomial Infection Surveillance (NNIS)

System– CDC program that reports aggregated surveillance data

from ~300 US hospitals

– Standard case-finding (by ICD-9 code), definitions for infection, and risk-stratification methodology

– Pooled mean and standard deviation reported for surgical procedures, including craniotomy, laminectomy, spinal fusion, C-section, and CABG

Background: Methodology• HEIC surveillance methodology

– Monthly denominator data from case-mix data base (all NNIS procedures by ICD-9 code)

– Complete chart review of all procedures performed to assess for infection

– Risk stratification• Length of procedure (1 point)• ASA score (1 point)• Wound class (assuming all procedures are clean because CANNOT get

wound class)

– Generation and distribution of standardized rates quarterly or semi-annually (if denominator < 50/quarter)

Background: Reporting

• HEIC reporting strategies– Rates with NNIS benchmarking – Weekly evaluation of numbers of infections

(includes non-NNIS procedures)

Present your local NNIS infection data here

Surgical Site Infections

GOALS

• Define and identify risk factors for SSI

• Discuss strategies for prevention

• Discuss antibiotic prophylaxis principles

Pamela A. Lipsett, MDProfessorDepartments of Surgery,Anesthesiology,

Critical Care Medicine, Nursing Johns Hopkins University Schools of Medicine

and Nursing

Proportion of Adverse EventsMost Frequent Categories

0%

5%

10%

15%

20%

25%

Drug-related

Woundinfect.

Tech.comp.

Latecomp.

Diag.mishap

Therap.mishap

Nontech.comp.

Proc.related

Brennan. N Engl J Med. 1991;324:370-376

Non-surgical

Surgical

INTRODUCTION

• 40 million operations annually

• 20% experience infection

• Surgical site infections (SSI) prolong hospital stay by 6.5 to 7.4 days and comprise 42% of extra charges

SSI:RISK FACTORSINTRINSIC-PATIENT RELATED

• Age• Nutritional status• Diabetes• Smoking• Obesity• Remote infections

• Endogenous mucosal microorganisms

• Altered immune system

• Preoperative stay-severity of illness

SSI:RISK FACTORSEXTRINSIC-

OPERATION RELATED

• Duration of surgical scrub

• Skin antisepsis• Preop shaving• Preop skin prep• Surgical attire• Sterile draping• Surgical technique

• Duration of operation

• Prophylaxis• Ventilation• Sterilization of

equipment• Wound class• Drains

NON-ANTIBIOTIC FACTORS

• Length of pre-operative stay

• Pre-operative shaving• Length of operation• Use of abdominal

drains

• Pre-operative showering

• Presence of remote infections

• Normothermia• Increased oxygenation• Glucose control

Temperature and SSI Following Colectomy

• Mechanical bowel prep

• Parenteral antibiotics at induction x 4 d

• Standard anesthetic-isoflurane

• Randomized after inductionT>36.5 º or T>34.5 º

• Supplemental O2 in PACU x 3h

• Aggressive fluid resuscitation

Kurz. NEJM 1996;334:1209

Temperature and SSI Following Colectomy

Normo (104) Hypo(96) P

SSI 6 18 .009

Collagen 328 254 .04

Time to eat 5.6d 6.5d <.006

Kurz. NEJM 1996;334:1209

Hyperglycemia and Infection RiskAbdominal and Cardiovascular Operations

Glucose POD#1<220 mg% >220 mg%

Any Infection 12% 31%

“Serious” Infection 5.7-fold increase for any glucose > 220 mg%

Pomposelli. JPEN 1998;22:77

Diabetes, Glucose Control, and SSIsAfter Median Sternotomy

0

5

10

15

20

<200 200-249 250-299 >300

% In

fect

ion

s

Latham. ICHE 2001; 22: 607-12

Insulin Treatment in SICU Patients

Treatment Group

Conventional Intensive

Death in ICU 63/783 (8%) 35/765 (5%)

Van den Berghe. NEJM 2001;345:1359

Preoperative Recommendations: Category 1A

• If hair is removed, remove immediately before the operation, preferably with electric clippers

Influence of Shaving on SSI

No HairGroup Removal Depilatory Shaved

Number 155 153 246

Infection rate 0.6% 0.6% 5.6%

Seropian. Am J Surg 1971; 121: 251

Shaving, Clipping and SSI

Cruse. Arch Surg 1973; 107: 206

% Infected

0

0.5

1

1.5

2

2.5

Shave Clip Neither

Hair Removal Techniques and SSI

% Infection

0

4

8

12

PMRazor

AMRazor

PMClipper

AMClipper

Clean

Clean-Contam

Alexander. Arch Surg 1983; 118: 347

GUIDELINES FOR ANTIBIOTIC PROPHYLAXIS

1. The procedure should carry a significant risk of infection and/or cause significant bacterial contamination.

Relative Benefit from Antibiotic Surgical Prophylaxis

Operation Prophylaxis (%) Placebo (%) NNT*Colon 4-12 24-48 3-5Other (mixed) GI 4-6 15-29 4-9Vascular 1-4 7-17 10-17Cardiac 3-9 44-49 2-3Hysterectomy 1-16 18-38 3-6Craniotomy 0.5-3 4-12 9-29Total joint 0.5-1 2-9 12-100Breast & hernia ops 3.5 5.2 58

* Number Needed to Treat

GUIDELINES FOR ANTIBIOTIC PROPHYLAXIS

2.The antibiotic selected must be active against the major contaminating organisms and should have previously been shown to be effective prophylaxis.

It is NOT necessary to cover ALL organisms present.

GUIDELINES FOR ANTIBIOTIC PROPHYLAXIS

3. The antibiotic chosen must achieve concentrations higher than the minimal inhibitory concentration (MIC) of the suspected pathogens in the wound site at the time of incision.

GUIDELINES FOR ANTIBIOTIC PROPHYLAXIS

4. The shortest possible course of the most effective least toxic antibiotic must be used for prophylaxis. Must consider distribution and half-life of individual agents.

GUIDELINES FOR ANTIBIOTIC PROPHYLAXIS

5. The newer broader spectrum agents must be saved for therapy of resistant organisms and should not be used for prophylaxis.

Antimicrobial Prophylaxis: Category IB

• Do not routinely use vancomycin for antimicrobial prophylaxis

WHEN (TIMING) OF PROPHYLACTIC AGENTS

• Antibiotic levels of the individual agents must be higher than the MIC at the time of incision

• Individual agents must be considered– Cefazolin has a Vd of 10-12 L can can be

pushed within minutes of incision– Additional doses dependent on half-life and

blood loss

Timing Analysis

01020304050607080

90100

Early Optimal Late Never

1985

1988

1992

1993

1994-96

Burke JP. CID. 2001;33;s78-s82

Appropriate Use:LDSYear # Operations SSI (%) Inappropriate

Prophylaxis (%)

1996 976 17 (1.7) 6 (35)

1997 1035 30 (2.9) 6 (20)

1998 963 12 (1.2) 1 (8)

1999 932 16 (1.7) 0

Burke JP. CID. 2001;33;s78-s82

2.7 1.24.3

20.3

56

2.8 1.4 0.9 0.9

9.6

0

10

20

30

40

50

60

Minutes Before or After Incision

Per

cen

t

Inc

isio

n

Antibiotic Timing Related to Incision

Bratzler DW, Houck PM, et al. Arch Surg 2005:140:174-182

26.2

10

22.6

6.2 6.32.2 2.7

9.3

14.5

40.7

50.7

73.3

79.5

85.888

90.7

0

20

40

60

80

100

Hours After Surgery End Time

Per

cent

0

20

40

60

80

100

Cum

ulat

ive

Per

cent

Discontinuation of Antibiotics

Patients were excluded from the denominator of this performance measure if there was any documentation of an infection during surgery or in the first 48 hours after surgery.

Bratzler DW, Houck PM, et al. Arch Surg 205:140:174-182

SPECIAL CONSIDERATION: MORBID OBESITY

• Cefazolin 1 gram is not the correct dose for everyone– At incision and closure

1g , blood and tissue levels all lower than “normal” weight

– Below MIC for gram pos cocci and gram neg rods

• Cefazolin 2gm good blood and tissue levels

• Wound infection rates from 16.5% to 5.1%

Forse et al:surgery 1989:106,751-767

CONCLUSIONS

• Must be familiar with principles of prophylaxis and CDC recommendations

• Morbidly obese patients should receive larger doses of antibiotics

CONCLUSIONS:Beyond CDC

• Maintenance of normothermia maybe important (Level II)

• Glucose control perioperatively

Improving Safety and Quality:Five Step Model for Improvement

Why do we need to improve care?

In U.S. Healthcare system

• 44,000- 98,000 preventable deaths

• $50 billion in total costs

Similar results in UK and Australia

IOM report “To err is human”

Why do we need to improve care?

• Patients – Do the right thing!

• Purchasers – Leapfrog group

• Insurers

• Regulators – JCAHO ICU measurement set– CMS surgical care improvement project

Outline

• Review 5 step model for improvement

• Provide practical examples

• How will we prevent SSI?

Model to Improve

• Pick an important clinical area• Identify what should we do?

– principles of evidence-based medicine

• Measure if you are doing it• Ensure patients get what they should

– education– create redundancy– reduce complexity

• Evaluate whether outcomes are improved

Important Clinical Areas

• Eliminating CR-BSIs

• Ventilator Associated Pneumonia

• Sepsis Bundle

• Perioperative Beta Blockers

• VTE Prophylaxis

• Decreasing SSI

Model to Improve

• Pick an important clinical area• Identify what should we do?

– principles of evidence-based medicine

• Measure if you are doing it• Ensure patients get what they should

– education– create redundancy– reduce complexity

• Evaluate whether outcomes are improved

Model to Improve

• Pick an important clinical area• Identify what should we do?

– principles of evidence-based medicine

• Measure if you are doing it• Ensure patients get what they should

– education– create redundancy– reduce complexity

• Evaluate whether outcomes are improved

Outcome vs. Process Measures• Process

– full barrier precautions– DVT and PUD prophylaxis– Appropriate abx timing

Adv/Disadvantages– short cycle– feedback meaningful– no risk-adjustment

• Outcome– mortality– catheter-related BSI – SSI

Adv/Disadvantages– long cycle– feedback difficult– important to patients

McGlynn, Jt Comm J Qual Improv 1988

Model to Improve

• Pick an important clinical area• Identify what should we do?

– principles of evidence-based medicine

• Measure if you are doing it• Ensure patients get what they should

– education– create redundancy– reduce complexity

• Evaluate whether outcomes are improved

Systems Approach

• Every system is perfectly designed to get the results that it gets

Berwick

• If you want to change performance you need to change the system

All improvement is local: we can provide concepts; you need to design interventions

Science of Safety

• Accept that we will make mistakes

• Focus on systems, including interpersonal communication, rather than people

• Largest barrier is lack of awareness evidence exists

• Standardize to reduce complexity

• Create independent checks

Model to Improve

• Pick an important clinical area• Identify what should we do?

– principles of evidence-based medicine

• Measure if you are doing it• Ensure patients get what they should

– education– create redundancy– reduce complexity

• Evaluate whether outcomes are improved

Eliminating SSI• Apply best practices

– If hair is removed, use clippers– Appropriate antibiotics

• Choice• Timing• Discontinuation

– Perioperative normothermia– Glycemic control

• Decrease complexity• Create redundancy

Tips for success• Engage

– Make the problem real– Publicly commit that harm is untenable

• Educate• Execute

– Culture, complexity and redundancy – Regular team meetings

• Evaluate – Measurement and feedback – Recognition and visibility– CELEBRATE SUCCESS !

Engage

– Make the problem real• Share local infection rates

• Share local compliance with process measures

• Share a story of a patient with SSI– (????) Have the patient share their story

– Publicly commit that harm is untenable• Institutional commitment

• Champions within the OR, within the teams, within the departments involved

Tips for success• Engage

– Make the problem real– Publicly commit that harm is untenable

• Educate• Execute

– Culture, complexity and redundancy – Regular team meetings

• Evaluate – Measurement and feedback – Recognition and visibility– CELEBRATE SUCCESS !

Educate

• Develop an educational plan to reach ALL members of the caregiver team– Use this power point or use you own local

experts – Educate on the evidence based practices AND

the data collection plan and other steps of the process.

• Use posters to educate the teams about the evidence-based process measures

Perioperative SSI Process Measures

Quality Indicator Numerator Denominator

Appropriate antibiotic choice Number of patients who received the appropriate prophylactic antibiotic

All patients for whom prophylactic antibiotics are indicated

Appropriate timing of prophylactic antibiotics

Number of patients who received the prophylactic antibiotic within 60 minutes prior to incision

All patients for whom prophylactic antibiotics are indicated

Appropriate discontinuation of antibiotics

Number of patients who received prophylactic antibiotics and had them discontinued in 24 hours

All patients who received prophylactic antibiotics

Appropriate hair removal Number of patients who did not have hair removed or who had hair removed with clippers

All surgical patients

Perioperative normothermia Number of patients with postoperative temperature ≥36.0oC

Patients undergoing colon surgery (Optional: All patients)

Perioperative glycemic control Number of cardiac surgery patients with glucose control at 6AM pod 1

Patients undergoing cardiac surgery

Perioperative SSI Process Measures Data collection plan

• How the process measures will be collected on ALL patients at the time of the surgical procedure

• The responsibility of all of the team members

BSI poster

Tips for success• Engage

– Make the problem real– Publicly commit that harm is untenable

• Educate• Execute

– Culture, complexity and redundancy – Regular team meetings

• Evaluate – Measurement and feedback – Recognition and visibility– CELEBRATE SUCCESS !

Execute• Culture

• Develop a culture of intolerance for infection• Reduce complexity of the process

• Checklists• Local antibiotic guidelines posted in ORs

• Redundancy• Add to briefing/debriefing checklist• Post reminders in the OR (White board)

• Regular team meetings• Develop a project plan

– One or two tasks a week• Identify who owns the steps of the process that works in your

environment

Catheter Related Blood Stream Infection Checklist

• Before the procedure, did they: – Wash hands

– Sterilize procedure site

– Drape entire patient in a sterile fashion

• During the procedure, did they:

– Use sterile gloves, mask and sterile gown

– Maintain a sterile field

• Did all personnel assisting with procedure follow the above precautions

• Empowered nursing to stop the procedure if violation occurred

Tips for success• Engage

– Make the problem real– Publicly commit that harm is untenable

• Educate• Execute

– Culture, complexity and redundancy – Regular team meetings

• Evaluate – Measurement and feedback – Recognition and visibility– CELEBRATE SUCCESS !

Sample Reports:SSI Process Measures Over Time Compared

to Cohort

Quality Measure Your TeamOther Teams in

Collaborative

Composite 84% 85%

Appropriate Abx Selection 87% 95%

Appropriate Abx Timing 98% 96%

Appropriate Hair Removal 96% 95%

Prevention of Hypothermia 61% 57%

Sample Reports:SSI Process Measures Over Time Compared

to CohortMCIC Perioperative Collaborative

Sample Report for SSI Process MeasuresPerformance Compared to Cohort

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Composite Appropriate AbxSelection

Appropriate AbxTiming

Appropriate HairRemoval

Prevention ofHypothermia

Quality Measure

Perc

en

t C

om

pli

an

ce

Your Team

Other Teams in Collaborative

Sample Reports:SSI rates Over Time Compared to Cohort

MCIC Perioperative Collaborative Quarterly SSI Rate Over Time Baseline to Third Quarter 2005

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

9.00

10.00

SS

I rate / 100 C

ases

Cohort

Your Team

Sample Reports:SSI rates Over Time Compared to CohortYour Team

Reporting Period # SSI CasesMedian SSI rate /

100 cases

Baseline 16 2533 6.32

Jan 05 - March 05 6 744 8.06

April 05 - June 05 2 637 3.14

July 05 - Sept 05 1 744 1.34

Oct 05 - Dec 05 1 546 1.83

All Teams in Cohort

Reporting Period # SSI CasesMedian SSI rate /

100 cases

Baseline 45 8900 5.06

Jan 05 - March 05 4 650 6.15

April 05 - June 05 8 1250 6.40

July 05 - Sept 05 6 1500 4.00

Oct 05 - Dec 05 3 1100 2.73

Tips for success• Engage

– Make the problem real– Publicly commit that harm is untenable

• Educate• Execute

– Culture, complexity and redundancy – Regular team meetings

• Evaluate – Measurement and feedback – Recognition and visibility– CELEBRATE SUCCESS !

QI ProcessProcess # hospitals Baseline 4th quarter Difference

< 1hour 44 72 95 15

Selection 44 90 95 3.4

Normothermia 29 57 74 12

NOT Shaving 14 59 95 27

Oxygenation 8 75 94 18

Glucose control 5 46 54 18

Dellinger P et al. Am J Surg 2005;190;9-15

QI Efforts

Dellinger P et al. Am J Surg 2005;190;9-15

Will You Commit to Improve Quality?

• If not now, then when?

• If not this, then what?• If not you, then who?