1

CDS PROJECTASSURING APPROPRIATE ADHERENCE AND REPORTING OF ANTIBIOTIC SURGICAL SCIP

MEASURE

Dave Robbins

Lisa Heavilon

Wendelyn Bradley

Bonnie Livingston

Hospital Acquired Infections

HAIs in American hospitals:

•1.7 million infections and 99,000 deaths each year •Of these infections, 22 percent are surgery-related

Post-operative infections:

•Prior to the mid 19th century “irritative fever” common – purulent incisional drainage, sepsis, and often death

•1860s - Joseph Lister’s work radically changed surgery from an activity associated with infection and death to a discipline that could eliminate suffering and prolong life

GENERAL BACKGROUND

Surgical site infection prevention

• Surgical site infections account for 15% of all hospital-acquired infections

• Patients who develop surgical site infections are twice as likely to die as other surgical patients

• Preoperative antibiotics given within 1 hour of incision optimize drug levels in the tissues and are more effective than prophylactic antibiotics administered during or after the operation

• Appropriately chosen antibiotics provide effective protection against bacteria common at surgical sites without giving excessively broad coverage.

Negative Outcome Poorer patient outcomes

• Increased length of stay• Need for additional health care (MD visits, home

care, medications)• Development of organism resistance

Costs • HAIs cost up to $45 billion per year• Infection control interventions could save approx

$31 billion per year• CMS refusing reimbursement for post-operative

infections

Public Perception• Published results i.e. Hospital Compare• Word-of-mouth

PROBLEM DEFINITION

• Hospital 80% compliant with SCIP Core Measure for antibiotic administration prior to surgical procedures

• CMS diminished payment due to current compliance number

• Tedious and time consuming chart review for report generation and submission to CMS

• Physician frustration

• IC concern over potential increase of post operative infection rate

Goal DEFINITION

• Improve compliance with antibiotic surgical SCIP measures from 80% to 100% within one year of CDS implementation

• Reduce CMS non-reimbursable HAI’s • Automated data, analysis, and

presentation reporting• Stay current with relevant regulations,

standards and benchmarks. – Facilitate HAI mandatory reporting to NHSN– Achieve TJC 2009 National Patient Safety Goals

MODEL UTILIZED

• Alert System [at two clinical junctures]– Use of data elements to include

• Transactional• Temporal• Text

• Data repository for reporting to include– Data Management– Model Management– Knowledge Engine– User Dashboard

MODEL KNOWLEDGE

Transactional Data Elements

• Antibiotic Algorithm for Surgical Type

• Over-ride transaction message

• CPT/ICD-9=Surgical Type• MR #• Account #• Surgery/Admit Date • NDC• Antibiotic Administration

Date• Discharges with an ICD-9-CM

Principal Procedure Code or ICD-9-CM Other

Temporal Data Elements

• Antibiotic Administration Time

• Surgical Incision Time

Database Elements• Data Base Management• Model Management• Knowledge engine• User Dashboard

MODEL KNOWLEDGE

Included Populations:• ICD-9-CM Principal Procedure

Code or ICD-9-CM Other Procedure Code for selected surgical types.

• Discharges with an ICD-9-CM Principal Procedure Code or ICD-9-CM Other

Excluded Populations:• Admission DX suggestive of

preoperative infectious diseases

• Antibiotics within 24 hours prior to arrival (except colon surgery patients taking oral prophylactic antibiotics).

• Readmissions of patients with MDRO history

• Post-surgical re-admits• Micro lab confirmation of

reportable diseases

Denominator Statement: All selected surgical patients with no prior evidence of infection

MODEL-SX-ABX Algorithm

HIP/KNEE ARTHROPLASTY

• Preferred: – Cefazolin (AncefÆ)

• High-risk for MRS (documented)– Vancomycin

• If Beta-lactam-allergy:– Vancomycin– Clindamycin

CV-VASCULAR SURGERY

• Preferred: – Cefazolin (AncefÆ)

• High-risk for MRS (documented)– Vancomycin

• If Beta-lactam-allergy:– Vancomycin– Clindamycin

Use of Vancomycin for surgical prophylaxis, in the absence of a documented beta-lactam allergy, requires physician documented rationale in the medical record.

MODEL-SX-ABX Algorithm

• COLORECTAL SURGERY-GENERAL SURGERY• Cefotetan (CefotanÆ) or Cefazolin (AncefÆ) and

Metronidazole (FlagylÆ)• Or Ampicillin-sublactam (UnasynÆ)• Or Ertapenem (InvanzÆ) as a single dose• If Beta-lactam allergy:

– Clindamycin combined with Gentamicin or parenteral Fluroquinolone

– or AztreonamorMetronidazole (FlagylÆ) with Gentamicin or parenteral Fluroquinolone (LevaquinÆ)

MODEL FRAMEWORK

System Description

• Key components

• HIS• AIS/OR • CPOE (with predefined order templates)• PIS • ADC (with antibiotic compliance alerts)• LIS• HAI Monitoring • Data Warehouse

• Integration made possible via HL7• Standard codes CPT, NDC

Functional Overview

Specialized Antibiotic Alert

• At the time of dispense the ADC presents an alert if the prescribed antibiotic (based in NDC) does not match the surgical procedure (based on CPT)

• Anesthesiologist or Nurse may override the alert to dispense the ordered or alternate antibiotic

• System log is maintained with date/time, user id, NDC and reason for override whenever the alert is triggered

Specialized Antibiotic Alert

• All overrides must be accompanied by a justification

• Non-conforming antibiotics must be chosen from a predefined list

• AIS/OR system records date and time of medication administration for comparison against cut time

Non-conforming Antibiotic Alert

Alert Override Justification

Evaluation Overview

• Core Evaluation Goals– Goal 1: Functional Integrity

• Assess the CDS to make sure it is functioning as intended.

– Goal 2: Intervention Performance• Evaluate the performance of the intervention

against organizational objectives and industry benchmarks.

– Goal 3: Continuous Product Improvement• Refine the intervention, keep it up to date,

evaluate it in context.

19

Goal 1: Functional Integrity

• Verification: Was the Intervention Built Correctly?– Confirm PFO is displayed under right

conditions.– Alerts are fired 100% at correct time, 0% at

incorrect time.

• Validation: Was the Right Intervention Built?– Staff interviews, workshops and surveys.– Observation.

21

Example Industry Benchmarks

Goal 2: Intervention Performance

• Direct Objectives: Increase Compliance with SCIP Guidelines– Appropriate Antibiotic Selection

• Automated data collection, monthly reporting• Compare to monthly trend and industry benchmarks

– Timeliness of Antibiotic Administration• Automated data collection, monthly reporting• Compare to monthly trend and industry benchmarks

• Indirect Objectives: Decrease Surgical Site Infections– Trend surgical site infections over time– Differentiate from overlapping interventions

Goal 3: Continuous Improvement

• Currency: Keep knowledge up to date• Annual knowledge expiration date• SCIP Program listserv• Receive updates from vendor

• Refinement: Improve and extend• Assess ways to improve efficiency and efficacy with

workshops and surveys• Evaluate ways to extend the system capabilities to

deliver additional value

• Portfolio Management: Evaluate in Context

• Evaluate high level goals across specific interventions• Plan for future interventions in coordinated fashion

CONCLUSION

We’ve presented • An overview• The Model• System Description

• Evaluation

Are there any questions?

Thanks!

Thanks to Gary Larson