Perioperative Enterprise CommitteeSurgical Site Infection Report

May 21, 2009

ProcedureRate Q1

2009Rate Q1

2008% Change from 1 yr

CDC Benchmark

O/E Infection

Rate*

Cardiac (Q4 Data)

Cardiac surgery (non-CABG) 0.4 0 100% 1.71 0.2

Coronary bypass w/chest and donor incision 3.3 4.1 -20% 4.88 0.7

Coronary bypass graft with chest incision 0 0 0% 2.88 0.0

Cardiac surgery (pediatric, primary closure) 0 0 0% 1.71 0.0

Colorectal

Colon 18.5 17.3 7% 10.8 1.7

  Rectal 30.2 18.9 60% 4.3 7.0

Vascular

AAA Repair 0 14.3 -100% 5.2 0.0

  CEA 0 0 0% 0.42 0.0

  Peripheral Bypass 0 7.1 -100% 6.7 0.0

ProcedureRate Q1

2009Rate Q1

2008% Change from 1 yr

CDC Benchmark

O/E Infection

Rate*

Orthopedic

 Total Hip 0 4.4 -100% 2.97 0.0

 Total Knee 1 0 100% 1.82 0.5

Craniotomy  3.3 6.4 -48% 4.68 0.7

OB/GYN

Hyst - Vaginal 4 9.1 -56% 1.26 3.2

Hyst - Abdominal 11 3.8 189% 4.37 2.5

 C-sections 3.4 11.8 -71% 2.64 1.3

Pediatric VP shunts  9.4 18 -48% 5.16 1.8

Pod 1

C-SectionHysterectomy

Cesarean Section SSIs

3.4%2.64%

Abdominal Hysterectomy SSIs

4.37%

11%

Vaginal Hysterectomy SSIs

1.3%

8%

Details Hysterectomy First quarter rates have increased Many of the patients were obese, experienced

prolonged OR time, or diabetic Antibiotic timing was per protocol including re-

dosing Will investigate further regarding other

operative issues including skin prep, hair removal, etc.

Pod 3

Colorectal Surgery

Colon Surgery SSIs

10.86%

18.5%

2.85%

30.2%

Rectal Surgery SSIs

Pod 6

Orthopedic Surgery

Total Hip Arthroplasty SSIs

2.97%

0%

Total Knee Arthroplasty SSIs

1.82%

1.0%

Pod 8

Neurosurgery

Craniotomy SSI

4.68%

3.3%

Pod 10

Cardiac SurgeryVascular Surgery

Adult CABG (Procedures w/ Sternotomy + Donor Site) SSIs

4.88%

3.3%

Adult CABG (Sternotomy-Only Procedures) SSIs

2.88%

0%

Adult Cardiac (non-CABG) SSIs

1.71%

0.4%

Abdominal Aortic Aneurysm SSI

5.2%

0%

Carotid Endarterectomy SSI

0.42%

0%

Peripheral Vascular Bypass SSI

6.7%

0%

VCH ORs

Pediatric CardiacPediatric V Shunt

Pediatric Cardiac SSIs

1.71%

0%

Pediatric VP Shunt SSI

5.16%9.4%

Total Knee Arthroplasty without Megaprothesis

1.82%

0%

INCORRECT