PowerPoint PresentationSSI INTEREST GROUP: HOSPITAL WEBINAR #2 FOCUS ON COLON SURGERY
March 17, 2016
speakers, please use the “chat” function;
Ask questions at any time. Webcast will be recorded.
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BACKGROUND
SSI Interest Group idea was developed by Mary Shanks • Coordinated with OAHHS and OHA • Hold a series of webinars to share hospital
experience • All Oregon hospitals invited
Goal to further share best practices with PfP hospitals on 04/29/16
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GROUND RULES
This is a ‘safe table’ format • The focus is on patient safety • Participants encouraged to openly share to
collaborate and educate their peers • Be respectful of sensitive info/data that you may
hear
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RESOURCES
• http://www.hret-hen.org/topics/ssi/13-14/2014- SSIChecklist.pdf
hen.org/topics/ssi/HRETHEN_ChangePackage_ SSI.pdf
Medical Center Today’s speakers:
• Mary Shanks, Infection Preventionist, Kaiser Westside Medical Center
• Donna Berning, Quality Coordinator, Kaiser • Brenda Quint Gaebel, Quality Specialist, OHSU • Jeannette Harris, Infection Preventionist, MultiCare
Health System
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SSI INTEREST GROUP: MARY SHANKS & DONNA BERNING KAISER WESTSIDE MEDICAL CENTER
March 17, 2016
KAISER WESTSIDE MEDICAL CENTER
Kaiser Westside is the 2nd Kaiser Facility in Oregon Opened in Aug 2013 Most surgical procedures performed at
KWMC are orthopedic Sister facility is Kaiser Sunnyside Colon surgeries mostly done at Sunnyside 2015: 90 procedures/years at KWMC, 248 at
KSMC
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Goal- Reducing Surgical Site Infections to zero…..by 2013
How- Working together as a multidisciplinary group creating a program involving multiple initiatives to reduce SSIs as derived from SHEA / IDSA, SCIP, and IHI “Plus” Measures Toolkit.
Surgical Site Infection Committee Kaiser Northwest Region
“Pathway to Zero” Surgical Site Infections
OR Environment
Continuous Monitoring and Improvement
2013
Pre-Operatively: Proper hand hygiene performed by all staff members Hair removal in the surgical prep unit SCIP: Appropriate prophylactic antibiotic and received within one hour prior to incision & bariatric
dosing , pre-warming for normothermia, All surgical patients glucose level obtained in the surgical prep unit - inpatient Isolation patients identified and appropriately placed according to infection control guidelines
Intra-Operatively: Appropriate attire worn in the operating room and new policy followed by all stall Proper hand hygiene performed by all staff members Environment appropriately cleaned and wiped down prior to patient entering 18 AORN standards addressed every time – every patient Patient included in time-out briefing process Reduced traffic in the OR by performing briefing on all cases Surgeon demonstrates leadership by making safety a focus and empowers staff to speak up Use warmed forced-air blankets during surgery Verify prophylactic antibiotic administration time during “time out”, and redosing with antibiotics if
case open longer than 3 hours. Control glucose throughout surgery for all surgical patients Dual agent surgical prep solution used Use of antiseptic dressing
Post-Operatively: Proper hand hygiene performed by all staff members Post-warming for continuation of normothermia Control glucose throughout entire post surgical stay for all patients Discontinue prophylactic antibiotics within 24 hours after surgery (48 hours for cardiac patients) Discontinued foley by second day post-op Isolation patients are appropriately placed according to infection control guidelines Infection Control / Quality monitor and report compliance
Discharge: Discharge teaching to decrease chances of an infection Infection Control monitors for triggers within the EMR, confirms and reports.
Ambulatory Care Patient Education provided on “How to avoid a surgical site infection” Use of Chlorahexidine (CHG) impregnated cloths for all procedures involving a skin incision
AIM Key Drivers Secondary Drivers & Tactics
Continuous Monitoring and Improvement
Reduce surgical site infections (SSI) to zero by 2013
Pre-Operatively:
Hair removal in the surgical prep unit
SCIP: Appropriate prophylactic antibiotic and received within one hour prior to incision & bariatric dosing , pre-warming for normothermia,
All surgical patients glucose level obtained in the surgical prep unit - inpatient
Isolation patients identified and appropriately placed according to infection control guidelines
Intra-Operatively:
Appropriate attire worn in the operating room and new policy followed by all stall
Proper hand hygiene performed by all staff members
Environment appropriately cleaned and wiped down prior to patient entering
18 AORN standards addressed every time – every patient
Patient included in time-out briefing process
Reduced traffic in the OR by performing briefing on all cases
Surgeon demonstrates leadership by making safety a focus and empowers staff to speak up
Use warmed forced-air blankets during surgery
Verify prophylactic antibiotic administration time during “time out”, and redosing with antibiotics if case open longer than 3 hours.
Control glucose throughout surgery for all surgical patients
Dual agent surgical prep solution used
Use of antiseptic dressing
Post-warming for continuation of normothermia
Control glucose throughout entire post surgical stay for all patients
Discontinue prophylactic antibiotics within 24 hours after surgery (48 hours for cardiac patients)
Discontinued foley by second day post-op
Isolation patients are appropriately placed according to infection control guidelines
Infection Control / Quality monitor and report compliance
Discharge:
Discharge teaching to decrease chances of an infection
Infection Control monitors for triggers within the EMR, confirms and reports.
Ambulatory Care
Patient Education provided on “How to avoid a surgical site infection”
Use of Chlorahexidine (CHG) impregnated cloths for all procedures involving a skin incision
DATA
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0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
KSMC Wound Occurrence Rate General / Vascular Surgeries Jan 06-Dec 11
Procedure Targeted General / Vascular / GYN Jan 12
KPNW Comparison Hospitals
SIR 2014-0.85 KSMC, 1.47 KWMC Sir 2015- 0.4 – KWMC- N/A
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SUMMARY
Team effort- identify and involve all stakeholders Audit, measure and report findings and data Share results widely Review all SSIs with the team to identify
missed opportunities
What advice do you have for me?
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971-310-4720 (office)
SSI INTEREST GROUP: HOSPITAL PRESENTATION BRENDA QUINT GAEBEL
March 17, 2016
OREGON HEALTH & SCIENCE UNIVERSITY FACTS: Staffed beds: 553
• Average Occupancy Rate 82.0% • Average LOS Adult: 5.9 • Average LOS Peds: 5.5; (Normal Newborn 1.8)
Inpatient Demographics • 32% Multnomah County • 34% Washington, Clackamas and Benton Counties • 33% All other Oregon Counties
Surgical Population (inpatient & outpatient) • 24,046 adult surgical cases (2015) • 8,227 pediatric surgical cases (2015) • Includes >400 colorectal surgeries by 40 different surgeons
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Surgical Service
DECREASING SSI RISK Processes put into place to achieve improved
SCIP measures (>2010) • Correct prophylactic antibiotic selection and timing • Foley removal < POD 2 • Standard use of convective warming intraoperatively
Hospital acquired infection prevention campaign (>2013): • Hand hygiene • “See something say something” • Bathing & oral care • Room standards
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SSI A3 Colon Interventions [Bundle creation] based on literature reviews and learnings from successful organizations
Pre-Op (Preop Medicine Clinic, Surgery Clinic or Inpatient Unit)
• Preop Glycemic testing
• Patient teaching • Standard
• Skin cleansing Hibiclens / CHG shower morning of surgery
Pre-Op Area (day of surgery)
• Patient Skin Cleansing (CHG)
• Glycemic Management
• Maintain >36C • Antibiotic
• Clean/Dirty Instrument Separation
Pre-Bundle Project data (2014) • Colon Surgery SIR* = 1.204
Post-Bundle Implementation data (Jan-Sep 2015) • Colon Surgery SIR = 0.851
Although we had some improvement in our rate, we did not meet our improvement goal of a SIR <0.4. • Each of our 2015 Colon SSI cases were missing at
least 2 bundle elements
*SIR = Standard Infection Rate Observed / Expected
RECENT ACTIONS TAKEN TO MOVE US TO OUR SSI REDUCTION GOAL Address root cause of bundle compliance failures
• SSI Oversight Group that includes more surgeons • 7 subgroups – one for each bundle with best practices / strategies
Example:
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Project Next Steps: • Subgroups work their bundle task assignments: 1. Dedicated wound closure tray and glove change before fascial closure
Additional trays purchased Closure trays added to EPIC MD Preference cards/ Pick Lists Staff communication / education of closure tray use Add documentation prompts in EPIC
o Dedicated wound closure tray is used: Yes/No Comment o Glove change before fascial closure: Yes/No Comment
2. Monitor new process for intraoperative normothermia 3. Periop Glycemic Management
HbA1c testing during pre-op clinic visits – Protocol to address what happens when a patient has an elevated level.
Determine number and location of glucometers and glucometer docking stations for the Operating Rooms
Add Icon to Anesthesia Tech Status Board, for patients flagged for glucose monitoring Simulation of
4. Develop & implement SSI Bundle Tracking tool 5. Standardize bowel prep for all surgeons performing colorectal surgery 6. Daily Management System for postop patient daily showers
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SUMMARY – KEY LEARNINGS
Make Accountability an integral part of the SSI prevention program • Build bundle compliance tracking and
monitoring tools and reports into the rollout • Provide ongoing bundle compliance
feedback to all stakeholders • Have the “Plan-Do-Check-Act” as a living
part of your project until you achieve and maintain your project goal
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QUESTIONS?
What advice do you have for me?
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Office phone: 503-418-8032
March 17, 2016
• Tacoma General • Mary Bridge Children’s
Hospital • Allenmore Hospital
• Good Samaritan Hospital
sites
• 11,000+ employees • 6 Counties
Historic Surgery Interventions • 2007 • SCIP measures monitored/reported in meetings • Scrub change from Iodophore to CHG/alcohol (Chloroprep) • Work begins on C-Sections (no surveillance prior) • 2008 • Pre-op MRSA screening at one facility with high MRSA SSI rates • 2010 • Pre-op CHG wipes (night before/morning of surgery) • Pre-op iodophore nares swabs (before “wheels in”)
• NOTE: We do NOT decolonize with Mupiricin. • See Phillips et al, Infect Control Hosp Epidemiol 2014;35(7):826-832
• add pediatrics 2013 • Joint camp for total joint patients • High Risk/Low Risk wound dressings with nanocrystalline silver strip • 2013 • Hyperglycemic testing pre-wheels-in, sporadic management • System-wide standardized OR education for all OR staff
• Why, How, When, Where, Who – even surgeons and anesthesia • 2014-2015 • Surgery Collaborative begins • System-wide order sets – “Surgery Bundles* (yaaaaayyyy!)
Collaborative: The Colon Bundle • Pre-op
– CHG bathing +Iodophone nares swabs – Glucose testing and control – Patient instructions – Warming – 2gm abx standard dosing – 3gm for >250# – CHG skin scrub – “Strong for Surgery” – Carb loading
• Intra-op – Warming – Redose antibiotic for long procedures – Hyper-glycemic control – Wound protector – Clean fascia closure – changing gloves/gowns with hand hygiene
• Post-op – Low volume negative pressure wound vac – Nano-crystal silver – Glucose control – Patient education – Wound care
CHG Wipes Education Video
0.606 0.000
0.789 0.000
Colon SSI SIR
TG/AH - INF COUNT GSH - INF COUNT AMC - INF COUNT TGH/AH SIR - COLO
GSH SIR - COLO AMC SIR - COLO NHSN SIR Benchmark <1
Start of Colon Order Sets/Bundle
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0
3
0
10
6
5
0
4
11
4
5
4
2
Colon # Inf Current State
N=510 colons 2015
N=115 colons 2016
What advice do you have for me?
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Specialist MultiCare Health System
Phone: 253-697-2328
ROUNDTABLE DISCUSSION
Share what you are doing: what is working and not working? Ask questions of your peers Steal shamelessly!
5/3/2016 42 Oregon Association of Hospitals & Health Systems
THANK YOU
SSI Interest Group: Hospital Webinar #2Focus on Colon Surgery
Housekeeping items
Resources
Introductions
SSI Interest Group: Mary shanks & Donna BerningKaiser Westside Medical Center
Kaiser Westside Medical Center
Oregon health & science university facts:
Decreasing SSI risk
SSI A3 Colon Interventions [Bundle creation] based on literature reviews and learnings from successful organizations
OHSU Surgical Site Infection DATA
Recent Actions taken to move us to our SSI reduction goal
Slide Number 26
Summary – Key learnings
MultiCare Healthcare System
Historic Surgery Interventions