© The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011

Surgical Site Infection Tools for ImprovementSUSP

Armstrong Institute for Patient Safety and Quality2

Learning Objectives

• Review approach to SSI reduction as part of SUSP project.

• Review auditing tools to help identify local defects contributing to SSIs.

• Next steps

Armstrong Institute for Patient Safety and Quality3

Surgical Care Improvement Project (SCIP)

No single SSI prevention bundle

• Deeper dive into SCIP measures to identify local defects

• Emerging evidence– Abx redosing and weight based dosing – Maintenance of normogylcemia– Mechanical bowel preparation with oral abx – Standardization of skin preparation

• Capitalize on frontline wisdom– CUSP/Staff Safety Assessment

Armstrong Institute for Patient Safety and Quality4

Armstrong Institute for Patient Safety and Quality5

DEEPER DIVE INTO SCIP MEASURES TO IDENTIFY LOCAL DEFECTS

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Deeper Dive: Auditing

“…to make an audit of (performance) to evaluate or improve its safety, efficiency, or the like” http://dictionary.reference.com

www.visualthesaurus.com

Armstrong Institute for Patient Safety and Quality7

• Evaluate a sample of patients – (ie: the next 5-10 patients)

• Practical and feasible strategy to evaluate performance and surface defects

• Needs to be adapted to local environment

• Empowers frontline staff

Auditing Practice

Armstrong Institute for Patient Safety and Quality8

Auditing tools

• Antibiotic – Selection, dosing, redosing

• Normothermia • Glucose Control• Skin Prep • Others?

Armstrong Institute for Patient Safety and Quality9

SCIP 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 surgery colorectal surgery

 Antibiotics practices All cases (n = 3002) number (%)

Nonemergency (n = 2743) number (%)

Emergency cases (n = 248) number (%)

Was an SCIP-compliant antibiotic chosen? 2,431 (81.4%) 2,293 (83.6%) 130 (52.4%)

Was antibiotic given within 1 h before incision? 2,712 (90.8%) 2,544 (92.7%) 159 (64.1%)

Antibiotics weight-adjusted (n = 972) 552 (56.8%)    

Antibiotics redosed (n = 398) 24 (6.0%)    

Total surgical site infection 269 (9.0%) 245 (8.9%) 24 (9.7%)

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Perioperative Antibiotic Compliance:Michigan Surgical Quality Collaborative

Hendren et al. Am. J Surg 2011

Armstrong Institute for Patient Safety and Quality11

SCIP measure performance

Johns Hopkins ComparisonHospitals

Surgery patients who were given an antibiotic at the right time (within one hour before surgery) to help prevent infection

98% 97%

Surgery patients who were given the right kind of antibiotic to help prevent infection

98% 98%

Surgery patients whose preventive antibiotics were stopped at the right time (within 24 hours after surgery)

97% 96%

Surgery patients needing hair removed from the surgical area before surgery, who had hair removed using a safer method (electric clippers or hair removal cream – not a razor)

100% 100%

Patients having surgery who were actively warmed in the operating room or whose body temperature was near normal by the end of surgery.

98% 99%

Johns Hopkins HospitalMay 2010 SCIPHospital Comparewww.medicare.gov

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SUSP Antibiotic Audit Tool

Armstrong Institute for Patient Safety and Quality13

Antibiotic Compliance ProjectJohns Hopkins

Before After0

25

50

75

100

33%

92%

Correct Dose of Gen-tamicin Received

% o

f Pat

ient

s C

ompl

iant

Interventions:• Increased amount of

gentamicin available in the room

• Added dose calculator in anesthesia record

• Educated surgeons, anesthesia and nursing, anesthesia and nursing in grand roundsWick et al, JACS 2012

Armstrong Institute for Patient Safety and Quality14

SCIP 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 surgery colorectal surgery

Armstrong Institute for Patient Safety and Quality15

Johns Hopkins ComparisonHospitals

Surgery patients who were given an antibiotic at the right time (within one hour before surgery) to help prevent infection

98% 97%

Surgery patients who were given the right kind of antibiotic to help prevent infection

98% 98%

Surgery patients whose preventive antibiotics were stopped at the right time (within 24 hours after surgery)

97% 96%

Surgery patients needing hair removed from the surgical area before surgery, who had hair removed using a safer method (electric clippers or hair removal cream – not a razor)

100% 100%

Patients having surgery who were actively warmed in the operating room or whose body temperature was near normal by the end of surgery.

98% 99%

Johns Hopkins HospitalMay 2010 SCIPHospital Comparewww.medicare.gov

SCIP measure performance

Armstrong Institute for Patient Safety and Quality16

SUSP Normothermia Audit Tool

Armstrong Institute for Patient Safety and Quality17

Normothermia Project Johns Hopkins

Before After0

25

50

75

10083%

95%

Temperature > 36 °C post-op

% o

f Pat

ient

s C

ompl

iant

Interventions:• Confirmed that

temperature probes were accurate (trial comparing foley and esophageal sensors)

• Initiated forced air warming in the pre-operative area

• Heightened awareness

Armstrong Institute for Patient Safety and Quality18

Use your hospitals glucose goal

SUSP Glucose Control Audit Tool

Armstrong Institute for Patient Safety and Quality19

How Do We Conduct Audits?

• Retrospective chart review• Concurrent review

– Place audit tool on chart – Complete over continuum of care

• We recommend auditing 5-10 patients– Larger samples yield better estimates of

performance

• Your data does not need to be submitted

Armstrong Institute for Patient Safety and Quality20

Summary

• No single SSI prevention bundle– Need to identify local defects

• Auditing is a practical and feasible strategy to evaluate performance and surface defects

• Tools are adaptable to local environment

• Empowers frontline staff

Armstrong Institute for Patient Safety and Quality21

Action Items

• Pick 2-3 audit tools – [Add website for tools]

• Audit 5-10 patients with each tool

• Be prepared to share your experience with other teams on upcoming call

• Share your tools and ideas for new tools

Content Call Evaluation

We want to ensure that the content callsprovide useful and pertinent information for theSUSP teams. For this reason we request thatyou complete a brief evaluation following eachcall. The evaluation may be found at thefollowing link:

• https://www.research.net/s/SUSP_C1_2_Content_Eval

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