Reducing Colorectal Surgical Site Infections

Dr. Tom WallaceNSQIP Surgeon ChampionRoyal Inland HospitalKamloops, BC

Disclosures

None

How Many F’s?

FINISHED FILES ARE THERESULT OF YEARS OF SCIENTIFICSTUDY COMBINED WITH THEEXPERIENCE OF YEARS

Kamloops and TCSPopulation / Geography of Community

Served Kamloops 112,549 TCS 225, 813 (2011/2012)

Royal Inland Hospital (RIH)

5

216 In-patient bed hospital

RIH Operating Room Quality Initiatives

NSQIP ERACS Culture Checklist QIPS Unit Leader LEAN

NSQIP at RIH

Date Started – April 2011

Team Composition SCRs Clerk Quality Surgeon Champion Administration

NSQIPData Sharing

Display Boards Patient Safety Leadership

Walkrounds Monthly Reports Non Risk Adjusted

Reports Quarterly Risk Adjusted Reports IH Collaborative Presentations Physician Letters

Projects to date

Catheter Associated Urinary Tract Infections – Gynecology

Surgical Site Infections - Colorectal

NS PQI

NSQIP

UTI Success

Month Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan -13 Feb 13 Mar 13 April 13 May 13 June 13

Occurrence 3 5 6 5 4 2 6 4 2 2 1 0 2 0 2 0 2 3 1 0 1 2

# of Surgeries 94 137 159 138 159 161 156 106 70 120 119 143 129 169 99 120 158 160 96 151 160 158

0%

2%

4%

6%

8%

10%

12%

14%

RIH Post Op Catheter Associated Urinary Tract Infection Rates(Non Risk Adjusted Data)

CA UTI Occurrence Rate RIH Mean NSQIP Mean UCL

CA UTI Improvementproject initial intervention implemented

Identifying Opportunities for Improvement

Question:Please describe howyou think your next patientmay be harmed?

NSQIPOpportunities Identified

All Cases Morbidity: 96 observed events and 1680 total casesAll Cases SSI: 46 observed events and 1679 total cases

SSI Data

0%

5%

10%

15%

20%

25%

2%

22%

5%

1% 1% 1% 0%

5%

2%

Wound Occurrence by SubspecialtyJuly 2012 - June 2013

N=306 N=92 N=507 N=117 N=184 N=76 N=82 N=195N=9120 Occurrences

SSI Data

RIH SQAN NSQIP0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

22%

17.7%

11.2%

Colorectal SSI Occurrence Rate comparison between RIH, SQAN and NSQIP

July 2012 - June 2013(Non Risk Adjusted)

Colorectal SSI Occurrence Rate

Patient Profiles

< 2 > 30

10

20

30

40

50

60

70

80

90

72.4

27.6

82.8

17.2

81.9

18.2

Comparison of Risk Factors for Colectomy Patients between RIH, SQAN and NSQIP

(Non Risk Adjusted Data)O/E period July 2012 - June 2013

RIH SQAN NSQIP

Why rob a bank…

Because that’s where the money is!

Our Goal

Aim Statement:Decrease Colorectal Surgical Site

Infections 30% by March 31, 2014

Our SSI Plan Why re-invent the wheel?

Dellinger U of W Wick JH Cima Mayo Laflamme Joint Commission Edminston

Literature Review

RIH NSQIP SSI BundlePre-OpPatient received pre op scrub Optimal Hair Removal (Clippers or None)Appropriate antibiotic Timing (0-60 min pre cut time)

Appropriate antibiotic givenPre Op BGM ValuePre op Bowel Prep & Oral AntibioticIntra- OpAppropriate Isolation techniqueWound barrier usedAntimicrobial sutures usedAntibiotic re-dosing for surgeries > 4 hrsNormothermiaIntra Op fluid volumeIntra Op BGM ValuePost - OpNormothermiaTotal Fluid volume in PARHigh O2 for 1 hr in PARBGM in PARStandardized wound care orders given (Remove POD 2)

Care for your surgical site information sheet given : Post Op outcome? If yes identify outcome

SSI Bundle Driver Diagram

SSI Bundle Driver Diagram

Baseline AuditWhat is our current practice?

Data Sources Custom Fields Procedure Targeted

Can we get this Process Data?

Pre Op Scrub

Yes No0%

10%

20%

30%

40%

50%

60%

70%

80%

90%78%

22%

Pre Operative Scrub done on patients admitted day of surgery

N=18

Pre Op Scrub

Yes No0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

14%

86%

Pre Operative Scrub done on patients admitted prior

to surgeryN=7

Pre Op Albumin

Yes No0%

10%

20%

30%

40%

50%

60%

70%

36%

64%

Pre Operative Albumin TakenN=25

Antibiotic Timing

Yes No0%

10%

20%

30%

40%

50%

60%

70%60%

40%

Appropriate Abx TimingGiven within 0-60 cut time

N=25

Appropriate Antibiotic

Yes No0%

10%

20%

30%

40%

50%

60%

70%

80%

68%

32%

Appropriate Abx givenN=25

Pre Op Bowel Prep

Yes No0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

8%

92%

Pre Operative Bowel PrepN=25

Pre op Oral Antibiotics

Yes No0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0%

100%

Pre Operative Oral Abx givenN=25

Surgical Site Infection Rates following Elective Colectomy

The Michigan Surgical Quality Collaborative

Englesbe. Ann Surg 2010;252: 514–520

n=195

All patientsGet I.V. antibiotics

Per

cent

of

patie

nts

* P < 0.05

*

*

Oral Antibiotics with a Bowel Preparation

A Propensity Matched Analysis (n=740)

*

Englesbe. Ann Surg 2010;252: 514–520

All patientsGet I.V. antibiotics

Containment Technique

Yes No0%

10%20%30%40%50%60%70%80%90%

100%

Appropriate Containment TechniqueN=25

Wound Barrier

Yes No0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Wound Barrier UsedN=25

New Technology

Yes No0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Antimicrobial Sutures UsedN=25

Anaesthesia

Yes No0%

10%

20%

30%

40%

50%

60%

44%

56%

Intra Operative Warming (Bair Huggers) doc-umented

N=25

Yes No45%

46%

47%

48%

49%

50%

51%

52%

53%52%

48%

Intra Operative Temperature taken and doc-umented

N=25

Yes No0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0%

100%

Intra Operative BGM TakenN=25

Anaesthesia

Average Time: 2:55 hrs (175 min)Average Crystalloid 1504 mlAverage Colloid 841 ml

Average Crystalloid over time: 515.7 ml / hrAverage Colloid over time: 288.3 ml / hr

Standardize Post Operative Wound Care

Yes No0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

16%

84%

Standardized Wound Care Orders Given (Removal POD 2)

N=25

Standardize Post Operative Wound Care

Yes No0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Surgical Site Incision Info Sheet ProvidedN=25

Our Journey Continues….

Early in the process Information gathering

phase

Auditing Post implementation process Measures Correspond to outcome

measures

Share, Share, Share the data

42

The future state…

43

Stay Tuned ……..

Questions?

44