The Bundle Approach to Reducing Surgical Site Infections

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The Bundle Approach to Reducing Surgical Site
Infections

• Virginia Lipke, RN, BS, ACRN, CIC
• Infection Control Practitioner
• The St. Luke Hospitals
• Ft. Thomas and Florence, Ky.
• September 9, 2008

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Outline

• Introduction to St. Luke Hospitals
• Standardizing Care
• Bundles in general are evidence based
• Impact of IHI 100,000 Lives Campaign
• Surgical Site Infection Risks Considerations
• Surgical Volume
• Targeted Infection Control Surveillance
• MRSA Bundle as an example
• Focus on Value of Bundle and Process

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About St. Luke Hospitals
St. Luke Hospitals, Inc. (SLH) consist of two
community facilities

• St. Luke Hospital East 310 bed facility
  located in Ft. Thomas, KY
• St. Luke Hospital West 177 bed facility
  located in Florence, KY

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Standardizing Care

• General agreement that standardization of care
  will improve efficiency of care and result in
  better outcomes
• IHI (Institute of Health Improvement)
  100,000 Lives Campaign
• Directed standardization of care
• Rapid Response Teams
• Medication Reconcilliation
• Ventilator-Associated Pneumonia
• Bloodstream Infections
• AMI
• SSI
• Creation and implementation of bundles or care
  paths facilitated care for these initiatives

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Methodology for Bundle Development

• Identify need and create clinical and business
  case
• Secure administrative support and medical staff
  buy-in through communication at various clinical
  committees
• Define the process and protocol for the bundle
• Complete implementation of the bundle
• Continued monitoring and evaluation

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Leveraging Findings for Organizational change

• Present findings to all committees
• Suggest protocol and practice changes
• Secure physician champions
• Bring in local talent to help
• Do your own study and share results
• Know the community standard

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Sustaining Impact and Results

• Ongoing monitoring
• Quantify results clinically and financially
• Communication of results to all stakeholders
• Reinforce education
• Physicians, clinical staff patients
• Revisit community and national data

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Adoption of Protocols and Bundles at St. Luke
Hospitals

• Employing a systematic approach and following a
  set methodology for protocol and bundle
  implementations resulted in success and
  credibility
• Pneumococcal Vaccination
• IHI 100,000 Lives Campaign Initiatives
• Mentor status for 4 of the initiatives
• Significant decrease in non-ICU codes
• No Ventilator Associated Pneumonia in 34 months
• IHI 5 Million Lives Campaign
• DVT Protocol implementation December 2008

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Surgical Site Infections (SSIs) Magnitude of the
Problem

• 1996 28.4M ambulatory surgery procedures in the
  U.S.(CDC, National Center for Health Statistics)
• 2003 30.8M inpatient surgical procedures and
  9.7M (37) of those performed on patients gt65
  years (CDC,National Center for Health Statistics)
• NNIS SSIs occur in 2.6¹ of all surgeries 1.5M
  SSIs annually
• Attributable cost 25,5246 (range 1,783
  -134,602)²
• 1.Mangram,AJ,et al.,Guidelines for the Prevention
  of Surgical Site Infections,1999,CDC. 2.Stone,PW
  et al.,Am J Infect Control,2005
• 2.Stone,PW, et al.,Am.J.Infect.Control,200533(9)
  501-9

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SSI Risk Factors for the Patient

• Age
• Nutritional Status
• Diabetes
• Nicotine Use
• Obesity
• Coexisting Infection
• Altered Immune Response
• Long Preoperative Stay

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Risk Factors for SSIPre-and Intraoperative

• Inappropriate use of antibiotic prophylaxis
• Infection at remote site
• Shaving versus clipping or no hair removal
• Improper skin preparation
• Improper hand antisepsis by operating room team
• Long duration of surgery
• Surgical attire and drapes
• Environment of room, (ventilation
  sterilization)
• Surgical technique homeostasis, sterile field, O2

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Surgical Care at St. Luke Hospitals

• Routine monitoring and surveillance
• Identification of risk associated with MRSA
• Business case for MRSA bundle
• Implementation of bundle
• Evaluating impact of bundle

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Surgical Volume and Infection Control Monitoring

• Total Surgeries
• Over 10,000 cases per year
• Targeted Surveillance
• C-Sections
• Total Hips
• Total Knees
• Gastric By-pass and Bandings
• Fusions
• Craniotomies
• Overall infection rates are low

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SLH SSI Rate
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Internal External Data

• Lab reports and testing methods
• Past years IC report compared to NNIS
• Antibiograms for the past years
• Literature searches-beware of old data and be
  open to new data
• What is our current practice?
• What new surgical services are we adding?
• What are the risks?

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Why Should Hospitals Place Greater Emphasis on
How Skin is Prepped?

• When we consider pathogenesis of SSI, it has been
  accepted for decades that most SSI are endogenous
  in nature.
• Usual Suspects
• S. aureus
• Co Ag Negative Staph
• E.coli
• K.oxytoca
• S.pneumonaie
• P.aeruginosa
• S.marcescens

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Community Hospital Impact

• St. Luke Hospitals Emergency Department visits
  where MRSA was noted for skin and soft tissue
  infections
• 8 MRSA-related Surgical Site Infections (SSIs)
  in
• CY2006 (47 of total SSIs) 0 in previous
  years
• Increased awareness by Emergency, Obstetrics,
  and
• Surgery Practitioners

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Projected Cost of MRSA Bundle
Potential SSI Cost Avoidance (based on CY2006
numbers) 5 SSI cases at 40,0002
200,000
2 Engemann, Clin.Inf.Dis 200336592-598.
Nicholson, AJIC 20063444-48.
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SLH MRSA Bundle

• Nasal cultures on all surgical patients in
  pre-admission testing (PAT) and hospital-based OB
  patients at 36-week visit
• All pre-admission surgical patients given 2 CHG
  (chlorhexadine) bathing cloths for use the day of
  surgery expecting mothers have 2 CHG cloths
  applied prior to delivery
• If patient is MRSA positive, 2 Mupirocin is
  applied to both nares prior to surgery
• MRSA () patients are provided with educational
  brochure Living with MRSA1

1 Resource created by Washington State Public
Health Department
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Implementing the MRSA Bundle

• Nasal swab training for PAT and hospital-based OB
  staff
• Coordination w/ lab
• Coordination w/ pharmacy
• Communication plan for result notification
• Data tracking and monitoring
• Patient education
• Staff education
• Physician education

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Timeline
November-December 2006
January 2007
March 2007
November 2007
CA-MRSA is noted to be impacting SSI rates
MRSA Bundle standing orders approved by Medical
Executive Committee
Surgery Committee proposes single dose of
Mupirocin for patients whose lab results are not
available prior to surgery
Proposed MRSA Bundle presented to various
clinical committees
October 2006
May 2007
December 2006-January 2007
February 2007
Review of existing best practices clinical and
financial impact analyses completed
All pre-admission testing and hospital-based OB
patients are screened for MRSA
1 MRSA-related SSI in initial nine months of
program
Letters are sent to Medical Staff proposing MRSA
Bundle protocol
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SLH MRSA Bundle Process

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Results and Impact

• Screening of all surgery patients who go through
  pre-admission testing ( 65 of all surgeries)
• Screening of all OB patients from St. Luke
  Physicians for Women Service ( 60 of all
  deliveries)
• Percentage of surgery patients with positive MRSA
  culture 3.9
• March December
• Two Surgical Site Infections
• One MRSA SSI (C-Section)

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Results and Impact
St. Luke Hospitals Combined Surgical MRSA Culture
Activity
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Barriers and Challenges

• Regular cultures have 2 day turn-around time
• Patients having pre-admission testing less than
  48 hours prior to surgery (culture results not
  available)
• Investigation into current lab collection and
  transport processes
• Timely communication with physician about
  positive results
• Questions about treatment for colonized MRSA
• Some physicians wanting to treat all colonization
  with vancomycin
• Patients reaction to positive culture results

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Where Do We Go From Here?

• Ongoing analysis of impact
• Continue to educate physicians about treating
  their patients with MRSA
• Continued education to patients and community
  about preventing and living with MRSA
• Expand scope of program to include inpatient and
  emergent surgery cases with possible expansion to
  all new admissions
• Consider utilization of a rapid screen test
• Evaluation and consideration of protocol revisions

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Our Goal
Drive to Zero!!
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Questions
Ginny Lipke [phone] Virginia.Lipke_at_healthal
l.com