SCIP: Preventing Surgical Site Infections

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SCIPPreventing Surgical Site Infections

• Gary Kanter, M.D.
• Betsy Lehman Center
• December 4, 2007

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www.medqic.org/sip
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Surgical Care Improvement Project

• National Quality Partnership
• CMS,CDC
• Reduce nationally the incidence of surgical
  complications by 25 by 2010
• (13,027 deaths, 271,055 complications)/yr
• Focus on
• Surgical infection prevention
• Adverse cardiac events
• Prevention of DVT
• Post operative pneumonia
• Using evidence based medicine

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How often do patients receive scientifically
indicated care in this country?

• Near 100- we are doing a great job
• 75- not too shabby
• 55- flip a coin
• What does science have to do with medicine?

• McGlynn, et al The quality of health care
  delivered to adults in the United States. NEJM
  2003 348 2635-2645 (June 26, 2003)

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How often do patients receive scientifically
indicated care in this country?

• Near 100- we are doing a great job
• 75- not too shabby
• 55- flip a coin
• What does science have to do with medicine?

• McGlynn, et al The quality of health care
  delivered to adults in the United States. NEJM
  2003 348 2635-2645 (June 26, 2003)

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Surgical Infection (SI) Epidemiology Impact

• Account for 14-16 of all Hospital Acquired
  Infections (HAI)
• 2-5 of operative patients will develop SI
• 0.8-2 million infections a year
• SI increase LOS
• Average 7.5 additional days
• Excess costs
• 130-845 million per year
• Adds 2,734 - 26,019 per pt (average 3,000)
• Pain and suffering

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SI Epidemiology Impact

• Patients who develop infection are
• 60 more likely to spend time in an ICU
• 5 times as likely to be readmitted
• Have a mortality rate twice that of noninfected
  patients
• An estimated 40-60 of these infections are
  preventable

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Business Case for SCIP
APU increased to 2
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Business Case for SCIP
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Baystate Medical Center

• 700 bed tertiary care referral center
  (population of 1M)
• Flagship of Baystate Health
• 41 k admissions/year
• Annual surgical volume 29,043
• Western Campus of TUFTS
• Member CoTH, 9 residency programs, 244 residents
• 1200 member medical staff, 206 faculty MDs
• Level 1 Trauma Center
• IHI Mentor Hospital Surgical Infection Prevention

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Use of antimicrobial prophylaxis for major
surgery baseline results from the National
Surgical Infection Prevention Project Arch
Surg. 2005 Feb140(2)174-82.
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Quality Improvement Process

• Benchmarking, measurement, and feedback
• Work with key physician champions
• Disseminate recommendations to educate
• Use physician order entry
• Enlist help of case managers as quality safety
  net
• Use PDSA cycles to test and improve

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Prophylactic Antibiotics

• Antibiotics given for the purpose of preventing
  infection when infection is not present but the
  risk of post-operative infection is present

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Prophylactic AntibioticsQuestions

• Which cases benefit?
• When should you start?
• Which drug should you use?
• How much should you give?
• How long should antibiotics be continued?

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Recently Updated Antibiotic Recommendations
For the purposes of national performance
measurement a case will pass the antibiotic
selection performance measure if vancomycin is
used for prophylaxis (in the absence of a
documented beta-lactam allergy) if there is
physician documentation of the rationale for
vancomycin use (effective for July 2006
discharges).
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Recently Updated Antibiotic Recommendations
(continued)
Ciprofloxacin, levofloxacin, gatifloxacin, or
moxifloxacin (effective for July 2006
discharges). For the purposes of national
performance measurement, a case will pass the
antibiotic selection indicator if the patient
receives oral prophylaxis alone, parenteral
prophylaxis alone, or oral prophylaxis combined
with parenteral prophylaxis.
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Prophylactic AntibioticsQuestions

• Which cases benefit?
• When should you start?
• Which drug should you use?
• How much should you give?
• How long should antibiotics be continued?

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Timing of Antibiotic ProphylaxisGI Operations
Stone HH et al. Ann Surg. 1976184443-452.
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Perioperative Prophylactic AntibioticsTiming of
Administration
14/369
15/441
1/41
1/47
Infections ()
1/81
2/180
5/699
5/1009
Hours From Incision
Classen. NEJM. 1992328281.
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Antibiotic Timing Related to Incision
Bratzler DW, Houck PM, et al. Arch Surg.
2005140174-182.0
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Visual Prompt and data collection
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Never Underestimate the Power of Competition
BMC AB Timing by Anesthesiologist
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Quality IndicatorsNational Surgical Infection
Prevention Project

• Quality Indicator 2
• Proportion of patients who receive prophylactic
  antibiotics consistent with current
  recommendations

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Antibiotic Recommendation Sources

• American Society of Health System Pharmacists
• Infectious Diseases Society of America
• The Hospital Infection Control Practices Advisory
  Committee
• Medical Letter
• Surgical Infection Society
• Sanford Guide to Antimicrobial Therapy 2003

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Antibiotic Selection - Successful
Interventions

• Distribution of guidelines to perioperative staff
  (standardize practice)
• Antibiotic selection and ordering (standardize
  process, opt out for selection)
• Decision aids in the system (active prompt )
• Use of cephalosporins and vancomycin/gentamicin
  in penicillin allergic patients
• Reviewed and revised AB selections in computer
  order sets (opt out, forcing function)

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Clin Infect Dis. 2004381706-1715.
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Expanded pt populations
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• Quality Indicator 3
• Proportion of patients whose prophylactic
  antibiotics were discontinued within 24 hours of
  surgery end time

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Discontinuation of Antibiotics
Patients were excluded from the denominator of
this performance measure if there was any
documentation of an infection during surgery or
in the first 48 hours after surgery.
Bratzler DW, Houck PM, et al. Arch Surg.
2005140174-182.
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Antibiotic Prophylaxis Duration

• Most studies have confirmed efficacy of ? 12
  hours
• Many studies have shown efficacy of a single dose
• Whenever compared, the shorter course has been as
  effective as the longer course

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Papers Comparing Duration of Peri-op Antibiotic
Prophylaxis

• Colorectal 3
• Mixed GI 4
• Hysterectomy 3
• Gyn GI 1
• Head Neck 3
• Orthopedic 4
• Vascular 3
• Cardiac __7__
• Total 28
• Papers supporting longer duration 1

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• Duration of prophylactic antibiotic
  administration should not exceed the 24-hour
  post-operative period
• Prophylactic antibiotics should be discontinued
  within 24 hours of the end of surgery
• Medical literature does not support the
  continuation of antibiotics until all drains or
  catheters are removed and provides no evidence of
  benefit when they are continued past 24 hours

http//www.aaos.org/wordhtml/papers/advistmt/1027.
htm
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Consequences of Prolonged AB Use

• Increased antibiotic and drug administration
  costs
• Increased antibiotic-associated complications
• Increased patterns of antibiotic resistance
• Clostridium difficile Enterocolitis
• Colonization with MRSA

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Barriers Antibiotic Use

• Timing
• Consistency
• Sustainability (constant monitor)
• Selection
• Resistance (surgeons and organism)
• Availability national consensus issues
• Duration
• Knowledge gap
• If its not broke, don't change it

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NNISS Benchmark 2-11
Surgical Infection Rate
1.13
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Duration of Antibiotic ProphylaxisWhat is Best
for Our Patients?

• Antibiotic prophylaxis is one of many methods for
  reducing the incidence of SSI
• There is a lack of evidence that antibiotics
  given after the end of the operation prevent SSIs
• There is evidence that increased use of
  antibiotics promotes antibiotic resistance

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Glycemic Control
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Diabetes Complications

• Estimated 10 million Americans
• Poor glucose control is associated with
• Increased risk of infection
• Delayed healing
• Increased mortality
• Blunts inflammatory response

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Diabetes, Glucose, Control and SI
Infections ()
Latham,ICHE 2001 22607-12
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Glucose Control and Deep Sternal Wound Infections
Furnary et al. Ann Thorac Surg 199967352
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Survival increased with intensive insulin therapy
( nondiabetic patients included ) targeting BG
80-110 mg/dL
Van den Berghe et al. NEJM 2001 3451359-1367
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Glycemic Control

• Established IV insulin protocol for cardiac
  surgery patients with known diabetes (Pre-op BG
  75 mg/dl) and all others (Pre-op BG 150 mg/dl)
• The protocol was developed by surgeons,
  anesthesiologists, endocrinologists, and nursing
• Insulin infusions to be initiated in OR
• Insulin infusion to be used for the duration of
  post-op period while the patient is in cardiac
  intensive care unit (CICU)
• Endocrine referral if insulin infusion is
  utilized
• Conversion protocol (IV infusion to sliding scale)

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Diabetes, Glucose Control, SIsICHE 2001 22
607-12

• Summary
• Peri-operative hyperglycemia and diabetes are
  associated with increased risk of SIs
• Early diagnosis of diabetes among high-risk
  patients may have short and long-term benefits

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Hair RemovalPre-operative Shaving

• Shaving the surgical site with a razor induces
  small skin lacerations
• Potential sites for infection
• Disturbs hair follicles which are often colonized
  with S. aureus
• Risk greatest when done the night before
• Patient education
• be sure patients know that they should not do you
  a favor and shave before they come to the
  hospital!

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Shaving, Clipping SI
Infections ()
Alexander. Arch Surg 1983 118347
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Hair Removal

• Preoperative shaving of the surgical site the
  night before an operation is associated with a
  significantly higher SI risk than either the use
  of depilatory agents or no hair removal
• Do not remove hair preoperatively unless the hair
  at or around the incision site will interfere
  with the operation (Category IA)
• If hair is removed, remove immediately before the
  operation, preferably with electric clippers
  (Category IA)

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Cochrane Database Syst Rev. 2006 Apr 19(2)

• Three trials involving 3193 patients
• Compared shaving with clipping
• Statistically significantly more SSIs when people
  were shaved rather than clipped (RR 2.02, 95CI
  1.21 to 3.36)

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Interventions

• Razors removed from ORs
• Razors removed from most clinical areas
• Patients may use razors for personal hygiene

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HYPOTHERMIA

• Increased myocardial ischemia VT
• Bleeding and increased transfusion requirements
• Surgical wound infections prolonged
  hospitalizations
• Lower pain threshold
• Drug metabolism decreased

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Temperature and SSI Following Colectomy

• Normo (N104) Hypo (N96) P
• SSI 6 18 .009
• Collagen dep 328 254 .04
• Time to eat 5.6d 6.5d

Kurz. NEJM 19963341209
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Normothermia

• Standardization
• Pre warm
• Removed random number generators
• One device and one measure (first PACU temp)
• Review by patient populations
• Education/communication
• Room set point pre-op
• Increased temperature upon pt arrival to room
  until draped
• Staff comfort balanced against patient centered
  care
• Products
• Forced hot air
• Warm fluids
• Cooling vests
• Temporal thermometers

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Barriers - Normothermia

• Staff comfort
• Expense
• Knowledge gap
• Impact
• Importance
• Consistent application

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Potentially PreventableThis complication may not
have occurred with the application of every
indicated prevention measure

• Apparently Unavoidable
• Despite the application of every indicated
  prevention measure the complication occurred
  anyway
• A mystery

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Surveillance

• List of patients sent to each surgeon, 30 days
  post procedure
• 97 return rate (SASE, interoffice mailing)
• Self report any post operative infection/
  comments
• Daily admissions with wound infection
• Review for surgical date and s/s infection
• Daily microbiology reports of all cultures
  reviewed for wound, fluid cultures, e.g joint
  aspirates
• Charts reviewed for NNIS criteria, surgical date
  and s/s infection

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Investigation

• NNIS criteria ASA, Wound Class, Length of
  Procedure
• Presence of interventions
• Antibiotic use
• Surgical prep and skin condition
• Implants
• Cluster evaluation
• Specific conditions of the patient
• Surgical environment
• Organism
• Surgical team

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Potentially Preventable Review

• All infections reviewed for potential
  preventability using SCIP guidelines
• Reviewed using other criteria as well
• Review done by IC dept and fed back to multiple
  cmts (COI, SCIP, SPIT, SAQI)
• System level changes made when applicable
• Consistently, 50 of infections have a SCIP
  miss!!

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Where Do Things Fall Through the Cracks?

• System information, tests, diagnoses
• Communication
• Hand offs
• Failure to recognize
• Failure to activate
• Failure to rescue

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Improvement Tools

• Systems
• Populations
• Cycles of Change
• PDSA, Six Sigma, LEAN
• Process Analysis
• Failure Mode Identification
• BH PI Tool Kit

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Keys to Success

• Persistence and reinforcement/high visibility
• Senior leader support
• Multidisciplinary cooperation collaboration
• Accurate, timely and relevant data
• Right people
• Willing to try changes and take a risk
• Develop reliable systems (strive for 10-2 90)
• Incorporate into workflow
• Make changes easy and transparent
• Stress importance of impact on patient and
  practitioner
• Make The Right Thing The Easy Thing

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Lessons Learned

• Involve all stakeholders
• Leave your stripes at the door
• Must have physician champions- credible
• Be humble
• Take more blame and give more credit
• BROAD shoulders
• Must work as team
• Small tests of change with frequent tempo
• Small pilot population
• Work within your culture
• Steal shamelessly
• Make the right thing the easy thing

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• Medicine used to be simple, ineffective, and
  relatively safe.
• Now it is complex, effective, and potentially
  dangerous.
• Sir Cyril Chantler
• 1999 Hollister Lecture at Northwestern
  University, Illinois
• James, B. 16th IHI Conference

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For More Information

• Gary Kanter, M.D.
• gary.kanter_at_bhs.org
• Department of Anesthesiology
• Baystate Medical Center
• Springfield MA 01199
• 413 794 3520