Improving Surgical Care

1
Improving Surgical Care The Expanded Infection
Module Normothermia, Glucose Control and Hair
Removal

• Stephanie McKoin R.N., M.P.A.H.S.A
• Clinical Director of Perioperative Services
• Wellspan Health-York Hospital
• York, PA

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Why focus on surgical quality?

• 40 million major operations each year
• in the US.
• Despite improvements in perioperative care and
  advances in surgical and anesthesia technique,
  variations in patients surgical outcomes are well
  known.

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Why focus on surgical quality?

• Among the most common complications
• Surgical site infections (SSIs) and postoperative
  sepsis.
• Cardiovascular complications including myocardial
  infarction.
• Respiratory complications including postoperative
  pneumonia and failure to wean.
• Thromboembolic complications.

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Medicare Surgical Infection Prevention (SIP)
Project Objective

• To decrease the morbidity and mortality
  associated with postoperative infection in the
  Medicare patient population.

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Opportunity to Prevent Surgical Infections

• An estimated 40-60 of SSIs are preventable.
• Overuse, underuse, improper timing and misuse of
  antibiotics occurs in
• 25-50 of operations.

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Surgical Site Infections (SSI)
2

• 2-5 of surgical patients will develop SSI
• 40 million operations annually in the US
• 0.8 - 2 million SSIs occur annually in the US
• SSI increases length of stay in hospital
• Average 7.5 days
• Excess cost per SSI
• 2,734-26,019 (1985, US)
• US national costs 130-845 million/year

Jarvis, Infect Control HospEpidemiol. 199617.
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Surgical Care Improvement Project
(SCIP)National Goal
36

• To reduce preventable surgical
• morbidity and mortality by 25
• by 2010.

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SCIP Steering Committee
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• American College of Surgeons
• American Hospital Association
• American Society of Anesthesiologists
• Association of Peri-Operative Registered Nurses
• Agency for Healthcare Research and Quality

• Centers for Medicare Medicaid Services
• Centers for Disease Control and Prevention
• Department of Veterans Affairs
• Institute for Healthcare Improvement
• Joint Commission on Accreditation of Healthcare
  Organizations

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Quality IndicatorsNational Surgical Infection
Prevention Project

• Proportion of patients who have their antibiotic
  dose initiated within 1 hour before surgical
  incision.
• (2 hours for vancomycin or fluoroquinolones)
• Proportion of patients who receive prophylactic
  antibiotics consistent with current
  recommendations. (published guidelines)
• Proportion of patients whose prophylactic
  antibiotics were discontinued within 24 hours of
  surgery end time. (48 hours for cardiac surgery)

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Surgical Care Improvement ProjectThe Expanded
Infection Module
39

• Surgical infection prevention
• Glucose control in cardiac surgery patients
• (lt 200 mg/dL).
• Blood glucose closest to 0600 on PO day 1 and 2
• (surgery end date is PO day 0).
• Proper hair removal.
• No hair removal, clippers, or depilatory.
• Normothermia in colorectal surgery patients.
• Temperature between 96.8-100.4 F within the
  first hour after leaving the OR.

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SCIP Infection 4

• Cardiac Surgery patients with controlled 6 a.m.
  postoperative serum glucose.

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Diabetes, Glucose Control and SSIs After Median
Sternotomy

• Latham. ICHE 2001 22 607-12

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Hyperglycemia and Risk of SSI after Cardiac
Surgery

• Hyperglycemia-doubled the risk of SSI.
• Hyperglycemic
• 48 of diabetics
• 12 of nondiabetics
• 30 of all patients
• 47 of hyperglycemic episodes were in non
  diabetics.

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Deep Sternal SSI and Glucose
Deep Sternal Infection
Day 1 Glucose (mg )

• Zerr . Ann Thorac Surg 1997 63356

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Diabetes, Glucose Control and SSI
ICHE 2001 22607-12
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York Hospital Glycemic Control Cardiac Surgery

• Worked in close collaboration with Operating
  Room, Anesthesia, Pharmacy and Nursing to improve
  glycemic control in our cardiothoracic surgery
  population of patients as a means to reduce
  surgical site infections.
• Task force formed.
• Developed protocol.
• Portland Protocol implemented in Cardiac
  Operating Rooms in December 2005.
• Prior to protocol implementation patients were
  started on protocol immediately postoperative in
  the Open Heart ICU.
• Currently in the process of revising protocol.

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York Hospital Glycemic Control Cardiac Surgery
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SCIP Infection 6

• Surgery patients with appropriate
• hair removal.

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Pre-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 and SSI
Infected
Cruse. Arch Surg 1973 107206
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SCIP Infection 7

• Colorectal surgery patients with immediate
  postoperative normothermia.

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Temperature Control

• 200 colorectal surgery patients
• Control - routine intraoperative thermal care
• (mean temp 34.7C)
• Treatment - active warming
• (mean temp on arrival to recovery 36.6C)
• Results
• Control - 19 SSI (18/96)
• Treatment - 6 SSI (6/104), P0.009

Kurz A, et al. N Engl J Med. 1996. Also Melling
AC, et al. Lancet. 2001. (preop warming)
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HYPOTHERMIA

• Major Complications
• Increased myocardial ischemia and VT.
• Bleeding and increased transfusion requirements.
• Surgical wound infections and prolonged
  hospitalizations.
• Management Strategy
• Monitor body temperature
• Forced air and/or increased room temperature
• Use of fluid warmers

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York Hospital- Normothermia for all
postoperative patients
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Prevention of SSIs in our Operating Rooms

• Antibiotics
• Glycemic control
• Temperature control
• Clipping

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Lessons Learned/Barriers to Implementation

• In Jan. 2004 the anesthesia providers started
  administering the pre operative antibiotics
  resulting in a significant improvement in
  antibiotic administration pre operatively.
• Revised standardized orders to automatically
  discontinue antibiotics at 24 hours post
  operatively.
• Increased the utilization of active warming
  devices (air and fluid) in the OR to maintain
  normothermia in our surgical patients.
• In Dec. 2005 the cardiac anesthesiologists
  implemented the Portland Protocol for our
  cardiac surgery patients.

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Questions