Antibiotic Lecture

2/23/11

1

Perioperative Antibiotic Prophylaxis: What Anesthesia

Needs to Know

Neil Roy Connelly, MD Professor of Anesthesiology

Tufts University School of Medicine

Outline

  Science/History   Consensus   Oversight   Results   Process

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Antibiotic Prophylaxis in Gastric, Biliary and Colonic Surgery, 1976

  400 patients   4 groups:

  Early (12 hrs before incision)   Preoperative (1 hr before incision)   Postoperative (1 hr after closure)   None

Antibiotic Prophylaxis in Gastric, Biliary and Colonic Surgery

  Early = Preoperative   Early/Preoperative better than None   Postoperative = None

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0%

5%

10%

15%

20%

12 hr Preop 1 hr Preop Postop Placebo

Stone HH et al. Ann Surg. 1976;184:443-452.

Timing of Antibiotic Prophylaxis GI Operations

  2847 patients   4 groups:

  Early (2-24 hrs before incision)   Preoperative (2 hrs before incision)   Perioperative (3 hrs after incision)   Postoperative (3-24 hrs after incision)

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Infection Rates

  Early 3.8%   Preoperative 0.6%   Perioperative 1.4%   Postoperative 3.3%

0

1

2

3

4

≤-3 -2 -1 0 1 2 3 4 ≥5

Classen. NEJM. 1992;328:281.

Perioperative Prophylactic Antibiotics

Timing of Administration

Infe

ctio

ns (%

)

Hours From Incision

14/369

5/699

5/1009

2/180 1/81

1/41 1/47

15/441

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Bratzler, et al…Advisory Statement

  3 Measures:   Tiiming   Correct Choice   Duration of therapy

Bratzler, et al…Advisory Statement

  Timing: within 1 hr   vs 30 min…vs 120 min   consensus opinion not scientific proof   Quality projects

  Correct Choice   Duration of therapy

  No evidence >24 hrs offers benefit   >24 hrs does inc resistance/ c diff

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Bratzler, et al.: Results

  Tiiming: 55.7%   Correct Choice: 92.6%   Duration of therapy: 40.7%

2.7 1.24.3

20.3

56

2.8 1.4 0.9 0.9

9.6

0

10

20

30

40

50

60

> 240

240-181

180-121

120-61

60-0 0-60

61-120

121-180

181-240

> 240

Minutes Before or After Incision

Per

cent

Inci

sion

Antibiotic Timing Related to Incision

Bratzler DW, Houck PM, et al. Arch Surg. 2005;140:174-182.0

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www.medqic.org/sip

Surgical Care Improvement Project

  Formerly SIP

  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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Surgical Infection (SI): Epidemiology & Impact

  SSI = Surgical Site Infection   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: Patients who develop infection

 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

IPPS Inpatient Prospective Payment System

APU Annual Payment Update

APU in

crease

d to 2

%

Financial Incentive for SCIP

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Baystate Medical Center   700 bed tertiary care referral center (population of

~1M)   41 k admissions/year   Annual surgical volume: 29,043   Member CoTH, 9 residency programs, 244

residents---Council of Teaching Hospitals   1200 member medical staff, 206 faculty MDs   Level 1 Trauma Center   IHI Mentor Hospital Surgical Infection Prevention—

institute for health care improvement

SIP Baseline 2002

0

20

40

60

80

100

SCIP 1 SCIP 2 SCIP 3

% P

atie

nts

BMC Baseline 02

National Baseline 02

Use of antimicrobial prophylaxis for major surgery: baseline results from the National Surgical Infection Prevention Project Arch Surg. 2005 Feb;140(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   HAVE BUY IN…ADMINISTRATION

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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Questions

  Which cases benefit?

  When should you start?

  Which drug should you use?

  How much should you give?

  How long should antibiotics be continued?

Recently Updated Antibiotic Recommendations

Surgery Type Antimicrobial recommendations

Hip or knee arthroplasty

Preferred: Cefazolin or cefuroxime If patient high risk for MRSA: Vancomycin*

Beta-lactam allergy:   Vancomycin or clindamycin

Cardiac or vascular Preferred: Cefazolin or cefuroxime If patient high risk for MRSA: Vancomycin*

Beta-lactam allergy:   Vancomycin or clindamycin

* 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).

Recently Updated Antibiotic Recommendations (continued)

Surgery Type Antimicrobial recommendations

Hysterectomy •  Cefotetan, cefazolin, cefoxitin, cefuroxime, or ampicillin-sulbactam

•  Beta-lactam allergy: •  Clindamycin + gentamicin or fluoroquinolone* or aztreonam •  Metronidazole + gentamicin or fluoroquinolone* •  Clindamycin monotherapy

Colorectal † •  Neomycin + erythromycin base; neomycin + metronidazole •  Cefotetan, cefoxitin, cefazolin + metronidazole, or ampicillin- sulbactam

Beta-lactam allergy: •  Clindamycin + gentamicin or fluoroquinolone* or aztreonam •  Metronidazole + gentamicin or fluoroquinolone*

* 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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Questions






Visual Prompt and data collection

Never Underestimate the Power of Competition

BMC AB Timing by Anesthesiologist

0

10

20

30

40

50

60

70

80

90

100

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

% P

atie

nts

20042005Jan-June 2006July-Dec 2006

BMC AB Timing by Anesthesiologist

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Memorandum

DIVISION OF HEALT H CARE QUALITY TO: , MD FROM: Associate Medical Director DATE: , 2006 SUBJECT: SCIP (Surgical Care Improvement Program) As part of the SCIP process, the medical record of PATIENT was reviewed. As eviden ced by the attached documentation , it appears that the patient’s prophylactic pre - operative antibiotic w as :

_____ given greater than 1 hour prior to th e initial incision time , _____ not re - dosed. _____given after the initial surgical incision. _ X __not g iven at all ( no time of administration was documented)

Please remember that current standard of practice is • prophylactic pre - operative an tibiotic administration within 60 minutes p rior to the incision (Levaq uin

and Vancomycin are within 120 minutes pri or to the incision ). • Re - dosing of antibiotics if the case extends beyond 3 hours when cefazolins are used

Please contact me at 4 4326 if you have any questions. Thank you .

SIP: Prophylactic AB given < 60 M Prior to IncisionBaystate Medical Center

Springfield MA USA

0

20

40

60

80

100

Apr-0

2

Jun-02

Aug-02

Oct-02

Dec-02

Feb-03

Apr-0

3

Jun-03

Aug-03

Oct-03

Dec-03

Feb-04

Apr-0

4

Jun-04

Aug-04

Oct-04

Dec-04

Feb-05

Apr-0

5

Jun-05

Aug-05

Oct-05

Dec-05

Feb-06

Apr-0

6

Jun-06

Aug-06

% P

ati

en

ts

National Top Decile

BMC Rate

SIP starts

Initial education all staff, Rates adoped for monthly report to PI teams

Pre op gives AB

Anesthesiologists to give Absrates posted in OR

Ongoing 1:1 review of outliers

Pre printed prompt on Anesthesia

record

Improved documentation

Anesthesiologist specif ic score card adopted for

posting; Ongoing 1:1 review of outliers

Ongoing Review

BMC Prophylaxis AB Timing (within 60 M of incision)

0

20

40

60

80

100

Apr-02

Jun-02

Aug-02

Oct-02

Dec-02

Feb-03

Apr-03

Jun-03

Aug-03

Oct-03

Dec-03

Feb-04

Apr-04

Jun-04

Aug-04

Oct-04

Dec-04

Feb-05

Apr-05

Jun-05

Aug-05

Oct-05

Dec-05

Feb-06

Apr-06

Jun-06

Aug-06

Oct-06

Dec-06

Feb-07

% P

atie

nts

National Top Decile

BMC Rate

BMC Prophylaxis AB Duration (DC within 24 H surgery end time )

0

20

40

60

80

100

Apr-02

Jun-02

Aug-02

Oct-02

Dec-02

Feb-03

Apr-03

Jun-03

Aug-03

Oct-03

Dec-03

Feb-04

Apr-04

Jun-04

Aug-04

Oct-04

Dec-04

Feb-05

Apr-05

Jun-05

Aug-05

Oct-05

Dec-05

Feb-06

Apr-06

Jun-06

Aug-06

Oct-06

Dec-06

Feb-07

% P

atie

nts

National Top Decile

BMC Rate

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How to do it

  Electronic prompt…reference


Questions






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Quality Indicator #2:

Proportion of patients who receive prophylactic antibiotics consistent with current recommendations

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

Antibiotic Selection - Successful Interventions

  Distribution of guidelines to perioperative staff (standardize practice)

  Antibiotic selection and ordering (standardize process)

  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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ADMISSION ORDER FORM FOR SURGICAL OR DIAGNOSTIC PROCEDURES

**SURGERY Last name: ____________________________ First name: ________________ MI: _______ Date of birth:______________

Physician: __________________ PCP:____________________ Surgery/procedure date:____/____/___ Time:__________

Hospital based PAE booked? YES: NO: If yes specify reason: ______________________________________________

PROCEDURE: __________________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ ________________________________________________________________________________________________________ CONSENT: _____________________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ ALLERGIES: _______________________________________________________________________ _________________________________________________________________________________ ___________________________________________________________________ Patient states none PRE OPERATIVE ORDERS include IV fluids, selected medications and laboratory tests including Type and Screen will be ordered according to Baystate Medical Center Preadmission Evaluation Guidelines. No additional laboratory requests are necessary. SPECIAL LABORATORY TESTS PER MD REQUEST:_________________________________________________________________

Type of Surgery (Pt’s weight in _____ KG)

If No Penicillin Allergy cefazolin or cefoxitin

1 gm (<70Kg) 2 gm (>70 Kg) IV

Alternative If anaphylaxis to penicillin or Cephalosporin or documented high risk for resistant organism

Colectomy/rectal resection Appendectomy Non-perforated

cefoxitin IV give 1 gm if wt < 70 Kg or 2 gm if wt > 70 kg

clindamycin IV 600 mg PLUS gentamicin IV 80 mg if pt wt < 70 K or 120 mg > 70 K

Biliary Tract and Pancreas/ Gastroduodenal/small intestine

cefazolin IV give 1 gm if wt < 70 Kg or 2 gm if wt > 70 kg

vancomycin IV 1 gm IVPB PLUS gentamicin IV 80 mg if pt wt < 70 K or 120 mg > 70 K

Breast; Hernia


vancomycin IV 1 gm OR clindamycin IV 600 mg

Orthopedic cefazolin IV give 1 gm if wt < 70 Kg or 2 gm if wt > 70 kg


Head/neck procedures Neurosurgery; Kidney transplant


vancomycin IV 1 gm

Hysterectomy cefazolin IV give 1 gm if wt < 70 Kg or 2 gm if wt > 70 kg


Urologic levofloxacin 500 mg PO OR IV


Urologic Robotic Procedure (radical prostatectomy)



DVT PROPHYLAXIS: (select chemical prophylaxis based on patient existing co-morbidities) Enoxaparin 40 mg subcutaneous x1 in Pre op Holding Unit. Hold for patients receiving epidural catheter Unfractionated Heparin 5000 units subcutaneous x1 in Pre op Holding Unit. Pneumatic compression device (if not lower extremity vascular procedure) in cases >30 minutes of general anesthesia

HAIR REMOVAL Clip or None OTHER: Confirm Advanced Directives PRE OPERATIVE MEDICATIONS: ________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________________________________________ Physician signature: ____________________________________________________________ Date: _____________________ H&P Dictated by________________ Date: ______ Where sent: ___________________

FAX COMPLETED AND SIGNED FORM TO PAE (413) 794 1856 OR (413) 794 4875

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Division of Healthcare Quality

June , 2006 Dear Doctor ____________: Healthcare Quality at Baystate Health System is a top priority for our patients and for our organization. Since May 2002, we have been participating in a number of national projects to improve the quality of care provided to patients admitted to BMC for surgical procedures. Two of the quality measures we monitor are prophylactic antibiotic selection and duration. Our goal is to achieve 100% compliance with appropriate selection (based on the latest recommendation to prevent surgical infections from national organizations and local experts) and short duration (stopping antibiotic within 24 hours of end time). It has been shown that prophylactic antibiotic use greater than 24 hours conveys no advantage than short term antibiotic (<24 hours) to decrease the rate of post operative surgical infections, and in some case will contribute to increases in development of resistant organisms. Since 2002, BMC has been working on correct selection and stopping antibiotic dosing within 24 hours of surgery end time. Currently, our rate is at the state average for selection and less than the state average for duration for Massachusetts teaching hospitals. Recently, you and your colleagues cared for _________________ at BMC (__/__/200_), whose chart was flagged as having the: ____ incorrect antibiotic selection based on document in the medical record ____ duration of prophylactic antibiotics > 24 hours of surgery end time We want to call your attention to this recent hospitalization to emphasize the current quality improvement measures we are tracking for some of your patients. If you believe there was an error in this determination, please contact Jan Fitzgerald, MS, RN at 794-2531 or Gina Trelease, MEd, RN at 794-2432. Attached to this letter is a list of quality measures we are tracking that may involve your patients. Thank you for participating in the quality improvement process. Please let us know how we can help you to provide the highest quality care to your patients admitted to BMC.

SIP: Appropriate Antibiotic Selection - All Patients

0

20

40

60

80

100

Jan-0

4

Mar-

04

May-0

4

Jul-04

Sep-0

4

Nov-0

4

Jan-0

5

Mar-

05

May-0

5

Jul-05

Sep-0

5

Nov-0

5

Jan-0

6

Mar-

06

May-0

6

% P

ati

en

ts

BMC Rate

Target

Expanded pt populations

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Questions






Quality Indicator #3

Proportion of patients whose prophylactic antibiotics

were discontinued within 24 hours of surgery end time

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26.2

10

22.6

6.2 6.32.2 2.7

9.3

14.5

40.7

50.7

73.379.5

85.8 88 90.7

0

20

40

60

80

100

12 or le

ss

>12-2

4

>24-3

6

>36-4

8

>48-6

0

>60-7

2

>72-8

4

>84-9

6> 9

6

Hours After Surgery End Time

Perc

ent

0

20

40

60

80

100

Cum

ulat

ive

Perc

ent

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. 2005;140:174-182.

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

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 should not exceed 24-hour   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 past 24 hours

http://www.aaos.org/wordhtml/papers/advistmt/1027.htm

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

Division of Healthcare Quality

July, 2006 Dear Doctor ___________: Healthcare Quality at Baystate Health System is a top priority for our patients and for our organization. Since May 2002, we have been participating in a number of national projects to improve the quality of care provided to patients admitted to BMC for surgical procedures. Two of the quality measures we monitor are prophylactic antibiotic selection and duration. Our goal is to achieve 100% compliance with appropriate selection (based on the latest recommendation to prevent surgical infections from national organizations and local experts) and short duration (stopping antibiotic within 24 hours of end time). It has been shown that prophylactic antibiotic use greater than 24 hours conveys no advantage than short term antibiotic (<24 hours) to decrease the rate of post operative surgical infections, and in some case will contribute to increases in development of resistant organisms. Since 2002, BMC has been working on correct selection and stopping antibiotic dosing within 24 hours of surgery end time. Currently, our rate is at the state average for selection and less than the state average for duration for Massachusetts teaching hospitals. Recently, you and your colleagues cared for __________ at BMC (____/06), whose chart was flagged as having the: ____ incorrect antibiotic selection based on document in the medical record __X duration of prophylactic antibiotics > 24 hours of surgery end time We want to call your attention to this recent hospitalization to emphasize the current quality improvement measures we are tracking for some of your patients. If you believe there was an error in this determination, please contact Jan Fitzgerald, MS, RN at 794-2531 or Gina Trelease, MEd, RN at 794-2432. Attached to this letter is a list of quality measures we are tracking that may involve your patients. Thank you for participating in the quality improvement process. Please let us know how we can help you to provide the highest quality care to your patients admitted to BMC. Sincerely,

confidential Gary Kanter, M.D. Neal Seymour M.D. Associate Medical Director, Vice Chairman Healthcare Quality Department of Surgery

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BMC SCIP Progress

0

20

40

60

80

100

SCIP 1 SCIP 2 SCIP 3

% P

ati

en

ts

BMC Baseline 02

National Baseline 02

BMC 06

National Benchmark 06

Barriers – Antibiotic Use

  Timing   Consistency   Sustainability (constant

monitor)   Selection

  Resistance (surgeons and organism)

  Availability; national consensus issues

  Duration   Knowledge gap   If it’s not broke, don't change it

Outcome

  What’s important?

  Meeting national criteria?

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GRAPH 21B

Control Chart - All Surgery (1 qtr periods)st.dev.0.39%

3.16%

2.77%

2.39%

avg2.00%1.61%

1.23%

0.84%

inhse0.86%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

Dec-

93

Sep-9

4

Jun-9

5

Mar-

96

Dec-

96

Sep-9

7

Jun-9

8

Mar-

99

Dec-

99

Sep-0

0

Jun-0

1

Mar-

02

Dec-

02

Sep-0

3

Jun-0

4

Mar-

05

Dec-

05

Sep-0

6

ratea+3sa+2sa+1savga-1sa-2sa-3sinhse

NNISS Benchmark = 2-11 %

Surgical Infection Rate

1.13 %

Duration of Antibiotic Prophylaxis: What is Best for Our Patients?

  Antibiotic prophylaxis is one (of many) methods for reducing SSI

  No evidence that antibiotics given after the operation prevent SSI

  There is evidence that increased use of antibiotics promotes antibiotic resistance

Hair Removal 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 & SI

0

4

8

12

PM Razor AM Razor PM Clipper AM Clipper

Clean

Clean-Contam

Alexander. Arch Surg 1983; 118:347

Infe

ctio

ns (%

)

Hair Removal " Shaving the night before an operation -- a

significantly higher SI risk than either the use of depilatory agents or no hair removal

" Do not remove hair unless it will interfere with the operation (Category IA)

" If hair is removed, remove immediately before, with electric clippers (Category IA)

Cochrane Database Syst Rev. 2006 Apr 19;(2)

  Three trials involving 3193 patients   Shaving vs clipping   More SSIs when people were shaved

(Rate Ratio 2.02, 95%CI 1.21 to 3.36)

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Interventions

  Razors removed from OR’s   Razors removed from most clinical areas   Patients may use razors for personal

hygiene   Clippers in every OR

ADMISSION ORDER FORM FOR SURGICAL OR DIAGNOSTIC PROCEDURES

**SURGERY Last name: ____________________________ First name: ________________ MI: _______ Date of birth:______________

Physician: __________________ PCP:____________________ Surgery/procedure date:____/____/___ Time:__________

Hospital based PAE booked? YES: NO: If yes specify reason: ______________________________________________

PROCEDURE: __________________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ ________________________________________________________________________________________________________ CONSENT: _____________________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ ALLERGIES: _______________________________________________________________________ _________________________________________________________________________________ ___________________________________________________________________ Patient states none

PRE OPERATIVE ORDERS include IV fluids, selected medications and laboratory tests including Type and Screen will be ordered according to Baystate Medical Center Preadmission Evaluation Guidelines. No additional laboratory requests are necessary. SPECIAL LABORATORY TESTS PER MD REQUEST:_________________________________________________________________

Type of Surgery

(Pt’s weight in _____ KG)

If No Penicillin Allergy cefazolin or cefoxitin

1 gm (<70Kg) 2 gm (>70 Kg) IV

Alternative If anaphylaxis to penicillin or Cephalosporin or documented high risk for resistant organism

Colectomy/rectal resection Appendectomy Non-perforated

cefoxitin IV give 1 gm if wt < 70 Kg or 2 gm if wt > 70 kg


Biliary Tract and Pancreas/ Gastroduodenal/small intestine



Breast; Hernia



Orthopedic cefazolin IV give 1 gm if wt < 70 Kg or 2 gm if wt > 70 kg


Head/neck procedures Neurosurgery; Kidney transplant


vancomycin IV 1 gm

Hysterectomy cefazolin IV give 1 gm if wt < 70 Kg or 2 gm if wt > 70 kg


Urologic levofloxacin 500 mg PO OR IV


Urologic Robotic Procedure (radical prostatectomy)



DVT PROPHYLAXIS: (select chemical prophylaxis based on patient existing co-morbidities) Enoxaparin 40 mg subcutaneous x1 in Pre op Holding Unit. Hold for patients receiving epidural catheter Unfractionated Heparin 5000 units subcutaneous x1 in Pre op Holding Unit. Pneumatic compression device (if not lower extremity vascular procedure) in cases >30 minutes of general anesthesia

HAIR REMOVAL Clip or None OTHER: Confirm Advanced Directives

PRE OPERATIVE MEDICATIONS: ________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________________________________________

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SSI Surveilance

  How do we do it?

  What is investigated?

  Administrative Quality Support

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

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!!

Where Do Things Fall Through the Cracks?

  System – information, tests, diagnoses

 Communication  Hand offs   Failure to recognize   Failure to activate   Failure to rescue

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 •  Willing to try changes and take a risk •  Develop reliable systems

•  Make changes easy and transparent •  Stress importance of impact on patient and

practitioner •  Make the Right thing the easy thing

Surveillance

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Background  >46,000 operations/year  2007 –three successive quarters of

elevated SSI  Cluster Investigation

Cluster Investigation

 Chart review  Surgical processing  OR traffic  Microbiology  OR observations  Link to specific OR?  Link to specific practitioner?  Link to Surgical Processing?  Correct/timing of antibiotics?

Two hand Sterilization Techniques

 “Standard”  Chlorhexidine/Alcohol

 Soap water pre-wash  Nail pick  Sufficient solution

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Solution Chosen  Education  Removal of Product

Conclusion  There is no “right” solution  Removal worked along with

education  Continued surveillance imperative

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Lessons Learned   Involve all stakeholders   Leave your stripes at the door   Must have physician champions- credible   Be humble   BROAD shoulders   Must work as team   Small tests of change with frequent tempo   Small pilot population   Work within your culture   Make the right thing the easy thing

Future

  Won’t be antibiotics   Will have equal or greater impact

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Check List Items

  Wash Hands   Prep Skin   Gown/glove/mask/full drape   Avoid Groin   Remove ASAP

Real Value

  Provide Framework for success/quality   Empower all providers   Standardize Care   Don’t worry about credit

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  The IRS would lose over 2 million documents this year   16,000 items would be lost in the mail every hour   There would be 37,000 ATM errors every hour   There would be a major plane crash every 3 days   12 babies would be given the wrong parents each day   107 erroneous medical procedures would be performed each day

  291 pacemakers would be incorrectly installed this year

If 99.9% were good enough….

 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

Antibiotic Lecture

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