Surgical Care Improvement Project

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  • The Surgical Care Improvement Project has it roots in the Surgical Infection Project (SIP) and some of the work that the Veterans Administration has done over the past years to reduce surgical complications. SCIP has been trialed through a 3-year pilot study that expanded the original SIP quality measures. If you were familiar with SIP, you may recall that SIP focused on the timing, appropriateness, and duration of prophylactic antibiotic administration. SCIP incorporates those quality measures and includes others designed to reduce the incidence of surgical AMI, PE, DVT and ventilator-associated pneumonia.
  • There are opportunities to improve surgical care. Opportunities exist in decreasing the surgical site infection (SSI) rate. Currently, SSI occurs in 14%–16% of all patients, but, more importantly, of that percentage, 40%–60% are preventable. There are opportunities to decrease the rate of DVT and PE. Without mechanical or pharmacological interventions, 25% of the general surgery population are at risk for DVT, and 7% are at risk for PE. In orthopedic cases the risk increases to more than a 50% risk for DVT and a 30% risk for PE. There are opportunities to decrease the rate of AMI in surgical patients. Patients undergoing noncardiac surgery face a 2%-5% risk of AMI during surgery—that percentage increases to 34% if the patient is having a vascular procedure. There are opportunities to minimize the pneumonia associated with postoperative ventilator use. Ventilator-associated pneumonia occurs in as many 40% of the ventilated patients, with mortality rates as high as 46%. These are the opportunities available to you to impact the care you provide.
  • The Medicare Surgical Infection Prevention Project was started with the objective to decrease morbidity and mortality associated with postoperative infection in the Medicare patient population. The funding for this project came largely through the Medicare program. But the concepts apply to all patients having surgery. Looking at current performance on a variety of measures of quality of care for surgery, if we could get performance up to benchmark levels we believe in the United States that we might be able to prevent—in the Medicare population alone—13,000 perioperative deaths and up to 300,000 surgical complications for patients undergoing major surgical cases in the United States on an annual basis. There is substantial opportunity to improve patient care and patient outcomes.
  • The presenter can individualize this slide to make it more meaningful for the audience. To determine the number of patients at risk in your organization, calculate the average number of cases per day (Y); from the earlier slide we know that 14%–16% of them are at risk for infection (Y x 15% = patients at risk; e.g., 51 x .15 = 7.65). To determine the preventable cases, from the previous slide we know that 40%–60% of the SSIs are preventable (patients at risk x 50%; e.g., 7.65 x .50 = 3.8)
  • Patients having surgery today are more informed than ever before. Don Berwick, MD, is quoted in Newsweek as saying, “Here’s the problem. Instead of helping me, health care might kill me . . . I have climbed Mount Rainier five times. Each time I made that tough trek, my risk of dying was about 100 times smaller than the risk I will face on the operating room table.” Stopping surgical-site infections is part of the Institute for Healthcare Improvement 100,000 Lives Campaign. Newsweek briefly describes how SSI can be avoided by “giving the right antibiotic at the right time during surgery, enforcing strict hand washing, and avoiding shaving the surgery site before the operation. In the January 1, 2006, edition of USA Today there was an article titled Patients Can Help Prevent Infections: "The single most important way patients can help prevent infections and errors is to be active members of their health care team," said Gregg Laiben, MD, the Medical Director for Primaris. "Ask questions, follow instructions, and stay informed. . . . Ask how the hospital works to prevent surgical infections.” Expect to see a more informed patient asking questions about surgical infections and wanting to know what you, the caregiver at their side at that moment, is doing to reduce their risk of a surgical infection.
  • SCIP is a quality partnership. This project has a steering committee that is made up of specialties societies, such as the American College of Surgeons, American Society of Anesthesiologists, Association of Perioperative Registered Nurses, Agency for Healthcare Research and Quality, the American Hospital Association, and the Institute for Healthcare Improvement. One of the key partners is the Department of Veterans of Affairs, which has extensive experience, and the Joint Commission on Accreditation of Healthcare Organizations
  • SCIP Quality Measures are evidence based. That is to say that there are published scientific studies and rationale to support the quality measures.
  • Based on published literature, we are aware that there is an overuse, underuse, and improper timing of antibiotics that occurs in anywhere from 25 percent to 50 percent of operations. This data is based on previous medical records audits that have been published. These quality measures are directed toward improving the processes that impact SSI.
  • VTE is a known complication of major surgery and carries a high morbidity and mortality rate. There are two process measures directed toward decreasing the patient’s risk. The first one is the proportion of patients who receive any form of venous thromboembolism prophylaxis, and the second process measure is the proportion of patients who receive the appropriate forms of venous thromboembolism prophylaxis. The American College of Chest Physicians’ consensus recommendations for prophylaxis is the guideline used for minimizing a patients risk.
  • We know that patients who are on a ventilator postoperatively, particularly those that require prolonged periods of ventilation, have relatively high rates of ventilator-associated pneumonia. So the outcome measure for this module is the rate of postoperative pneumonia cases that are diagnosed during the indexed hospitalization.   Quality measure #1 is a process measure from the Joint Commission. JCAHO has already evaluated this process measure in its ICU measures set. There is data that suggests that keeping the head of the bed elevated to thirty degrees, for those ventilator patients that do not have a contraindication to elevation to the head of the bed, can reduce the rate of postoperative pneumonias. One published study looked at the elevation of the head of the bed, the semi-recumbent position reduced the frequency and risk of nosocomial pneumonia as compared to patients who were kept in a supine position. One of the biggest challenges with this measure in the pilot program was that sometimes it is difficult to find documentation in the medical record that the head of the patient’s bed was elevated to thirty degrees.
  • The American College of Cardiology and the American Heart Association, in their guidelines for perioperative management of patients, already give a Class I recommendation for beta-blockers for patients who have required beta-blockers in the recent past to control symptoms of angina, symptomatic arrhythmias, or hypertension. The patient who is chronically on beta-blockers should continue to receive beta-blockers through surgery.
  • This is older data, but it is the most recent that is readily available. The results are from the fourth quarter of 2004. Data surrounding the appropriate antibiotic were not released for multiple reasons. These reasons included the availability of cefazolin and cefatetan and concerns voiced from hospitals and medical staffs recommending that Vancomycin be used as the prophylactic antibiotic due to the rate of MRSA within the facility.
  • As noted in Newsweek , and what we all know, hand washing is still an important factor in preventing and reducing infection rates. Unfortunately, health care workers are often given a false sense of security when wearing gloves. That is, the clinicians believes that their hands are clean when the gloves are removed. If the clinicians fail to wash their hands when the integrity of the gloves was compromised, bacteria can survive for over two hours on their hands, unless the hands are cleansed by washing or using an alcohol scrub. One minute of use with an alcohol scrub is equivalent to hand washing for 4 – 7 minutes with other agents.
  • What is the impact of surgical site infections? As you can see, infected patients are twice as likely to die, more likely to spend time in an ICU — which translates into additional costs and resources of providing care, and more than four times more likely to be readmitted. No one can dispute the value of reducing surgical site infections.
  • Organizations can make an impact in reducing their rate of surgical site infections by implementing processes surrounding these four aspects of surgical care.
  • An easier way to remember the aspects of care that the clinician impacts is this: C = Clipping rather than using razors A = Antibiotic timing, selection and duration T = Thermia, that is, patients will do better if their body temperature remains close to normothermia S = Sugar or glucose, control the glucose levels of all cardiac patients
  • There are three aspects of prophlyactic antibiotic administration: timely administration, using the appropriate antibiotic, and discontinuing the drug. It is important to note that when discussing antibiotics the quality measures are about the use of prophylactic antibiotics. This discussion is not appropriate for patients with pre-existing or postoperative infections.
  • The first quality measure is the proportion of patients that received antibiotics within one hour before the surgical incision. The exception to this is patients who require treatment with either vancomycin or flouroquinolones. Because those antibiotics must be infused over a one-hour time frame, they may be started within two hours before the incision. But for all other antibiotics, the performance measure looks at whether the antimicrobial is started within one hour before the incision is made. It is important to note that this measure focuses only on the start time, it does not address whether the drug was completely infused. Published studies as early as the late 1950s demonstrated that giving antibiotics within a one-hour time frame before the incision is made results in the lowest infection rates. A study by John Burke in 1961 demonstrated that antibiotics given up to about four hours after the incision were really no better than doing nothing at all to prevent infections. Antibiotics given at any significant length of time after the incision was made did not prevent surgical site infections.
  • David Classen, with Inter Mountain Health, looked at the timing of administration of antimicrobials in patients undergoing cardiac surgery and demonstrated that the lowest infection rates were for those patients who received their antimicrobial dose within one hour before the incision. Patients who received the antibiotics earlier had much higher rates of infection. Patients who received the antibiotics at progressively longer periods of time after the incision had been made also had significantly higher infection rates. So there seems to be something quite important about giving the antibiotic within that important time frame—zero to one hour before the incision is made, and based on this data the national expert panel created the performance measure that the antimicrobial should be started within one hour before the incision. And what we found in the United States was that 56 percent of the patients having surgery received their antimicrobial dose in the zero to sixty-minute time frame before the incision was made. Another 20 percent of the patients received the antibiotic dose in the time frame from 61 to 120 minutes before the surgery. There were a number of patients who received their antibiotics after the incision, and, indeed, 9.6 percent of the patients received their first antimicrobial dose more than four hours after the incision was made.
  • The second quality measure is the proportion of patients who received prophylactic antimicrobials consistent with current recommendations. An expert panel reviewed all of the published guidelines for antimicrobial prophylaxis for patients having surgery and then made their recommendations based on the guidelines.
  • The organisms likely to be present dictate the choice of antibiotic for prophylaxis. The cephalosporins are ideally suited to prophylaxis: their features include a broad spectrum of activity, an excellent ratio of therapeutic to toxic dosages, a low rate of allergic responses, ease of administration, and attractive cost advantages. Mild allergic reactions to penicillin are not contraindications for the use of a cephalosporin. First-generation cephalosporins (e.g., cefazolin) are ideal agents for prophylaxis. The most important first-generation cephalosporin for surgical patients continues to be cefazolin. Administered I.V. in the OR at the time of skin incision, it provides adequate tissue levels throughout most of the operation. A second dose administered in the OR is beneficial if the procedure is long.
  • The third quality measure is the proportion of patients whose prophylactic antibiotics were discontinued within 24 hours after the end of surgery. Most of the national experts believe, based on published data, that giving a single preoperative dose of antibiotic is sufficient to prevent surgical site infections, that giving antibiotics after the incision is closed is of no value in reducing infection rates further. So, when you review the literature in total, most studies have confirmed the efficacy of very short duration of antibiotic therapy. Most have looked at less than 12 hours and have shown no difference in infection rates. Many studies have shown efficacy of giving a single dose of antimicrobial, and, whenever compared, the shorter course has been as effective as a longer course and results in less antibiotic resistance. This is an important point because a number of studies have demonstrated that longer durations of prophylactic antimicrobials postoperatively are associated, when infection does occur, with more antimicrobial resistance. So there does appear to be some harm in prolonging antimicrobial therapy. This particular performance measure is not about reducing infection rates, because all of these studies have demonstrated that the infection rate for short versus long durations is no different. It is about reducing resistance.
  • For this particular quality measure, if there was any documentation in the chart in the operating room or postoperatively for the first two days after surgery that the patient had an infection, the case was excluded from this performance measure. So, this is a group of patients who had surgery, no infection preoperatively, and had no documented infection in the chart for at least two days postoperatively. Even at 48 hours, 27 percent of the patients are still receiving prophylactic antimicrobials, and at 96 hours 9 percent of the patients were still receiving prophylactic antimicrobials.
  • So about 93 percent of the patients received an appropriate drug based on guidelines. Then there were some differences between surgical types and when antibiotics were discontinued post-operatively. Cardiac and orthopedic surgeons were least likely to stop the antibiotics within 24 hours after surgery. Patients undergoing hysterectomy were most likely to have their antimicrobials discontinued. But once again, only about 41 percent of the patients having surgery had their antibiotics discontinued within 24 hours.
  • Cardiac surgeons were vocal with their concerns about the risk of infection due to the presence of chest tubes. The Society of Thoracic Surgeons recently released an optimal practices guideline about the discontinuation of prophylactic antibiotics. The STS stated that, “there is evidence indicating that antibiotic prophylaxis of 48 hours duration is effective. There is some evidence that single-dose prophylaxis or 24-hour prophylaxis may be as effective as 48-hour prophylaxis, but additional studies are necessary before confirming the effectiveness of prophylaxis lasting less than 48 hours. There is no evidence that prophylaxis administered for longer than 48 hours is more effective than a 48-hour regimen.” As a result, the quality measure for discontinuation of prophyalctic antibiotic was expanded to 48 hours for cardiac surgery only. Optimal Practice : Antibiotic prophylaxis is not continued for more than 48 hours postoperatively. Class IIa. Level B. Conclusion : The duration of antibiotic prophylaxis should not be dependent on indwelling catheters of any type. Optimal Practice : Decisions regarding the continuation of antibiotic prophylaxis are not guided by the presence of indwelling catheters. Class IIb. Level C. The Society of Thoracic Surgeons Practice Guideline Series; Antibiotic Prophylaxis in Cardiac Surgery Duration of prophylaxis
  • Shaving the surgical site with a razor induces small skin lacerations and causes potential sites for infection. When you shave the skin, particularly the area of where the surgery will be performed, you disturb skin follicles, and most of the studies have demonstrated that it increases the risk of surgical site infections. This risk is particularly great when the shaving is done the night before surgery. So patient education needs to be conducted to make sure patients don’t do you a favor and shave the surgical site the day before they come into the hospital. That can result in a higher infection rate.
  • No strong evidence was found to advocate against preoperative hair removal. Furthermore, there was strong evidence to recommend that when hair removal is considered necessary, shaving should not be performed. Instead, a depilatory or electric clipping, preferably immediately before surgery, should be used. Changes for improvement include: Remove all razors from the operating room and supply area Perform hair removal when necessary with clippers right before surgery Establish protocol for when and how to remove hair in affected areas Provide patient education and materials on appropriate hair removal techniques to prevent shaving at home  Avoid shaving heart surgery patients for EKG conducted shortly before surgery
  • There is very strong data that blood sugar control in patients undergoing cardiac surgery is important in reducing surgical site infections. Most of the published data on blood sugar control to reduce surgical site infections, however, has been published in Cardiac Surgery . So the strength of the evidence for controlling blood sugar to prevent surgical site infections in diabetics undergoing noncardiac surgery is not as strong. JCAHO and CMS are looking at this as a test measure to see if we can collect the information, whether performance improvement is possible, and whether that might improve patient outcomes. But, at this time, the measure is limited to cardiac surgery patients.    
  • Robert Latham (Vanderbilt) was able to correlate postoperative hyperglycemia with an increase in SSI rates. In this study done by Latham looking at 1,000 patients undergoing cardiothoracic surgery, he included diabetics and nondiabetics. Only about half of the patients in the study maintained normal glycemia, even though only 30 percent of the patients in the study were actually diabetic. But what they found in their study, regardless of whether the patient was a diabetic or not, was that any patient that had a blood sugar that was greater than 300 within 48 hours after the end of surgery was 3.3 times more likely to develop a surgical site infection than that of patients whose blood sugars were less than 200. Hyperglycemia appeared to be associated with increased infection rates, regardless of whether the patient had a diagnosis of diabetes or not.
  • What about normothermia? There have been a variety of studies. One of the most prominently published was by Kurtz and his colleagues in 1996. It looked at 200 colorectal surgery patients. Their control group received normal or routine intraoperative thermal care—basically standard care. And when those patients got back to the recovery room, their mean core temperature was 34.7 degrees Centigrade. And then they had a second group of patients that had active warming. Their mean temperature on arrival to the recovery room was 36.6—they were kept warm with warm infused fluids, with the use of bear huggers, and other methods. What they demonstrated in the project was that the control group had a 19 percent surgical site infection rate. The treatment group—those patients that were kept warm—had a 6 percent surgical site infection rate. So it did appear that maintaining normothermia in patients, particularly in this study that looked at colorectal surgery patients, reduced surgical site infections.
  • Surgical Care Improvement Project

    1. 1. Surgical Site Infections The Medicare Quality Improvement Organization for Arizona
    2. 2. What is SCIP? <ul><li>Surgical Care Improvement Project </li></ul><ul><li>Evolved from SIP </li></ul><ul><li>Encompasses additional aspects of surgical care </li></ul><ul><ul><li>Reduce/prevent: Cardiac events, emboli, and ventilator-associated pneumonia </li></ul></ul>
    3. 3. Opportunities to Improve Care <ul><li>SSI: occurs in 14% – 16% surgical patients </li></ul><ul><ul><li>40%–60% of SSIs are preventable </li></ul></ul><ul><li>Cardiac: 2% – 5% noncardiac surgery, 34% in vascular, AMI mortality rate as high as 70% </li></ul><ul><li>DVT/PE: without prophylaxis: general surgery cases 25%, 7% orthopedic cases, > 50% DVT, 30% PE </li></ul><ul><li>VAP: occurs 9% – 40%, with associated mortality rates of 30%–46% </li></ul>
    4. 4. SCIP Goals <ul><li>Reduce postoperative mortality and </li></ul><ul><li>morbidity by 25% over 5 years </li></ul>
    5. 5. A Closer Look at SSI <ul><li>SSI in a 51-case day </li></ul><ul><ul><li>7.65 patients at risk for infection </li></ul></ul><ul><ul><li>4.59 of those infections are preventable </li></ul></ul>
    6. 6. Insert Organizational Data
    7. 7. SCIP in the News <ul><li>Newsweek , December 12, 2005 </li></ul><ul><ul><li>6 Keys to Safer Hospitals </li></ul></ul><ul><li>USA Today </li></ul><ul><li>ABC News 20/20 </li></ul><ul><ul><li>More Killed Annually Than by Auto Accidents and Homicides (10-14-2005) </li></ul></ul>
    8. 8. SCIP Support <ul><li>American College of Surgeons </li></ul><ul><li>American Society of Anesthesiology </li></ul><ul><li>American Hospital Association </li></ul><ul><li>CDC </li></ul><ul><li>JCAHO </li></ul><ul><li>AORN </li></ul><ul><li>Veterans Administration </li></ul><ul><li>AHRQ </li></ul>
    9. 9. Evidence Based <ul><li>“ Evidence-based medicine is the process of systematically finding, appraising, and using contemporaneous research findings as the basis for clinical decisions.” </li></ul><ul><li>“ Evidence-based medicine is about asking questions, finding and appraising the relevant data, and harnessing that information for everyday clinical practice.” </li></ul><ul><li>BMJ 1995;310:1122-1126 (29 April) </li></ul><ul><li>William Rosenberg , Anna Donald </li></ul><ul><li>Evidence-based Medicine: An Approach to Clinical Problem-solving </li></ul>
    10. 10. SSI Quality Measures <ul><li>1: Prophylactic antibiotic received within 1 hour prior to surgical incision </li></ul><ul><li>2: Prophylactic antibiotic selection for surgical patients </li></ul><ul><li>3: Prophylactic antibiotics discontinued within 24 hours after surgery end time (48 hours for cardiac patients) </li></ul><ul><li>4: Cardiac surgery patients with controlled 6 a.m. postoperative serum glucose </li></ul>
    11. 11. SSI Quality Measures <ul><li>5: Postoperative wound infection diagnosed during index hospitalization </li></ul><ul><li>6: Surgery patients with appropriate surgical site hair removal </li></ul><ul><li>7: Colorectal surgery patients with immediate postoperative normothermia </li></ul>
    12. 12. VTE Quality Measures <ul><li>1: Surgery patients with recommended venous thromboembolism prophylaxis ordered </li></ul><ul><li>2: Surgery patients who received appropriate venous thromboembolism prophylaxis, within 24 hours prior to surgery to 24 hours after surgery  </li></ul><ul><li>3: Intra- or postoperative pulmonary embolism (PE) diagnosed during index hospitalization and within 30 days of surgery </li></ul><ul><li>4: Intra- or postoperative deep vein thrombosis (DVT) diagnosed during index hospitalization and within 30 days of surgery </li></ul>
    13. 13. VAP Quality Measures <ul><li>1: Number of days ventilated surgery patients had documentation of the head of the bed (HOB) being elevated, from recovery end date (day zero) through postoperative day seven. </li></ul><ul><li>2: Patients diagnosed with postoperative ventilator-associated pneumonia (VAP) during index hospitalization </li></ul><ul><li>3: Number of days ventilated surgery patients had documentation of stress ulcer disease (SUD) prophylaxis, from recovery end date (day zero) through postoperative day seven. </li></ul><ul><li>4: Surgery patients whose medical record contained an order for a ventilator-weaning program (protocol or clinical pathway) </li></ul>
    14. 14. Cardiac Quality Measures <ul><li>  2: Surgery patients on a beta-blocker prior to arrival that received a beta-blocker during the perioperative period </li></ul><ul><li>  3: Intra- or postoperative acute myocardial infarction (AMI) diagnosed during index hospitalization and within 30 days of surgery. </li></ul>
    15. 15. Arizona’s Ranking
    16. 16. Before SCIP <ul><li>Alcohol scrubs </li></ul><ul><ul><li>Most rapid reduction of bacteria counts </li></ul></ul><ul><ul><li>1 minute = 4 – 7 minutes of other agents </li></ul></ul><ul><li>Transfer of 1,000 organisms </li></ul><ul><ul><li>Bacterial survival 20–150 minutes </li></ul></ul><ul><ul><li>Virus survival 20–30 minutes </li></ul></ul><ul><ul><li>Chapters from ACS Surgery </li></ul></ul><ul><ul><li>Prevention of Postoperative Infection </li></ul></ul><ul><ul><li>Jonathan L. Meakins, M.D., D. Sc., F.A.C.S. </li></ul></ul>
    17. 17. Impact *Pairs matched for procedure, NNIS index, age *General inpatient surgical population; 22, 742 procedures included Kirkland. Infect Control Hosp Epidemiol . 1999;20:725. Prospective, case-controlled study of 22,742 patients undergoing inpatient surgical procedures between 1991–1995 . Information adapted from the Institute for Healthcare Improvement ( www.ihi.org ). +$5,038 (median) Total excess cost +$3,644 (median) Initial excess cost 7d 18d Median total LOS 6d 11d Median initial LOS 7% 41% Readmission 18% 29% ICU admission 3.5% 7.8% Mortality (in-hospital) Uninfected Infected
    18. 18. Opportunity <ul><li>Decreasing the rate of SSI is an opportunity to: </li></ul><ul><ul><li>Improve care </li></ul></ul><ul><ul><li>Promote improved outcomes </li></ul></ul><ul><ul><li>Increase patient satisfaction </li></ul></ul><ul><ul><li>Reduce costs </li></ul></ul>
    19. 19. Components of SSI <ul><li>Antibiotic Administration </li></ul><ul><li>Hair Removal </li></ul><ul><li>Glucose Control </li></ul><ul><li>Normothermia </li></ul>
    20. 20. CATS <ul><li>Clipping (Hair Removal) </li></ul><ul><li>Antibiotic Administration </li></ul><ul><li>Thermia (Normothermia) </li></ul><ul><li>Sugar (Glucose Control) </li></ul>
    21. 21. Antibiotics <ul><li>Timely administration </li></ul><ul><li>Selection </li></ul><ul><li>Timely discontinuation </li></ul>
    22. 22. Timely Administration <ul><li>Most studies indicate that optimum timing for prophylactic antibiotic is within 1 hour of incision time. (Cephalosporins) </li></ul><ul><li>When cuff is used, make sure all antibiotic is infused prior to inflation of cuff. </li></ul><ul><li>Note: Because of the longer required infusion time, vancomycin, when indicated for beta-lactam allergy, should be started within 2 hours before the incision. </li></ul>Information adapted from the Institute for Healthcare Improvement ( www.ihi.org ).
    23. 23. Timing of Abx. Prophylaxis Classen, et al. N Engl J Med . 1992;328:281. Information adapted from the Institute for Healthcare Improvement ( www.ihi.org ).
    24. 24. Insert Organizational Data
    25. 25. Antibiotic Selection <ul><li>Choose prophylactic antibiotics consistent with national guidelines </li></ul><ul><ul><li>Special cases: </li></ul></ul><ul><ul><ul><li>Allergy (anaphylactoid) to  -lactam antibiotics </li></ul></ul></ul><ul><ul><ul><li>High rate of MRSA wound infections locally </li></ul></ul></ul><ul><ul><ul><li>Recent prolonged course of antibiotics or ICU stay </li></ul></ul></ul>Information adapted from the Institute for Healthcare Improvement ( www.ihi.org ).
    26. 26. Ancef <ul><li>Cefazolin </li></ul><ul><ul><li>Effective against gram positive and negative </li></ul></ul><ul><ul><li>Low rate of allergic responses </li></ul></ul><ul><ul><li>Easy to administer </li></ul></ul><ul><ul><li>Inexpensive </li></ul></ul>
    27. 27. Prophylaxis Dosing <ul><li>Always give at least a full therapeutic dose of antibiotic. </li></ul><ul><li>Consider the upper range of doses for large patients and/or long operations. </li></ul><ul><li>Repeat doses for long operations (> 4 hours) </li></ul>Information adapted from the Institute for Healthcare Improvement ( www.ihi.org ).
    28. 28. Prophylaxis Duration <ul><li>Most studies have confirmed efficacy of  12 hrs. </li></ul><ul><li>Many studies have shown efficacy of a single dose. </li></ul><ul><li>Whenever compared, the shorter course has been as effective as the longer course. </li></ul><ul><li>There is no need to continue coverage beyond 24 hours. </li></ul>Information adapted from the Institute for Healthcare Improvement ( www.ihi.org ).
    29. 29. Duration Concerns <ul><li>Antibiotic prophylaxis is one of many methods for reducing the incidence of SSI. </li></ul><ul><li>There is a lack of evidence that antibiotics given after the end of the operation prevent SSIs. </li></ul><ul><li>There is evidence that unnecessary or prolonged use of antibiotics promotes antibiotic resistance. </li></ul>Information adapted from the Institute for Healthcare Improvement ( www.ihi.org ).
    30. 30. Tubes, Lines, and Drains <ul><li>“ 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.” </li></ul><ul><li>Advisory Statement: </li></ul><ul><li>Recommendations for the Use of Intravenous Antibiotic </li></ul><ul><li>Prophylaxis in Primary Total Joint Arthroplasty </li></ul><ul><li>American Association of Orthopedic Surgeons (AAOS) </li></ul>
    31. 31. Duration in Cardiac Surgery <ul><li>“ Our findings confirm that continuing ABP beyond 48 hours after CABG surgery is still widespread; however, this practice is ineffective in reducing SSI, increases antimicrobial resistance, and should therefore be avoided.” </li></ul><ul><li>Prolonged Antibiotic Prophylaxis After Cardiovascular Surgery and Its </li></ul><ul><li>Effect on Surgical Site Infections and Antimicrobial Resistance </li></ul><ul><li>Stephan Harbarth, MD, MS; Matthew H. Samore, MD; </li></ul><ul><li>Debi Lichtenberg, RN; Yehuda Carmeli, MD, MPH </li></ul><ul><li>Circulation . 2000;101:2916-2921 </li></ul>
    32. 32. Insert Organizational Data
    33. 33. Hair Removal Quality Measure <ul><li>Surgery patients with appropriate surgical site h hair removal. </li></ul>
    34. 34. Hair Removal <ul><li>Appropriate: </li></ul><ul><ul><li>No hair removal at all </li></ul></ul><ul><ul><li>Clipping </li></ul></ul><ul><ul><li>Depilatory use </li></ul></ul><ul><li>Inappropriate: </li></ul><ul><ul><li>Razors </li></ul></ul>Information adapted from the Institute for Healthcare Improvement ( www.ihi.org ).
    35. 35. Shaving Influence <ul><li>No Hair Group Removal Depilatory Shaved </li></ul><ul><li>Number 155 153 246 </li></ul><ul><li>Infection rate 0.6% 0.6% 5.6% </li></ul><ul><li>Seropian. Am J Surg . 1971; 121: 251. </li></ul>Information adapted from the Institute for Healthcare Improvement ( www.ihi.org ).
    36. 36. Glucose Control <ul><li>Cardiac surgery patients with controlled 6:00 a.m. postoperative serum glucose. The measure looks at the glucose result for postoperative day 1 and day 2. </li></ul>
    37. 37. Risk, Glucose Control, Cardiac Surgery <ul><li>Increased risk: Diagnosed diabetes Undiagnosed diabetes Post-op glucose > 200 mg% within 48h </li></ul><ul><li>Latham. Inf Contr Hosp Epidemiol . 2001;22:607. </li></ul><ul><li>Dellinger. Inf Contr Hosp Epidemiol . 2001;22:604. </li></ul>
    38. 38. SSI Related to Glucose Control Cardiac Surgery after Median Sternotomy Latham. ICHE . 2001; 22: 607-612. Information adapted from the Institute for Healthcare Improvement ( www.ihi.org ).
    39. 39. Additional Benefits of Glucose Control <ul><li>Decreased: </li></ul><ul><ul><li>Acute renal failure </li></ul></ul><ul><ul><li>Red cell transfusions </li></ul></ul><ul><ul><li>Ventilator support </li></ul></ul><ul><ul><li>Time spent in intensive care </li></ul></ul><ul><li>van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in the critically ill patients. N Engl J Med . 2001 Nov. 8; 345(19):1359-1367. PMID: 11794168 </li></ul>
    40. 40. Normothermia Quality Measure <ul><li>Colorectal surgery patients with immediate normothermia (96.8–100.4° F) within the first hour after leaving the operating room. </li></ul>
    41. 41. Normothermia <ul><li>Patients who had a decrease of only 1.9°C in core temperature were three times as likely to develop surgical wound infections as were those in whom a normal body temperature of 37°C was maintained. </li></ul><ul><li>Kurz A, Sessler DI, Lenhardt RA. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. N Engl J Med 1996; 334:1209–15. </li></ul>
    42. 42. Be An Advocate <ul><li>Advocate to reduce the risk of surgical site infections by using evidence-based care. Your patients will thank you. </li></ul>
    43. 43. Be Aware <ul><li>Be aware of evidence-based measures to reduce surgical site infection </li></ul><ul><ul><li>Hair Removal ( C lipping) </li></ul></ul><ul><ul><li>Antibiotic Usage ( A ntibiotic) </li></ul></ul><ul><ul><li>Normothermia ( T hermia) </li></ul></ul><ul><ul><li>Glucose Control ( S ugar) </li></ul></ul>
    44. 44. Be Alert <ul><li>Be alert to the care your surgical patient is receiving. Is the care evidence-based or something else? </li></ul>
    45. 45. Be Active <ul><li>Ask the surgeon if he or she wants an antibiotic administered. </li></ul><ul><li>Throw every razor away. </li></ul><ul><li>Check the glucose on cardiac patients. </li></ul><ul><li>Keep your patients warm. </li></ul><ul><li>Work with a team to improve surgical care, increase patient satisfaction, improve patient outcomes, and decrease costs. </li></ul>
    46. 46. Insert Organizational Interventions
    47. 47. Be Active <ul><li>WASH </li></ul><ul><li>YOUR </li></ul><ul><li>HANDS </li></ul>
    48. 48. www.hsag.com This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for Arizona, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. AZ-8SOW-1C-021506-06

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