SSI account for about 14-16% pf all hospital acquired infections. Up to 5% ,or 1 out of every 20 patients undergoing surgical procedures, are likely to develop a surgical site infection. In the United States, that means about 500,000 patients every year will develop a SSI. Reports indicate that SSI adds an average of one week to hospitalization . The excess costs associated with SSIs can be over $8 million / year, and much of that cost is not reimbursable through insurance companies. Hospitals, depending on the type of reimbursement contracts they have, can lose money when patients become infected. But for the patient and family, the cost is much more serious.
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The Surgical Care Improvement Project A National Initiative to Improve Outcomes for Patients having Surgery Dale W. Bratzler, DO, MPH QIOSC Medical Director Oklahoma Foundation for Medical Quality, Inc.
Surgical Care Improvement Project National Goal To reduce preventable surgical morbidity and mortality by 25% by 2010
Single vs Multiple Dose Surgical Prophylaxis: Systematic Review McDonald. Aust NZ J Surg 1998;68:388 Favors single dose Favors multiple dose All studies, fixed All studies, random Multi > 24h Multi < 24h
Antibiotic Timing Related to Incision Bratzler DW, Houck PM, et al. Arch Surg . 2005; 140:174-182 .
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 .
Surgical Infection Prevention Performance Stratified by Surgery 1 1 All results are weighted to reflect adjustment based on the state-specific sampling scheme. 2 Reflects data for only 11 220 cases that had an explicitly documented incision time. These results include patients who received vancomycin between one and two hours before the incision (N=213). Cases were excluded from this performance measure if there was insufficient data to determine the time interval between prophylactic antimicrobial dose and surgical incision (N=22,902). In addition, patients undergoing colon surgery who received oral antimicrobials only for prophylaxis were excluded from the denominator (N=11). Bratzler DW, Houck PM, et al. Arch Surg . 2005; 140:174-182 . 55.7 (54.8-56.6) All Surgeries (11,220) 54.8 (51.4-58.3) Hysterectomy (432) 46.0 (43.5-48.4) Colon (732) 59.7 (58.3-61.2) Hip/knee (2,694) 47.0 (44.0-49.9) Vascular (1,116) 58.5 (56.8-60.2) Cardiac (3,287) Antibiotic within 1 hour 2 % (95% CI) Surgery (N)
Surgical Infection Prevention Performance Stratified by Surgery 1 1 All results are weighted to reflect adjustment based on the state-specific sampling scheme. Antimicrobials were considered “prophylactic” if they were given before surgery, given intraoperatively, or given within 24 hours after the end of surgery. Cases were excluded from this performance measure if no antimicrobials were administered, if no antimicrobials administered were considered “prophylactic,” or if there was insufficient data to make the determination on timing (N=336). In addition, because there are no published guidelines for antimicrobial selection for beta-lactam allergic patients undergoing colon surgery or hysterectomy, cases with a documented beta-lactam allergy that did not pass the performance measure for these two operations were excluded from the denominator (N=568). Bratzler DW, Houck PM, et al. Arch Surg . 2005; 140:174-182 . 92.6 (92.3-92.8) All Surgeries (33,229) 90.2 (89.0-91.3 Hysterectomy (2,395) 75.8 (74.6-77.0) Colon (4,855) 97.2 (96.7-97.5) Hip/knee (14,996) 91.5 (90.5-92.5) Vascular (3,140) 95.1 (94.7-95.6) Cardiac (7,843) Correct Antibiotic % (95% CI) Surgery (N)
Surgical Infection Prevention Performance Stratified by Surgery 1 1 All results are weighted to reflect adjustment based on the state-specific sampling scheme. Antimicrobials were considered “prophylactic” if they were given before surgery, given intraoperatively, or given within 24 hours after the end of surgery. Cases were excluded from this performance measure if no antimicrobials were administered, if no antimicrobials administered were considered “prophylactic,” or if there was insufficient data to make the determination of timing (N=344). Any patient with documentation in the medical record of an infection during surgery or within 48 hours after the end of surgery was excluded from the denominator (N=634). In addition, patients who underwent more than one surgical procedure of interest during the hospitalization were excluded from the denominator (N=552). Bratzler DW, Houck PM, et al. Arch Surg . 2005; 140:174-182 . 40.7 (40.2-41.2) 77.9 (76.3-79.5) 40.8 (39.5-42.2) 36.7 (35.9-37.4) 45.2 (43.4-47.0) 34.4 (33.4-35.5) Antibiotic Stopped within 24 hours % (95% CI) 40.4 21.4 57.0 39.0 42.7 40.9 Median Time to Discontinuation (Hours) All Surgeries (32,603) Hysterectomy (2,569) Colon (4,911) Hip/knee (14,575) Vascular (2,913) Cardiac (7,635) Surgery (N)
Latham R, et al. Infect Control Hosp Epidemiol . 2001.
Perioperatively administered beta blockers have the potential to:
Decrease myocardial oxygen demand
Reduced heart rate
Reduced wall tension
Decrease myocardial ischemia and adverse cardiac events
Prevention of Cardiac Events A Sample of Some of the Studies Decreased myocardial ischemia Esmolol Total knee 60 PR Urban, 2000 Decreased cardiac events from 34% to 3.4% at 30-days Bisoprolol Major vascular 59 PR Poldermans, 1999 Decreased cardiac events from 21% to 10% at two years Atenolol Noncardiac 99 PR Mangano, 1996 50% decreased MI Unknown General vascular 53 CC Yeager, 1995 Decreases silent myocardial ischemia Metroprolol Peripheral vascular 48 CC Pasternack, 1989 Decreased myocardial oxygen demand, infarction, and arrhythmias Propranolol CABG 50 PR Hammon, 1984 No perioperative cardiac events Propranolol Gen. Abdominal 13 CC Smulyan, 1982 Findings Drug Surgery N Study Type Study, y
Prevention of Cardiac Events Mangano DT, et al. N Engl J Med. 1996;335:1713-1720.
Randomized, placebo controlled trial of perioperative atenolol on overall survival and cardiovascular mortality in patients with or at risk of cardiovascular disease.
200 patients (99 atenolol)
Atenolol or placebo before anesthesia induction, immediately after surgery, and for seven days postoperatively
Heart rate maintained > 55 bpm, BP maintained > 100 mm Hg
Mangano DT, et al. N Engl J Med . 1996;335:1713-20.
How often is postoperative myocardial infarction potentially preventable?
72 Patients identified with postoperative MI using 2º dx
Charts reviewed by trained nurse abstractors
Diagnosis of MI required both laboratory physician confirmation
Mean age 70
81% White, 7% Black, 1% Latino, 10% unknown
35% Vascular, 28% General, 17% Ortho, 10% Ob-Gyn, 11% other
25% in-hospital mortality rate
Lindenauer PK, et al. Arch Intern Med . 2004;164:762-766.
72 Patients with PMI 70 at high risk 58 ideal candidates 12 with BB contraindications 2 not high risk 30/58 Rx with BB (5 optimal Rx) 28/58 Not Rx with BB 22 Previously treated 8 initiated in hospital 26 previously untreated 2 discontinued
48 % of postoperative myocardial infarction potentially preventable
Only 9% of patients received optimal beta blocker therapy
Perioperative Beta Blocker Use in Patients with Postoperative MI Lindenauer PK, et al. Arch Intern Med . 2004;164:762-766.
Despite the well known risk of VTE and the publication of evidence-based guidelines for prevention, previous medical record audits have demonstrated underuse of prophylaxis
Anderson FA Jr, et al. Ann Intern Med . 1991;115:591-595. Anderson FA Jr, et al. J Thromb Thrombolysis . 1998; 5 (1 Suppl):7S-11S. Bratzler DW, et al. Arch Intern Med . 1998;158:1909-1912. Stratton MA, et al. Arch Intern Med . 2000;160:334-340.
Surgical Care Improvement Project Performance measures - Process
Prevention of venous thromboembolism
Proportion who receive recommended VTE prophylaxis
Proportion who receive appropriate form of VTE prophylaxis (based on ACCP Consensus Recommendations)
Published Audits of VTE Prophylaxis General Surgery
Anderson, et al.
1986 audit of 16 Massachusetts hospitals
Approximately 1/3 received prophylaxis
Anderson, et al.
1994 audit, statewide in Massachusetts
84% of colectomy patients received prophylaxis
regional variation 57-93%
Anderson FA Jr, et al. Physician practices in the prevention of venous thromboembolism. Ann Intern Med . 1991;115:591-595. Anderson FA Jr, et al. Practices in the prevention of venous thromboembolism. J Thromb Thrombolysis . 1998; 5 (1 Suppl):7S-11S.
Published Audits of VTE Prophylaxis General Surgery Use of any form of prophylaxis based on level of risk for venous thromboembolism among 419 Medicare patients from 20 hospitals undergoing major abdominothoracic surgery. Measures were implemented for patients at moderate risk (35%; 95% CI, 25-46%), at high risk (40%; 95% CI, 29-51%), and at very high risk (39%; 95% CI, 33-45%). Overall utilization rate for prophylaxis was 38% (95% CI, 33-43%). Bratzler DW, et al. Arch Intern Med . 1998;158:1909-1912.
Published Audits of VTE Prophylaxis General Surgery
Stratton, et al
Audit in 10 teaching or community university-affiliated hospitals (size ranged from 350-747 beds)
495 major abdominal surgery patients
372 (75.2%) received prophylaxis
249/495 (50.3%) received grade A therapy
Stratton MA, et al. Prevention of venous thromboembolism: adherence to the 1995 American College of Chest Physicians Consensus Guidelines for surgical patients. Arch Intern Med . 2000;160:334-340.
VTE Prophylaxis in General Surgery National SIP Project - Results * Prophylaxis was considered appropriate if the patient received IPC, LDUH, or LMWH with or without other modalities (American College of Chest Physicians’ grade 1A recommendation). † This column is limited to the subset of patients who had a principal diagnosis of malignancy. Prophylaxis was considered appropriate if the patient received a combination of LDUH or LMWH with IPC or ES with or without other interventions (American College of Chest Physicians’ grade 1C recommendation), or warfarin with or without other interventions (American College of Chest Physicians’ grade 2C recommendation). Bratzler DW, et al. (in review). 53.0 47.9 41.3 66 73 63 94.4 91.3 88.5 96.8 94.4 94.3 125 160 122 Highest performance District of Columbia Connecticut Michigan 16.1 25.3 25.9 87 79 54 54.4 65.0 69.9 59.8 75.9 77.0 169 137 113 Lowest performance Puerto Rico Mississippi Texas 31.4 3533 80.6 86.7 6896 All Recommended Prophylaxis † % Cases (N) Recommended Prophylaxis* % Any Prophylaxis % Cases (N) State/territory Very-high-risk High-risk
ACCP Guidelines for VTE Prevention Geerts WH, et al. CHEST . 2004;126:338S-400S.
Potential to Reduce Perioperative Complications in SCIP Based on the goal of achieving near-complete guideline compliance to prevent each of these complications as compared to current national rates of guideline compliance for each complication.