antibiotic lecture
DESCRIPTION
fsdfsdfsdfsdTRANSCRIPT
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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Prophylactic Antibiotics
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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Prophylactic Antibiotics
Questions
Which cases benefit?
When should you start?
Which drug should you use?
How much should you give?
How long should antibiotics be continued?
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
Prophylactic Antibiotics
Questions
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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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
cefazolin IV give 1 gm if wt < 70 Kg or 2 gm if wt > 70 kg
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
vancomycin IV 1 gm OR clindamycin IV 600 mg
Head/neck procedures Neurosurgery; Kidney transplant
cefazolin IV give 1 gm if wt < 70 Kg or 2 gm if wt > 70 kg
vancomycin IV 1 gm
Hysterectomy cefazolin 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
Urologic levofloxacin 500 mg PO OR IV
vancomycin IV 1 gm IVPB PLUS gentamicin IV 80 mg if pt wt < 70 K or 120 mg > 70 K
Urologic Robotic Procedure (radical prostatectomy)
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
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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Prophylactic Antibiotics
Questions
Which cases benefit?
When should you start?
Which drug should you use?
How much should you give?
How long should antibiotics be continued?
Quality Indicator #3
Proportion of patients whose prophylactic antibiotics
were discontinued within 24 hours of surgery end time
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20
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
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
cefazolin IV give 1 gm if wt < 70 Kg or 2 gm if wt > 70 kg
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
vancomycin IV 1 gm OR clindamycin IV 600 mg
Head/neck procedures Neurosurgery; Kidney transplant
cefazolin IV give 1 gm if wt < 70 Kg or 2 gm if wt > 70 kg
vancomycin IV 1 gm
Hysterectomy cefazolin 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
Urologic levofloxacin 500 mg PO OR IV
vancomycin IV 1 gm IVPB PLUS gentamicin IV 80 mg if pt wt < 70 K or 120 mg > 70 K
Urologic Robotic Procedure (radical prostatectomy)
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
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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30
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