Download - Surgical Site Infection SUSP
Surgical Site InfectionSUSPArmstrong Institute for Patient Safety and Quality
Presented by: Elizabeth C. Wick, M.D. and Deborah B. Hobson, R.N.
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• Understand pathogenesis, monitoring and prevention of SSIs
• To explore how to implement evidence-based behaviors to prevent SSIs
Learning Objectives
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0%
5%
10%
15%
20%
25%
Drug-related
Woundinfect.
Tech.comp.
Latecomp.
Diag.mishap
Therap.mishap
Nontech.comp.
Proc.related
Proportion of Adverse EventsMost Frequent Categories
Brennan. N Engl J Med. 1991;324:370-376
Non-surgical
Surgical
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• SSI is the most common nosocomial infection in the surgical patient
• SSI is the most common complication after colorectal abdominal surgery (3-30%)
• SSI is associated with increased mortality, length of stay and readmission
• An SSI costs between $6,200 - $15,000/per patient (superficial-organ space)
Background
Smith et al, Ann Surg, 2004 Wick et al, Arch Surg, 2011
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Pathogenesis of SSI
Bacteria
Procedure
Host
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• Superficial– purulent drainage from wound– positive wound culture– pain, redness swelling– diagnosis by surgeon
• Deep– purulent drainage from deep aspect of wound– dehiscence– abscess on exam or CT scan
• Organ Space– infection in surgical cavity (abdomen)
SSI Definitions
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NEW MANDATORY Monitoring: colon and hysterectomy
• Rate will be risk adjusted based on age and ASA
• Deep incisional and organ space rates for colon and hysterectomy will be reported to CMS (required for full payment)
• Data to be transmitted to CMS late 2012, 2013
• Hospital specific standardized infection ratios will be generated for colon and hysterectomy
Monitoring: NHSN(CDC-National Healthcare Safety Network)
http://www.cdc.gov/nhsn/PDFs/FINAL-ACH-SSI-Guidance.pdf
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• Data – Robust preoperative risk factors for risk adjustment– 30-day postoperative mortality and morbidity
• Program– Costs approximately $30K/year; infection only one of many
outcomes studied– Requires full time RN dedicated to data collection AND surgeon
champion– Includes annual audit by NSQIP and risk adjusted reports – Option to collect all colon and rectal procedures vs. random sample
of surgical procedures
Monitoring: NSQIP(National Surgical Quality Improvement Program)
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SCIP PROCESSES TO PREVENT SSI
SCIP Data Johns Hopkins ComparisonHospitals
Surgery patients who were given an antibiotic at the right time (within one hour before surgery) to help prevent infection
98% 97%
Surgery patients who were given the right kind of antibiotic to help prevent infection 98% 98%
Surgery patients whose preventive antibiotics were stopped at the right time (within 24 hours after surgery)
97% 96%
Surgery patients needing hair removed from the surgical area before surgery, who had hair removed using a safer method (electric clippers or hair removal cream – not a razor)
100% 100%
Patients having surgery who were actively warmed in the operating room or whose body temperature was near normal by the end of surgery.
98% 99%
Johns Hopkins Hospital. May 2010 SCIP, Hospital Compare, www.medicare.gov
Does SCIP Give Us Enough information?
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Problem : Penicillin-allergic patients undergoing colorectal surgery were not receiving proper prophylactic antibiotics (Clindamycin and Gentamycin).
Johns Hopkins CUSP Experience:Room for Improvement in SCIP Compliance
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Antibiotic Compliance ProjectJohns Hopkins
Before After0
25
50
75
100
33%
92%
Correct Dose of Gentam-icin Received
% o
f Pat
ient
s C
ompl
iant
Interventions
• Increased amount of gentamicin available in the room
• Added dose calculator in anesthesia record
• Educated surgeons, anesthesia, and nursing in
Wick et al, JACS 2012 (in press)
Antibiotics practices All cases (n = 3002) number (%)
Nonemergency (n = 2743) number (%)
Emergency cases (n = 248) number (%)
Was an SCIP-compliant antibiotic chosen? 2,431 (81.4%) 2,293 (83.6%) 130 (52.4%)
Was antibiotic given within 1 h before incision? 2,712 (90.8%) 2,544 (92.7%) 159 (64.1%)
Antibiotics weight-adjusted (n = 972) 552 (56.8%)
Antibiotics redosed (n = 398) 24 (6.0%)
Total surgical site infection 269 (9.0%) 245 (8.9%) 24 (9.7%)
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Perioperative Antibiotic Compliance:Michigan Surgical Quality Collaborative
Hendren et al. Am. J Surg 2011
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Problem: Patients arrive in the recovery room with temperature < 36°C despite having a forced air warmer during surgery
Johns Hopkins CUSP Experience:Room for Improvement in SCIP Compliance
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Normothermia Project Johns Hopkins
Before After0
25
50
75
100
83%
95%
Temperature > 36 °C Post-Op
% o
f Pat
ient
s C
ompl
iant
Interventions
• Confirmed that temperature probes were accurate (trial comparing foley and esophageal sensors)
• Initiated forced air warming in the pre-operative area
• Heightened awareness
Wick et al, JACS 2012 (in press)
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EMERGING EVIDENCE FOR SSI PREVENTION
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1. Antibiotic Usage– Redosing– Weight based dosing of cephalosporins
2. Maintenance of normogylcemia3. Utilization of mechanical bowel preparation
with oral antibiotics4. Standardization of skin preparation
Emerging Evidence for SSI Prevention
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• Antibiotic Redosing
– Maintain therapeutic antibiotic serum levels during entire procedure
Additional Interventions to Improve Antibiotic Efficacy
Consensus Guidelines, in pressIDSA/SIS/SHEA/AHPS
Medication Dosing Interval
Cefazolin q3hrs
Cefotetan q6hrs
Cefoxitin q2h
Clindamycin q6h
Vancomycin q12h
BACKGROUND:• Hyperglycemia is common in
hospitalized patients
• 38% of medical and surgical patients had hyperglycemia (26% diabetic and 12% non-diabetic
• In cardiac surgery, degree of post-operative hyperglycemia correlates with SSI; adopted as SCIP measures
GOAL: Glucose <180mg/dl in all hospitalized patients
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Hyperglycemia and Infection
Ramos. Ann Surg 2008
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BACKGROUND• 1012 Bacteria reside on the skin• Staphlococcus and Streptococcus species among others
GOAL OF SKIN PREPARATION• Reduce bacterial burden on skin prior to incision
BEST PRACTICE• Dual-agent skin preparation (chlorhexidine + alcohol, providone-iodine
+alcohol)• Skin prep should include alcohol to increase durability of sterilization• Prep should be applied to specification (duration and amount)• Prep must dry before incision
Preparation of the Surgical Site
Darouiche RO et al. N Engl J Med. 2010 Swenson BR et al. Infect Control Hosp Epidemiol. 2009
• Oral antibiotics for prevention of SSI was first described in the 1940’s
• 1973 Nichols and Condon FAVORABLE
• 1974 Washington et al randomized trial FAVORABLE
• 1990’s-2000’s oral antibiotics fell out of favor in US– Patients not tolerant of preparation (nausea, dehydration)
• 2002 Lewis et al – Randomized controlled trial– Oral neomycin and metronidazole plus systemic antibiotics vs
systemic antibiotics alone (5% neomycin and metronidazole vs 17% placebo)
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Bowel Preparation:A Brief History
Reviewed in Fry, 2011.
Bowel Preparation:A Brief History
• Rigorous studies of IV antibiotics did not include oral antibiotics
• 1990’s-2000’s oral antibiotics fell out of favor in US– Patients not tolerant of preparation (nausea, dehydration)– Patients no longer admitted to hospital pre-operatively
• Lewis et al (2002)– Randomized controlled trial– Oral neomycin and metronidazole plus systemic antibiotics vs systemic
antibiotics alone (5% neomycin and metronidazole vs 17% placebo)
• 2012– AHPSA guidelines on antimicrobial prophylaxis endorse use of oral
antibiotics with mechanical bowel preparation plus IV antibiotics to prevent SSIs
25Reviewed in Fry, 2011.
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Cochrane Review:Oral Antibiotics + Bowel Preparation is Associated with Lowest SSI Rate
1Guenega, Cochrane Database Syst Rev,20092Nelson, Cochrane Database Syst Rev,2009
Slide adapted fromPatch Dellinger, MD University of Washington
SS
I Rat
e
Nelson Study1 Guenaga Study2
SS
I Rat
eMBP + oral +
parenteral
MBP - no oral +
parenteral
MBP + + parenteral
No MBP + + parenteral
MBP = Mechanical Bowel Preparation
• Appropriate prophylactic antibiotics– Selection*– Weight-based dosing of cephalosporins– Timing*– Redosing– Discontinuation*
• Appropriate hair removal as close to time of surgery as possible*
• Temperature management*• Appropriate glycemic control• Dual agent (with alcohol) surgical skin prep • Mechanical bowel prep and oral antibiotics
Summary of SCIP and Emerging Evidence to Prevent Colorectal SSIs
*SCIP measures 28
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• Review current colorectal SSI bundles at your hospital (policy and practice)
• Review hospital process measure data
• With assembled CUSP team, plan for administration of staff safety assessment
Next Steps
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Who’s on the call?
Poll
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Does your hospital have a colorectal SSI bundle in place?
Poll
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If your hospital has a colorectal SSI bundle in place, what’s in it?
Poll
On-boarding Call Evaluation
We want to ensure that the on-boarding callsprovide useful and pertinent information for theSUSP teams. For this reason we request thatyou complete a brief evaluation following eachcall. The evaluation may be found at thefollowing link:
https://www.research.net/s/Onboarding_Evaluation