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Quality Improvement in Surgical Settings: Perioperative Standardization

Khalid Yousuf, M.D.

Orthopedic Surgery & Joint Replacement

Little Company of Mary Medical Group

April 12, 2017

1


Describe the trends in infection rates, public awareness and cost implications

Discuss the role of quality improvement and standardization

Identify system-wide initiatives to manage risk factors in surgical care

Focus on improving patient skin preparation in surgical care

Illustrate the implementation process with case studies

Objectives

2


Healthcare-Associated Infections Are a Quality Issue


The U.S. Healthcare System Has a Serious Quality Problem

4

HAIs Approach 100,000 Defects per Million Patients

Buck CR. GE; 2003. Adapted by Dr. Sam Nussbaum, Wellpoint, and Mark Sollek, Premera; 2007.

DEFEC

TS

P

ER

M

ILLIO

N

σLEVELS


700+ Hospitals Failed Infection Measures in 2014

5

CartoDB/Healthcare Finance. https://healthcarefinance.cartodb.com/viz/83392ff0-e82c-11e4-a865-0e9d821ea90d/public_map. Updated 2015. Accessed July 12, 2016.

https://healthcarefinance.cartodb.com/viz/83392ff0-e82c-11e4-a865-0e9d821ea90d/public_map










The most recent economic evaluation showed an average attributable cost of $9.8 billion/year

HAIs Place Financial Strain on the Healthcare System

6

Zimlichman E, et al. JAMA Intern Med. 2013;173:2039-46.

CAUTI = catheter-associated urinary tract infection; CDI = Clostridium difficile infection; CLABSI = central line-associated bloodstream infection; LOS = length of stay; NR = not reported; SSI = surgical site infection; VAP = ventilator-associated pneumonia.

aPer 1000 device-days. bPer 1000 patient-days. cPer 100 patient procedures.

33%

18%

0.3%

31%

15%

% of Total HAI cost

SSI

CLABSI

CAUTI

VAP

CDI

HAI Incidence

Rate Cost/

Patient LOS

CAUTI 1.87a $896 NR

CDI 3.85b $11,285 3.3

CLABSI 1.27a $45,814 10.4

SSI 1.98c $20,785 11.2

VAP 1.33a $40,144 13.1


• 1% reimbursement penalty for poor performance under Hospital-Acquired Conditions Reduction Program

• 758 hospitals were penalized in 2015

• $364 million in lost revenue from Medicare

7

1. Centers for Medicare & Medicaid Services (CMS). https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-12-10-2.html. Published December 10, 2015. Accessed May 19, 2016. 2. QualityNet. https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier2&cid=1228774189166. Accessed April 7, 2016. 3. Medicare.gov|Hospital Compare. https://www.medicare.gov/hospitalcompare/HAC-reduction-program.html. Accessed April 7, 2016. 4. CMS Rules for Hospital-Acquired Conditions Pose Challenges and Opportunities. inFocus: The Quarterly Journal for Health Care Practice and Risk Management. Volume 13, Fall 2010. http://www.fojp.com/sites/default/files/inFocusFall10.pdf. Accessed April 7, 2016. 5. CMS. http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Hospital_VBPurchasing_Fact_Sheet_ICN907664.pdf. Accessed May 31, 2016. 6. CMS. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/HAC/2015-2017-HAC-Summary.docx. Accessed July 8, 2016.

HAC program expanded to high rates of HAIs

2013 2017 2015 2016 2014

VBP withholding

begins Medicare penalties for HAIs begin [HAC

Reduction Program]

Poor performance for FY2016 is based on 4 quality

measures: • AHRQ PSI 90 Composite • CDC NHSN CLABSI • CDC NHSN CAUTI • CDC NHSN SSI (colon and hysterectomy)

ACA HAC Reduction Program goes into effect

Increasing Scrutiny & Financial Penalty for Healthcare-Acquired Conditions

In FY2017 and beyond, additional measures include: • MRSA bacteremia • Clostridium difficile (CDI)

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-12-10-2.html















https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic/Page/QnetTier2&cid=1228774189166

https://www.medicare.gov/hospitalcompare/HAC-reduction-program.html





http://www.fojp.com/sites/default/files/inFocusFall10.pdf

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Hospital_VBPurchasing_Fact_Sheet_ICN907664.pdf











https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/HAC/2015-2017-HAC-Summary.docx




















Resistant Strains Spread Rapidly

8

Infectious Disease Society of America. Bad Bugs, No Drugs. https://www.idsociety.org/uploadedFiles/IDSA/Policy_and_Advocacy/Current_Topics_and_Issues/Advancing_Product_Research_and_Development/Bad_Bugs_No_Drugs/Statements/As%20Antibiotic%20Discovery%20Stagnates%20A%20Public%20Health%20Crisis%20Brews.pdf. Published July 2004. Accessed November 30, 2016.

1980 1985 1990 1995 2000

0

10

20

30

40

50

60

% I

ncid

ence

MRSA

VRE

FQRP

FQRP =Fluoroquinolone-resistant Pseudomonas aeruginosa; MRSA = Methicillin-resistant Staphylococcus aureus; VRE = Vancomycin-resistant enterococci

Year


HAIs: Evolving as Antibiotic Resistance Becomes More Common

9

*Data for all HAIs, combined years (2011-2014) Centers for Disease Control and Prevention. http://gis.cdc.gov/grasp/PSA/MapView.html. Accessed April 18, 2016.

46%

National percentages*

of S. aureus HAIs are methicillin-resistant

14%

of E. coli HAIs are multi-drug resistant 7%

of Pseudomonas HAIs are multi-drug resistant

of Enterobacter HAIs are carbapenem-resistant 4%

http://gis.cdc.gov/grasp/PSA/MapView.html


• Patient safety and the delivery of quality care are intertwined.

• Prevention is key for fighting HAIs, especially resistant HAIs.

• Consistent, safer care through prevention is achievable in the inpatient and outpatient setting with standardization.

HAIs are a Threat to Patient Safety and Quality Care

10


Standardization Relies on Systemic Quality Improvement

11

Health Resources and Services Administration. http://www.hrsa.gov/quality/toolbox/methodology/qualityimprovement/. Accessed April 13, 2016.

QI works as systems and processes

Focus on patients

Focus on being part of a team

Focus on the use of

data

4 principles of QI in

healthcare

http://www.hrsa.gov/quality/toolbox/methodology/qualityimprovement/


Standardization and Bundled Infection Prevention Strategies to Improve Quality


Standardization Can Minimize Variability in Processes

13

LSL = lower specification limit; USL = upper specification limit.

High variation High potential defects Unpredictable quality

LSL USL

Low variation Low potential defects

Consistent quality

LSL USL

• Processes with less variation have fewer defects

• The concept of defect reduction applies to processes across industries, not just healthcare


Clinical Practice Bundles are Tools

14

Resar R, et al. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2012. http://www.ihi.org/resources/pages/ihiwhitepapers/usingcarebundles.aspx. Accessed April 13, 2016.

Clinical practice bundles target

variable processes to improve outcomes

Potential for great

harm

High cost Strong

evidence base

http://www.ihi.org/resources/pages/ihiwhitepapers/usingcarebundles.aspx


Comprehensive Unit-Based Safety Program (CUSP) is a model for safety improvement that leverages QI methodologies

Safety Improvement Complements Quality Improvement

15

Educate staff in the science of

safety

Identify defects

Engage executive leaders

Learn from

defects

Implement teamwork

tools

March A. http://www.ahrq.gov/professionals/quality-patient-safety/cusp/cusp-success/index.html. Published September 28, 2012. Accessed April 14, 2016.

http://www.ahrq.gov/professionals/quality-patient-safety/cusp/cusp-success/index.html







© 2017 BD. BD, the BD Logo and all other trademarks are property of Becton, Dickinson and Company. 16

Multiple Factors Contribute to HAI Risk

One factor could lead to failure 1. Adapted with permission from Spencer M. Working Toward Zero Healthcare Associated Infections. Available at: http://www.workingtowardzero.com/uploads/4/6/4/2/4642325/aorn1929_going_forward_-_preventing_ssis__dec_2014.pdf. Accessed 2016. 2. Fletcher N, et al. J Bone Joint Surg Am. 2007;89:1605-18.

http://www.workingtowardzero.com/uploads/4/6/4/2/4642325/aorn1929_going_forward_-_preventing_ssis__dec_2014.pdf




Variability in Surgical Practices Compounds Impacts from Risk Factors

58%

89%

92%

96%

71%

99%

64%

98%

0% 20% 40% 60% 80% 100%

Education re: scrub technique w/in past yr

CHG preoperative skin prep when used

prior to abdominal hysterectomy

CHG preoperative skin prep when used

prior to colon surgery

Periop temperature evaluation

Preop glucose monitoring

Hair removal by clippers

Antimicrobial dose based on weight

Antimicrobial w/in 1 hr of incision

Fakih MG, et al. Am J Infect Control. 2013;41:950-4.

Percent (%) of hospitals surveyed, n = 71

CHG = chlorhexidine gluconate


Improvement Must be Multidimensional

Successful standardized

HAI prevention

Simplify processes and procedures

Ensure personnel have competencies in evidence-based methods

Use tools to improve processes

El-Othmani MM, et al. Int Surg J. 2016; 3(1): 1-10.


Variability in Skin Preparation Yields Opportunities for Standardization


Selected Opportunities for Standardizing Skin Preparation

20

Hand hygiene

Compliance with procedures

Hand/forearm scrubbing

Scrub technique1

Scrub duration2

Drying and gloving techniques1

Hair removal

Clipping outside the OR2

Use of vacuum assisted hair removal

Only around incision site only when hair will interfere with the operation1

Preventing abrasions: electric clippers > depilatory agent = no hair removal > razor1

Surgical site antiseptic

Antiseptic agent

Application method

Dry time

1. Mangram AJ, et al. Infect Control Hosp Epidemiol. 1999;20:250-78. 2. Association of Perioperative Registered Nurses (AORN). Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc.; 2013:75-89.


High Variability in Patient Skin Prep Use and Processes

21

86%

63%

91%

53%

60%

Skin prep application

from surgical site toperiphery


follows label directions

Gloves used during

skin prep application

Skin prep drying time

sufficient


time sufficient

Processes Followed1,2

1. Data generated from the BD Focus on Quality Care Program. 2. Xi H, et al. Focus on Quality Care: An Audit of Surgical Skin Prep Practices in U.S. Hospitals. Presented at the 2014 AORN Surgical Expo and Conference; March 30–April 2, 2014; Chicago, IL. Trademarks are the property of their respective owners.

aOR observations conducted between October 2013 and July 2014.

Primary Skin Prep Use1

3005 Observations in 197 Hospitalsa

10% PVP Paint PVP Scrub and Paint

7.5% PVP Scrub Iodine Gel Prep

Merlin Prevail

Prevail FX DuraPrep

Aqueous CHG (2% & 4%) ChloraPrep

Hibiclens Technicare/PCMX/Other

Alcohol


Differing Application Instructions Among Patient Skin Prep Agents

22

1. CareFusion. Labels. http://www.carefusion.com/our-products/infection-prevention/skin-preparation/chloraprep-patient-preoperative-skin-preparation-products. Accessed July 12, 2016. 2. 3M. 3M™ DuraPrep™ Surgical Solution Application Instructions. http://multimedia.3m.com/mws/mediawebserver?mwsId=66666UF6EVsSyXTtMxTXOXf6EVtQEVs6EVs6EVs 6E666666--&fn=0503-MS-22164E.pdf. Accessed July 12, 2016. 3. CareFusion. Prevail-Fx® In-Service Video. http://www.carefusion.com/medical-products/infection-prevention/skin-preparation/surgical-trays-brushes-bulk-solutions/prevail-fx-in-service-video.aspx. Accessed July 12, 2016. 4. Jeng DK. Am J Infect Control. 2001;29:370-6. 5. CareFusion. Exidine® 2% CHG Scrub Solution. http://www.carefusion.com/medical-products/infection-prevention/skin-preparation/surgical-trays-brushes-bulk-solutions/exidine-scrub-solution-2percent.aspx. Accessed July 12, 2016. 6. CareFusion. Scrub & Pain In-Service Video. http://www.carefusion.com/medical-products/infection-prevention/skin-preparation/surgical-trays-brushes-bulk-solutions/scrub-and-paint-in-service-video.aspx. Accessed July 12, 2016. 7. Scrub Care® Povidone Iodine Cleansing Solution, Scrub [product label]. San Diego, CA: CareFusion; 2010. Trademarks are the property of their respective owners.

aOn hairless skin.

CHG/IPA Iodine/IPA Aqueous CHG Iodine

Scrub/Pain

Example ChloraPrep®1 DuraPrep™2

Prevail-Fx®3 Exidine®5 Wet PVP-I Tray6

Application method

Gentle back and forth strokes

Paint in concentric

circles

Swab back and forth

Scrub and paint in concentric

circles

Application time

0.5-2 min ≥0.5 min4 4 min 5 min7

Dry timea ≥3 min ≥3 min Blot ~2-3 min

http://www.carefusion.com/our-products/infection-prevention/skin-preparation/chloraprep-patient-preoperative-skin-preparation-products

















http://multimedia.3m.com/mws/mediawebserver?mwsId=66666UF6EVsSyXTtMxTXOXf6EVtQEVs6EVs6EVs 6E666666--&fn=0503-MS-22164E.pdf







http://www.carefusion.com/medical-products/infection-prevention/skin-preparation/surgical-trays-brushes-bulk-solutions/prevail-fx-in-service-video.aspx























http://www.carefusion.com/medical-products/infection-prevention/skin-preparation/surgical-trays-brushes-bulk-solutions/exidine-scrub-solution-2percent.aspx





















http://www.carefusion.com/medical-products/infection-prevention/skin-preparation/surgical-trays-brushes-bulk-solutions/scrub-and-paint-in-service-video.aspx


























Compliance Variability Yields Opportunity for Standardization

23

59%

72%

0% 20% 40% 60% 80%

2-Step

combination preps

1-Step

combination prepsIodine and alcohol, chlorhexidine and alcohol

Iodine based: 2-step PVP-I scrub and paint; 7.5% PVP scrub

One-step skin preps yield greater clinical

efficacy and time savings for staff,

which could impact overall quality

Pearson L and Xi H. Focus on Quality Care: Surgical Skin Prep Practices in U.S. Hospitals and Ambulatory Care Centers. Presented at the OR Manager Conference. 2014.

aBased on 5439 procedures observed in 257 hospitals between December 2013 and December 2014 DFU=directions-for-use

Compliance of application method with label instructions


Compliance is a Source of Variation

24

El-Othmani MM, et al. Int Surg J. 2016; 3(1): 1-10.

Compliance Definition

Perform EITHER prep time or dry time according to the manufacturers direction for use

Perform BOTH prep time or dry time according to the manufacturers direction for use

Compliance Rate

61%

25%

Factors correlated with higher rates of compliance: One-step

applicator Central-to-

peripheral application

Use of chlorhexidine-alcohol

Performing a single prep


Evidence-based Selection of Skin Prep Agents

25

1. Saltzman MD, et al. J Bone Joint Surg Am. 2009;91:1949-53. 2. Ostrander RV, et al. J Bone Joint Surg Am. 2005;87:980-5. Trademarks are the property of their respective owners.

7%

19%

31%

0%

5%

10%

15%

20%

25%

30%

35%

40%

ChloraPrepskin prep

DuraPrep PVI

Positive Culture After Prep1

P=.05

P<.0001

P=.01

0%

20%

40%

60%

80%

100%

Before prep ChloraPrepskin prep

DuraPrep Techni-Care

Hallux ToeaP<.05 vs DuraPrep; bP<.001 vs Techni-Care; cP<.05 vs Techni-Care and preop.

Positive Culture After Prep2


High Variability in Surgeon Antiseptic Techniquea

26

Lundberg PW, et al. Surg Infect (Larchmt). 2016;17(1):32-37.

CHG/IPA, n (%) PVI p-value

Prepped for recommended time 30 (100%) 0 <0.0001

Break in sterile technique 8 (26.7) 11 (36.7) 0.58

Performed all steps 5 (16.7) 0 .03

Performed all critical steps 27 (90) 10 (33.3) 0.0001

Total prep time, sec 84.9 102.9 0.05

aThirty subjects who routinely perform surgical skin preparation were recruited from four hospitals to participate in this study. Participants were selected to randomly perform skin preparation using one formula on one site and another formula on the other site.


Hair Removal Techniques Vary

27

Xi H, Pearson L and Perl TM. Minimizing hair dispersal: is this an opportunity for improvement in HAI prevention? IDWeek, October 7-11, 2015, San Diego, CA.

aOnline survey of 250 members from the AORN database with at least 2 years of OR experience and with at least 2 procedures requiring surgical site hair removal conducted in April 2015.

98% 96%

40%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Clipping SSH

instead of

shaving

Single-use

clipper used

Clipping

outside OR

Co

mp

lian

ce R

ate

(%

)

Compliance rates with key recommended practices on surgical site hair (SSH) removal

6%

22%

28%

37%

40%

43%

57%

67%

0% 20% 40% 60% 80% 100%

Lack of space

Nursing/staff preference

Lack of trained staff

No set policy

at our institution

Lack of time

Insufficient clipping

outside of OR…

Patient safety/privacy

Surgeon/physician

preference

Reasons for clipping in the OR

Provider

Patient

Policy Administrator


Proper Skin Preparation is an Important Preventive Measure

28

• 80% of skin flora in the first 5 cell layers of the stratum corneum1

• 1013 cells in the human body, 1014 colonizing microbial cells, a 10-to-1 inequality2

• Major risk factor for HAIs

Proper skin preparation is critical to prevent serious complications

1. Brown E, et al. J Infect Dis. 1989;160:644-50. 2. Wenzel RP. N Engl J Med. 2010;362:75-7.


Deploying Technology to Standardize Hair Removal

29

Hair can harbor colonizing microbes and contaminate the

operative field

Hair dispersed from preoperative clipping

requires lengthy cleanup time

Significant reduction in

microbial contamination

from chest samples for SSC

vs. SCVAD (0.8 vs 0.0 Log10 colony-

forming units, p<0.01)

Replacing standard surgical clippers (SSC) with surgical clippers that have a vacuum-

assisted hair collection device

(SCVAD) to limit opportunities for contamination and improve surgical team

efficiency

PROBLEM RESULT SOLUTION

Medical College of Wisconsin (Milwaukee, WI)

Edmiston CE, et al. Am J Infect Control. 2016 June 30. [Epub ahead of print]

Study of simulated surgical clipping performed on 18 subjects. Computer-generated randomization was used to select matched clip sites. SSC=standard surgical clipper, SCVAD=surgical clippers with vacuum-assisted hair collection device


Vacuum-assisted Hair Removal Reduces Contamination Risks

30

Hair is removed at the point of

clipping

Results

Microbial contamination

in the operative field is significantly

reduced

Ease of use with the SCVAD and elimination of post-clipping cleanup simplifies the hair removal process

Edmiston CE, et al. Am J Infect Control. 2016 June 30. [Epub ahead of print]

Medical College of Wisconsin (Milwaukee, WI)

SCVAD=surgical clippers with vacuum-assisted hair collection device


Initiating Quality Improvement in Surgery


Power in Prevention

32

Observe Monitor Report

Clinicians and consultants observe operating room procedures:

• Surgeon hand scrub

• Hair removal

• Patient pre-operative skin preparation

Observations are collected daily and digitally recorded on a mobile device

Practice is monitored for compliance with: product directions, clinical practice guidelines and practice standards

Percent compliance is calculated and quantified to uncover areas that can be improved with standardization and education

Educate

Focus is on robust education and hands-on lessons rather than didactic approaches:

• Team is trained using best-practices roadmaps

• Evidence-based guidelines & recommendations are the basis for templates

• Regular review and reinforcement of competency


Impact of the Power in Prevention Program

33

Over 800 hospitals

4 years More than 20,000

OR skin prep observations

1 publication and 4 posters

generated

4 YEARS


Preparing for Standardization

34

Identify best practice: • Processes • Products • Behaviors

Set expectations and

milestone dates

Conduct multiple-day observations/

audits to determine

baseline and identify

opportunities

Present findings and confirm

timeline

Build support from surgical services and

surgeons Develop

evidence-based Best

Demonstrated Practice template

and change preference cards

Ongoing and repeatable training; program

implementation and rollout

Review results, refine metrics

and evaluate on a regular basis


Implementing Standardized Procedures To Reduce HAIs

35

Pronovost PJ, et al. BMJ. 2008;337:963-5. 2. Anderson DJ, et al, Infect Control Hosp Epidemiol. 2014;35:605-27.

• Develop action plan • Implement new

processes and leverage clinical job aids

• Educate patients on proper preop preparation at home

• Use OR audit tools to assess current state

• Analyze procedures with competency worksheets

• Train staff on new processes

• Assess patient understanding

• Ongoing OR observation

• Track and analyze data

• Competency testing

• Communicate successes and failures

• Commit to reducing HAIs

• Communicate your commitment and rationale

• Obtain team buy-in

• Engage patients

EVALUATE EXECUTE

ENGAGE EDUCATE


Case Studies: Practice Bundles for Standardizing Skin Preparation


The Preventive Surgical Site Infection Bundle

in Colorectal Surgery: An Effective Approach to Surgical Site Infection Reduction and Health Care

Cost Savings Duke University

Must present slides 38-42

Case Study Module 1

37


Bundled Infection Prevention Strategies in Colorectal Surgery

38

Superficial HAI rate was nearly 20%, this was associated with increased patient

morbidity and health care costs

Implement a clinical practice bundle and evaluate outcomes before and after implementation

PROBLEM SOLUTION

Duke University Medical Center (Durham, NC)

Significant reduction in HAIs, sepsis and costs associated with

infection

RESULT

Keenan JE, et al. JAMA Surg. 2014;149(10):1045-1052.


Clinical Practice Bundle Covers Variable Processes and Procedures

Preoperative Operative Postoperative

Chlorhexidine shower

Mechanical bowel preparation with oral antibiotics

Ertapenem within 1 h of incision

Standardization of preparation of surgical field with chlorhexidine alcohol

Patient education and reinforcement of HAI preventive measures and objectives

Fascial wound protector

Gown and glove change before fascial closure

Dedicated wound closure tray

Limited OR traffic

Maintenance of euglycemia

Maintenance of normothermia during surgery and in the early postoperative period

Removal of sterile dressing within 48 h

Daily washings of incisions with chlorhexidine




Standardization Reduces HAI Rates1


19.3%

8%

5%

2%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

Superficial Postoperative sepsis

Infection Rates*

Preintervention (n=212) Postintervention (n=212)

P<.001

P=.009

*pre- and post-intervention groups were propensity matched to account for potential differences in patient characteristics.



Impact of Clinical Practice Bundles on Cost and LOS1


$0

$2,000

$4,000

$6,000

$8,000

$10,000

$12,000

$14,000

Variable direct costs

Dollars

($)

Impact of HAI post-bundle on cost

Superficial HAI occurrence post-bundle

No superficial HAI occurrence post-bundle

P=.001 R2=.504 0

1

2

3

4

5

6

7

8

9

Length of stay (LOS)

Days

Impact of HAI post-bundle on LOS

Superficial HAI post bundle

No superficial HAI post bundle

P<.001 R2=.359

*multivariate analysis of a subgroup analysis of patients who experienced occurrence of SSI in the post-bundle period LOS = length of stay

1Keenan JE, et al. JAMA Surg. 2014;149(10):1045-1052.

35% increase

71% increase


Results of Targeted Changes

42

The clinical bundle is a viable method to improve quality

of care

RESULTS



Length of stay reduced by one day (P = 0.001)

13.6% reduction in superficial HAIs


Colorectal Surgery Surgical Site Infection Reduction

Program: A National Surgical Quality Improvement

Program-Driven Multidisciplinary Single-Institution

Experience Mayo Clinic


Case Study Module 2

43


Bundled Clinical Practices to Reduce HAI Rates

44

High rates of HAIs

Lean Six Sigma quality improvement approach to introduce multiple interventions

across the entire surgical episode

of care

PROBLEM SOLUTION

Mayo Clinic (Rochester, MN)

Significant declines in overall

and superficial HAI rates

RESULT

Cima R, et al. J Am Coll Surg. 2013;216:23-33.


Multidisciplinary Team Identified Targets for Improvement

45

Surgeon, project leader

Quality advisor

Infection preventionist

Nurse managers on colon and rectal surgery patient care units

Clinical administrator

Clinical nurse specialist

Wound, ostomy, continence nurse

Operating room nursing managers supporting colon and rectal surgery

Quality improvement advisor

ACS NSQIP data abstraction and analysis

Pharmacist

Process engineer

Extended nurse practitioner

Research fellow

Cima R, et al. J Am Coll Surg. 2013;216:23-33



Phased Approach to Developing the Clinical Practice Bundle

46



Creating infrastructure to support change and education

Phase 3

Taking evidence-based steps to reduce variability between surgeons

Phase 2

Developing an understanding of HAIs and surgical processes by evaluating literature,

facility data and current state findings as a team

Phase 1


GOAL: Reduce HAI

by 50% (10 → 5%)

47

Bundled Clinical Practices to Reduce HAI Rates1


CHG = chlorhexidine gluconate Cima R, et al. J Am Coll Surg. 2013;216:23-33.

Signage encouraging hand hygiene

Use closing tray for closure of fascia and skin

Ensure dressing removal within 48 hours

Patient shower with CHG skin cleanser after dressing removal

Patient education on wound care and recognizing infection symptoms

Hand sanitizing wipes made available to patients

Follow-up phone call from nurses

Dismiss patient with 4 oz. bottle of CHG skin cleanser

Glove change by staff before closure of fascia and skin

Ensure understanding by reading “Preventing HAI” pamphlet

Hand cleansing agent readily available

Ensure re-dose of cefazolin within 3-4 hours after incision

ChloraPrep applied – use appropriate amount to ensure complete coverage of incision area

Shower with CHG skin cleanser night before and day of surgery

Practice good hand hygiene

Ensure SCIP compliance: (1) Right antibiotics, (2) Administer 60 minutes prior to incision, (3) Discontinued within 24 h

Chlorhexidine cloths at AM admission

Pre-operative processes

Intra-operative processes

Post-hospitalization

processes

Post-operative processes

Patient cleansing

Antibiotic administration

Closing protocol at time of fascia

closure

Patient and hand hygiene


Additional Targeted Changes Contributed to Success

48

Including a question on hospital intake to determine if patients used chlorhexidine packets the night before and morning of surgery.

Implementing a nurse-initiated protocol ensures use of chlorhexidine cloths over the entire body in the morning admission area if patient did not use chlorhexidine packets provided

Instituting strict hand-hygiene policies and practices for staff, patients, and patient visitors.




HAI Rates Reduced With Standardization1


0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

Overall Superficial Organ Space

Infection Complications Reported with Colorectal Surgeries

Preintervention (2009-2010) Postintervention (2011)

P<.05

P<.05

P=.10



Results of Targeted Changes

50

Significant reduction in overall and

superficial HAIs

RESULTS



Sustained reduction in HAIs

Comprehensive approach that

revolved around culture

and quality


Implementation of a Surgical Comprehensive

Unit-Based Safety Program to Reduce Surgical

Site Infections Johns Hopkins University


Case Study Module 3

51


Report of Implemented Colorectal Surgery Practice Bundle

52

Nearly 1/3 of patients undergoing elective

colorectal surgery were developing HAIs after

surgery

Multidimensional, collaborative approach using evidence-based quality improvement

strategies

PROBLEM SOLUTION

Wick EC, et al. J Am Coll Surg. 2012;215:193–200.

Johns Hopkins University and Hospital (Baltimore, MD)

33% percent decrease in

infection rate sustained for 12

months after interventions

RESULT


Collaborative Approach Identifies Improvement Focus Areas

53

Successful HAI Reduction

Communication & teamwork


Education & training


Coordination of care

Equipment & supplies

Policies & protocols

Infection control


Multiple Targeted Changes Contributed to Success

54


Evidence-based elimination of mechanical bowel preparation for select patients only

Instituting aggressive warming procedures for patients in the pre-anesthesia area

Adopting consistent processes enhanced sterile techniques for skin and fascial closure

Using techniques that promoted standardized adoption and created redundancy in processes to correct lapses in antibiotic prophylaxis that were brought to light by the compliance audit



• Chlorhexidine gluconate used for all patients, including those with ostomy

• Gastrointestinal surgery nurses trained on preparation application; now the only team member to apply skin preparation agent

• All patients given chlorhexidine wash cloths to use the night before surgery; 95% compliance rate achieved

AFTER

Approaches to Standardizing Skin Preparation

55

Two preparation options: chlorhexidine gluconate or povidone-iodine solution

Preparation application technique was variable

Some applications were performed by nurses, others by residents

Confusion around which preparation to use if the patient had an ostomy

BEFORE

Patients not involved or inconsistently engaged in preoperative skin preparation




Selected Improvements Lead to Enhanced Sterile Technique

56

• Designated instruments to be used exclusively for bowel manipulation

• Instruments are physically moved off of the sterile field after anastomosis

• Cautery and suction tip changed

• Education plan implemented to train nurses and scrub technicians to separate instruments and change entire team’s gloves both after completing bowel work and before starting wound closure

AFTER

Same instruments used for surgical procedure often used for skin closure

Used instruments remained in the surgical field

Lack of standardized education on sterile technique and processes

BEFORE




27.3

16.9

9

18.2

13.6

4

0

5

10

15

20

25

30

Overall HAI Rate Superficial HAI Organ space infections

Perc

ent

Infection Rates

Preintervention (n=278) Postintervention (n = 324)

HAI Rates Decrease Significantly

57

P < 0.0001


aBased on evaluation of consecutive patients undergoing elective colorectal surgery procedures and included in the American College of Surgeons National Surgical Quality Improvement program at Johns Hopkins University from July 2009 to July 2011.



Collective Impact of Targeted Changes

58

Rate of HAIs decreased by

33%

RESULTS

28 infections prevented in a

single year

$168-280,000 saved by the

institution

Estimated $102 to $170

million in healthcare savings*

*Assuming widespread application of CUSP HAI intervention




Conclusions


HAIs are evolving, threatening patient safety and the delivery of quality care

Safety and quality improvement to mitigate risk of HAIs can be achieved with standardization

Processes, technologies and/or behaviors selected for standardization should be grounded in evidence

There are many opportunities for standardization in surgery, including skin preparation, antibiotic prophylaxis and policies and procedures that minimize risk

Conclusions

60


Questions?

61


Thank you!

62

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