Surgical Infection Prevention

Team Members:Anesthesia: W. Scott Jellish - chair, Maureen Kawka, Joe RinehartInfectious Disease: Paul O’Keefe, Chris SchrieverSurgical Services: Jeri Katsaros, Margaret VorrierLabor & Delivery: Maureen DaveyQuality Resource Management: Mary Altier, Carmen Barc, Vada GrantInfection Control: Jayne HaakeCCE: William Barron, LuAnn Vis, Michael Wall

Opportunity Statement

Surgical site infections are a major complication after surgery, resulting in considerable morbidity, mortality, and resource utilization. Proper use of antibiotics – giving the right drug at the right time – is effective in preventing infections after surgery

Project Goals: To achieve 100% compliance for the following measures:

1. Administer antibiotics within one hour before surgical incision2. Administer the appropriate antibiotic3. Stop antibiotics within 24 hours after surgery

Targeted Surgeries

Abdominal and Vaginal Hysterectomy Hip and Knee Replacement Cardiac Bypass Other Cardiac Surgery Vascular Surgery Colon Surgery

Solutions Implemented in 2005

Data collection processes completely overhauled Restructured data collection to CMS/JCAHO specifications Monthly chart audits (50-70/month) by RN Quality Specialists Forwarded data to UHC for “practice” and benchmarking Began abstracting additional SIP measures – glucose control, hair

removal, normothermia

Communication with key stakeholders Overall results available on luhs.org Department specific results available on internal website

Barriers Addressed Adjusted post-operative orders for antibiotic

discontinuation Focused efforts with Orthopaedic NP to improve

SIP-3 Shared patient/MD level data Forwarded endorsement from American Academy of Orthopaedic

Surgeons

Engaged colon surgery physician leader OR management team focused on appropriate hair

removal Improved access to clippers Removed razors from OR – only available through case carts

Per

cent

* Preliminary data for quality improvement purposes onlyMonth

Apr-0

4 (n

=67)

May

-04

(n=5

0)

Jun-

04 (n

=58)

Jul-0

4 (n

=55)

Aug-0

4 (n

=48)

Sep-0

4 (n

=43)

Oct-0

4 (n

=50)

Nov-0

4 (n

=51)

Dec-0

4 (n

=55)

Jan-

05 (n

=47)

Feb-0

5 (n

=46)

Mar

-05

(n=4

8)

Apr-0

5 (n

=47)

May

-05

(n=5

1)

Jun-

05 (n

=54)

Jul-0

5 (n

=47)

Aug-0

5 (n

=48)

Sep-0

5 (n

=49)

Oct-0

5 (n

=36)

Nov-0

5 (n

=37)

Dec-0

5 (n

=37)

80

85

90

95

100

105UCL = 103.95

LUHS Mean = 93.0%

LCL = 81.98

LUMC patients who receive prophylactic antibiotics within LUMC patients who receive prophylactic antibiotics within 60 minutes prior to surgical incision60 minutes prior to surgical incision

UHC Rate: 77%

Per

cent

* Preliminary data for quality improvement purposes onlyMonth

Apr-0

4 (n

=61)

May

-04

(n=4

8)

Jun-

04 (n

=55)

Jul-0

4 (n

=53)

Aug-0

4 (n

=47)

Sep-0

4 (n

=42)

Oct-0

4 (n

=46)

Nov-0

4 (n

=51)

Dec-0

4 (n

=50)

Jan-

05 (n

=47)

Feb-0

5 (n

=46)

Mar

-05

(n=4

8)

Apr-0

5 (n

=47)

May

-05

(n=5

2)

Jun-

05 (n

=54)

Jul-0

5 (n

=46)

Aug-0

5 (n

=49)

Sep-0

5 (n

=49)

Oct-0

5 (n

=35)

Nov-0

5 (n

=37)

Dec-0

5 (n

=39)

65

70

75

80

85

90

95

100UCL = 99.02

LUHS Mean = 82.5%

LCL = 66.05

LUMC patients who receive prophylactic antibiotics LUMC patients who receive prophylactic antibiotics consistent with current CMS guidelinesconsistent with current CMS guidelines

UHC Rate: 89%

LUMC patients who have prophylactic antibiotics LUMC patients who have prophylactic antibiotics discontinued within 24 hours after surgery enddiscontinued within 24 hours after surgery end

Per

cent

* Preliminary data for quality improvement purposes onlyMonth

Apr-0

4 (n

=62)

May

-04

(n=4

4)

Jun-

04 (n

=57)

Jul-0

4 (n

=54)

Aug-0

4 (n

=44)

Sep-0

4 (n

=40)

Oct-0

4 (n

=48)

Nov-0

4 (n

=49)

Dec-0

4 (n

=51)

Jan-

05 (n

=46)

Feb-0

5 (n

=46)

Mar

-05

(n=4

7)

Apr-0

5 (n

=46)

May

-05

(n=4

9)

Jun-

05 (n

=54)

Jul-0

5 (n

=46)

Aug-0

5 (n

=47)

Sep-0

5 (n

=48)

Oct-0

5 (n

=34)

Nov-0

5 (n

=37)

Dec-0

5 (n

=35)

50

60

70

80

90 UCL = 89.94

LUHS Mean = 69.8

LCL = 49.70

Orthopedic NP involvement and order changes

UHC Rate: 61%

Next Steps: Where do we go from here?

SIP-1: Individual feedback (letters) concerning protocol noncompliance

to Anesthesiologists, Residents, & CRNA’s Incorporate prompt for antibiotic administration during the time-

out Signage prompts at OR doors and Pharmacy

SIP-2: Awaiting response for Vancomycin use in CV valve cases

SIP-3: Collect CV data for 48 hour discontinuation Brainstorm improvement opportunities with CV Nurse

Practitioners and General surgeons (colon surgeries)

Next Steps: Where do we go from here?

Engage Operating Room staff and OR Pharmacy in improvement efforts

Initiate use of UHC online tool and sampling process to assist with data collection of the extended measure set Glucose control Hair removal Normothermia SSI rates

Submit SIP-1 measure to CMS