1 building your ssi prevention bundle armstrong institute for patient safety and quality presented...

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Building your SSI Prevention Bundle

Armstrong Institute for Patient Safety and QualityPresented by: Elizabeth C. Wick, M.D. /Brad Winters, M.D.

DRAFT – final pending AHRQ approval

Learning Objectives

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Develop and implement an SSI reduction goal and prevention bundle that addresses up to three surgical care processes that your team feels needs to be improved to address SSIs

Understand how to use the results of your staff safety assessment to build a bundle

Review how to initiate audits of your processes

Create a performance goal (improvement in outcome) for your team

Learn how to proceed with improvements that do not have a strong evidence base

Locate SUSP resources on the project website


Background

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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 re-admission

An SSI costs between $6,200-$15,000/per patient (superficial-organ space)


SSI Definitions

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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 the wound

-Dehiscence

-Abscess on exam or CT scan

Organ Space-Infection in the surgical cavity (abdomen)


Colorectal Surgery Readmissions/Johns Hopkins Hospital

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Readmission rate 17.6% (2009-12)


Pathogenesis of SSI

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Bacteria

Procedure

Host


No single SSI prevention bundle

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Deeper dive into SCIP measures to identify local defects

Emerging evidence– Abx redosing and weight based dosing – Maintenance of normogylcemia– Mechanical bowel preparation with oral abx – Standardization of skin preparation

Capitalize on frontline wisdom– CUSP/Staff Safety Assessment


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Deeper Dive Into SCIP Measures to Identify Local Defects


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Does SCIP give us enough information?

Johns Hopkins HospitalMay 2010 SCIPHospital Comparewww.medicare.gov


http://www.medicare.gov/

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NSQIP Report 2009


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CUSP Step 2:Safety Issue Identified

CUSP Steps 4 & 5:Opportunities to improve

Infection Control • Skin preparation• Hypothermia• Contamination of bowel contents into the wound• Antibiotic timing• Selection and redosing • Length of case

Coordination of Care • Increase utilization of preoperative evaluation center,• Improve surgical posting accuracy (case name and duration)• Computer assistance for antibiotic selection and redosing

Communication and Teamwork • Improve communication throughout perioperative period • Empower team members to speak up • Improve compliance with briefings/debriefings• Implement teamwork tools

Equipment/ Supplies • Accurate temperature probes• Point of care glucose monitoring• Under body warmers • Sanitizing wipes near anesthesia machine

Policies/Protocols • Standardize care/protocols/policies• Monitor sterile technique policies

Education/Training • Ongoing education (with supportive data)• Development of a SSI prevention checklist

Wick, et al. 2012.

Peri-operative Antibiotic Compliance:Michigan Surgical Quality Collaborative2

12 DRAFT – final pending AHRQ approval

Auditing Your Practice

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Evaluate a sample of patients undergoing your procedure of interest for compliance with processes your team identified as potential areas to improve– (i.e: the next 10-20 patients)

Adapt tool from SUSP website or develop new tool

Practical and feasible strategy to evaluate performance and surface defects

Empowers frontline staff


How do we conduct audits?

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Retrospective chart review

Concurrent review– Place audit tool on chart – Complete over continuum of care

We recommend auditing 5-10 patients– Larger samples yield better estimates of performance

Your data does not need to be submitted


Gentamicin

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Despite a 95% compliance on SCIP

Interventions-

Increased amount of gentamicin available in room

Added dose calculator in anesthesia record

Educated surgery, anesthesia, and nursing


SUSP Antibiotic Audit Tool


Normothermia

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Interventions-

Confirmed that temperature probes were accurate (trial comparing foley and esophageal sensors)

Initiated forced air warming in the pre-operative area


SUSP Normothermia Audit Tool


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What about interventions with no data to support them?


Separation of “Dirty” and “Clean” Instruments

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Intervention-

Built separate tray of instruments used for bowel anastomosis

Extra suction and bovie tip and gloves opened and changed after anastomosis

Educational sessions with scrub techs and nurses about instrument separation

Audits and education on the spot


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Bringing Emerging Evidence for SSI Prevention to Your Patients


Emerging Evidence for SSI Prevention

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Antibiotic Usage

-Redosing

-Weight based dosing of cephalosporins

Utilization of mechanical bowel preparation with oral antibiotics

Normoglycemia/Prevention of hyperglycemia

Standardization of skin preparation


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Available on SUSP website

https://armstrongresearch.hopkinsmedicine.org/susp/ssi/resources.aspx



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Bowel Prep

Redosing and Weight Based Dosing

JHU Antibiotic Poster

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Entire document available on SUSP website




Additional Interventions to Improve Antibiotic Efficacy

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Weight-based dosing of cephalosporins

Antiobiotic Re-Dosing

- Maintain therapeutic antibiotic serum levels during the entire procedure- If using cefoxitin consider changing because of short redosing interval

• Audit your practice!!• Develop standard selections for based on procedure for your hospital• Engage surgery, nursing and anesthesia to implement standard protocol• Consider integrating into EMR if available• Audit your results and share success


Hyperglycemia and Infection

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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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University of Washington/Glucose Control

Johns Hopkins Glucose Control


Could you do better with glycemic management?

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Audit your current practice

Do you have a policy?

Consider gathering a multidisciplinary team (endocrinology, surgery, anesthesiology, nursing (ward and pre-op)) to develop a protocol for your hospital

Look at SUSP website for examples from other hospitalshttps://armstrongresearch.hopkinsmedicine.org/susp/ssi/resources.aspx



Preparation of the Surgical Site

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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 be dry before incision


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Chloraprep better than Betadine

Chloraprep and Duraprep better than Betadine


Is Skin Prep an Area You Could Improve?

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Audit your practices

- what is being used for what cases?

- who is doing the prep?

-how long are they taking for the prep?

Develop an educational plan, engaging frontline providers, for standardization

-? In-services

-? Video education

-? Change doctor preference cards

Audit again after your interventions…. How well did you do? Share the results!


Summary

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No single SSI prevention bundle– Need to identify local defects

Auditing is a practical and feasible strategy to evaluate performance and surface defects

Tools are adaptable to local environment

The CUSP method empowers frontline staff


Resources to find the information that you need for SUSP

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Armstrong Institute for Patient Safety and Quality

https://armstrongresearch.hopkinsmedicine.org/susp.asp





Action Items

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Review staff safety assessment results

Pick 2-3 audit tools based on frontline feedback, SCIP measures and emerging evidence

Find tools on our website-https://armstrongresearch.hopkinsmedicine.org/susp/ssi/resources.aspx

Audit 5-10 patients with each tool

Create a performance goal for each intervention for your team

Develop your bundle

Develop system changes to implement interventions

Share your tools and ideas for new tools



References

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1. Merriam-Webster Dictionary. “Auditing.” Merriam-Webster Dictionary web site. http://www.merriam-webster.com/dictionary/auditing. Accessed September 1, 2013.

2. Hendren S, Englesbe MJ, Brooks L, et al. Prophylactic antibiotic practices for colectomy in Michigan. Am J Surg. 2011;201(3):290-293.

3. Hospital Compare. Medicare: the official U.S. government site for medicare. Medicare.gov Website.

http://www.medicare.gov/hospitalcompare/profile.html#profTab=2&ID=210009&loc=21287&lat=39.2962372&lng=-76.5928888&name=johns%20hopkins%20hospital. Accessed May 30, 2010

4. Wick EC, Hobson DB, Bennett JL, et al. Implementation of a Surgical Comprehensive Unit-Based Safety Program to Reduce Surgical Site Infections. JACS. 2012; 215(2):193-200.


Content Call Evaluation

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We want to ensure that the content calls provide useful and pertinent information for the SUSP teams. For this reason we request that you complete a brief evaluation following each call. The evaluation may be found at the following link:

https://www.surveymonkey.com/s/SUSP_Cohort4




1 building your ssi prevention bundle armstrong institute for patient safety and quality presented...

Documents

patient safety

ssi prevention checklist

safety issues

ssi reduction goal

surgical care processes

scip measures

redosing communication

surgical patientssi