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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
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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
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Healthcare-Associated Infections Are a Quality Issue
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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
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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.
© 2017 BD. BD, the BD Logo and all other trademarks are property of Becton, Dickinson and Company.
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
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• 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)
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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
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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%
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• 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
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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
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Standardization and Bundled Infection Prevention Strategies to Improve Quality
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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
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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
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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.
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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.
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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
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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.
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Variability in Skin Preparation Yields Opportunities for Standardization
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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.
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High Variability in Patient Skin Prep Use and Processes
21
86%
63%
91%
53%
60%
Skin prep application
from surgical site toperiphery
Skin prep application
follows label directions
Gloves used during
skin prep application
Skin prep drying time
sufficient
Skin prep application
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
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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
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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
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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
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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
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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.
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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
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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.
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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
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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
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Initiating Quality Improvement in Surgery
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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
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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
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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
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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
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Case Studies: Practice Bundles for Standardizing Skin Preparation
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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
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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.
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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
Keenan JE, et al. JAMA Surg. 2014;149(10):1045-1052.
Duke University Medical Center (Durham, NC)
© 2017 BD. BD, the BD Logo and all other trademarks are property of Becton, Dickinson and Company. 40
Standardization Reduces HAI Rates1
Duke University Medical Center (Durham, NC)
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.
Keenan JE, et al. JAMA Surg. 2014;149(10):1045-1052.
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Impact of Clinical Practice Bundles on Cost and LOS1
Duke University Medical Center (Durham, NC)
$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
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Results of Targeted Changes
42
The clinical bundle is a viable method to improve quality
of care
RESULTS
Duke University Medical Center (Durham, NC)
Keenan JE, et al. JAMA Surg. 2014;149(10):1045-1052.
Length of stay reduced by one day (P = 0.001)
13.6% reduction in superficial HAIs
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Colorectal Surgery Surgical Site Infection Reduction
Program: A National Surgical Quality Improvement
Program-Driven Multidisciplinary Single-Institution
Experience Mayo Clinic
Must present slides 44-50
Case Study Module 2
43
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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.
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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
Mayo Clinic (Rochester, MN)
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Phased Approach to Developing the Clinical Practice Bundle
46
Mayo Clinic (Rochester, MN)
Cima R, et al. J Am Coll Surg. 2013;216:23-33.
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
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GOAL: Reduce HAI
by 50% (10 → 5%)
47
Bundled Clinical Practices to Reduce HAI Rates1
Mayo Clinic (Rochester, MN)
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
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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.
Mayo Clinic (Rochester, MN)
Cima R, et al. J Am Coll Surg. 2013;216:23-33.
© 2017 BD. BD, the BD Logo and all other trademarks are property of Becton, Dickinson and Company. 49
HAI Rates Reduced With Standardization1
Mayo Clinic (Rochester, MN)
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
Cima R, et al. J Am Coll Surg. 2013;216:23-33.
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Results of Targeted Changes
50
Significant reduction in overall and
superficial HAIs
RESULTS
Mayo Clinic (Rochester, MN)
Cima R, et al. J Am Coll Surg. 2013;216:23-33.
Sustained reduction in HAIs
Comprehensive approach that
revolved around culture
and quality
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Implementation of a Surgical Comprehensive
Unit-Based Safety Program to Reduce Surgical
Site Infections Johns Hopkins University
Must present slides 52-58
Case Study Module 3
51
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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
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Collaborative Approach Identifies Improvement Focus Areas
53
Successful HAI Reduction
Communication & teamwork
Wick EC, et al. J Am Coll Surg. 2012;215:193–200.
Education & training
Johns Hopkins University and Hospital (Baltimore, MD)
Coordination of care
Equipment & supplies
Policies & protocols
Infection control
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Multiple Targeted Changes Contributed to Success
54
Wick EC, et al. J Am Coll Surg. 2012;215:193–200.
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
Johns Hopkins University and Hospital (Baltimore, MD)
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• 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
Wick EC, et al. J Am Coll Surg. 2012;215:193–200.
Johns Hopkins University and Hospital (Baltimore, MD)
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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
Johns Hopkins University and Hospital (Baltimore, MD)
Wick EC, et al. J Am Coll Surg. 2012;215:193–200.
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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
Wick EC, et al. J Am Coll Surg. 2012;215:193–200.
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.
Johns Hopkins University and Hospital (Baltimore, MD)
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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
Wick EC, et al. J Am Coll Surg. 2012;215:193–200.
Johns Hopkins University and Hospital (Baltimore, MD)
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Conclusions
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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
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Questions?
61
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Thank you!
62