The Bundle Approach to Reducing The Bundle Approach to Reducing Surgical Site InfectionsSurgical Site Infections

Virginia Lipke, RN, BS, ACRN, CIC Infection Control Practitioner

The St. Luke HospitalsFt. Thomas and Florence, Ky.

September 9, 2008

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OutlineOutlineOutlineOutline

Introduction to St. Luke Hospitals Standardizing Care

Bundles in general are evidence based Impact of IHI 100,000 Lives Campaign

Surgical Site Infection Risks & Considerations Surgical Volume Targeted Infection Control Surveillance

MRSA Bundle as an example Focus on Value of Bundle and Process

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About St. Luke HospitalsAbout St. Luke HospitalsAbout St. Luke HospitalsAbout St. Luke Hospitals

St. Luke Hospital – East: 310 bed facility located in Ft. Thomas, KY

St. Luke Hospital – West: 177 bed facility located in Florence, KY

St. Luke Hospitals, Inc. (SLH) consist of two community facilities:

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Standardizing CareStandardizing CareStandardizing CareStandardizing Care General agreement that standardization of care will

improve efficiency of care and result in better outcomes

IHI (Institute of Health Improvement) 100,000 Lives Campaign Directed standardization of care

• Rapid Response Teams• Medication Reconcilliation• Ventilator-Associated Pneumonia• Bloodstream Infections• AMI• SSI

Creation and implementation of bundles or care paths facilitated care for these initiatives

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Methodology for Bundle Methodology for Bundle DevelopmentDevelopmentMethodology for Bundle Methodology for Bundle DevelopmentDevelopment

Identify need and create clinical and business case

Secure administrative support and medical staff buy-in through communication at various clinical committees

Define the process and protocol for the bundle

Complete implementation of the bundleContinued monitoring and evaluation

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Leveraging Findings for Leveraging Findings for Organizational changeOrganizational changeLeveraging Findings for Leveraging Findings for Organizational changeOrganizational change

Present findings to all committees Suggest protocol and practice changesSecure physician championsBring in local talent to helpDo your own study and share resultsKnow the community standard

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Sustaining Impact and ResultsSustaining Impact and ResultsSustaining Impact and ResultsSustaining Impact and Results

Ongoing monitoring Quantify results clinically and financially

Communication of results to all stakeholders

Reinforce education Physicians, clinical staff & patients

Revisit community and national data

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Adoption of Protocols and Bundles at Adoption of Protocols and Bundles at St. Luke HospitalsSt. Luke HospitalsAdoption of Protocols and Bundles at Adoption of Protocols and Bundles at St. Luke HospitalsSt. Luke Hospitals Employing a systematic approach and following

a set methodology for protocol and bundle implementations resulted in success and credibility

Pneumococcal Vaccination IHI 100,000 Lives Campaign Initiatives

Mentor status for 4 of the initiatives Significant decrease in non-ICU codes No Ventilator Associated Pneumonia in 34 months

IHI 5 Million Lives Campaign DVT Protocol implementation December 2008

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Surgical Site Infections (SSIs): Surgical Site Infections (SSIs): Magnitude of the ProblemMagnitude of the ProblemSurgical Site Infections (SSIs): Surgical Site Infections (SSIs): Magnitude of the ProblemMagnitude of the Problem 1996: 28.4M ambulatory surgery procedures in the

U.S.(CDC, National Center for Health Statistics) 2003: 30.8M inpatient surgical procedures and

9.7M (37%) of those performed on patients >65 years (CDC,National Center for Health Statistics)

NNIS: SSIs occur in 2.6%¹ of all surgeries = 1.5M SSIs annually

Attributable cost: $25,5246 (range $1,783 -$134,602)²

1.Mangram,AJ,et al.,Guidelines for the Prevention of Surgical Site Infections,1999,CDC. 2.Stone,PW et al.,Am J Infect Control,2005

2.Stone,PW, et al.,Am.J.Infect.Control,2005;33(9):501-9

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SSI Risk Factors for the Patient SSI Risk Factors for the Patient SSI Risk Factors for the Patient SSI Risk Factors for the Patient

Age Nutritional Status Diabetes Nicotine Use Obesity Coexisting Infection Altered Immune Response Long Preoperative Stay

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Risk Factors for SSI:Risk Factors for SSI:Pre-and IntraoperativePre-and IntraoperativeRisk Factors for SSI:Risk Factors for SSI:Pre-and IntraoperativePre-and Intraoperative

Inappropriate use of antibiotic prophylaxis Infection at remote site Shaving versus clipping or no hair removal Improper skin preparation Improper hand antisepsis by operating room team Long duration of surgery Surgical attire and drapes Environment of room, (ventilation & sterilization) Surgical technique: homeostasis, sterile field, O2

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Surgical Care at St. Luke HospitalsSurgical Care at St. Luke HospitalsSurgical Care at St. Luke HospitalsSurgical Care at St. Luke Hospitals

Routine monitoring and surveillance Identification of risk associated with

MRSABusiness case for MRSA bundle Implementation of bundleEvaluating impact of bundle

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Surgical Volume and Infection Surgical Volume and Infection Control MonitoringControl MonitoringSurgical Volume and Infection Surgical Volume and Infection Control MonitoringControl Monitoring Total Surgeries

Over 10,000 cases per year

Targeted Surveillance C-Sections Total Hips Total Knees Gastric By-pass and Bandings Fusions Craniotomies

Overall infection rates are low

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SLH SSI RateSLH SSI RateSLH SSI RateSLH SSI Rate

St. Luke Hospitals Combined - Surgical Site Infection Count and Rate

0

2

4

6

8

10

12

14

16

18

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of

SS

Is

0.00

0.20

0.40

0.60

0.80

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1.20

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1.60

1.80

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SSI Count SSI Rate

SSI Count 6 12 17 7

SSI Rate 0.97 1.22 1.56 0.56

2004 2005 2006 2007

Gastric Bypasses started

8 SSIs were MRSA-relatedMRSA Bundle initiated

2 SSIs were MRSA-related

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Internal & External DataInternal & External DataInternal & External DataInternal & External Data

Lab reports and testing methods Past years IC report compared to NNIS Antibiograms for the past years Literature searches-beware of old data and

be open to new data What is our current practice? What new surgical services are we adding? What are the risks?

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Why Should Hospitals Place Greater Emphasis Why Should Hospitals Place Greater Emphasis on How Skin is Prepped?on How Skin is Prepped?Why Should Hospitals Place Greater Emphasis Why Should Hospitals Place Greater Emphasis on How Skin is Prepped?on How Skin is Prepped?

When we consider pathogenesis of SSI, it has been accepted for decades that most SSI are endogenous in nature.

Usual Suspects S. aureus Co Ag Negative Staph E.coli K.oxytoca S.pneumonaie P.aeruginosa S.marcescens

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St. Luke Hospitals Emergency Department visits where MRSA was noted for skin and soft tissue infections:

8 MRSA-related Surgical Site Infections (SSIs) in CY2006 (47% of total SSIs); 0 in previous years Increased awareness by Emergency, Obstetrics, and Surgery Practitioners

Community & Hospital ImpactCommunity & Hospital ImpactCommunity & Hospital ImpactCommunity & Hospital Impact

2003 2004 2005 2006

173 244 504 660

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Projected Cost of MRSA BundleProjected Cost of MRSA BundleProjected Cost of MRSA BundleProjected Cost of MRSA Bundle

SiteCY2006 Elective Surgical Volume

via PAT

Lab Test and CHG Costs

Mupirocin Costs

(based on 5% MRSA(+) rate)

Total Annual Projected

Costs

St. Luke East 3400$13.83

($12.00+$1.83)$6,460 $53,482

St. Luke West 3500$13.83

($12.00+$1.83)$6,650 $55,055

St. Luke Hospitals

6900$13.83

($12.00+$1.83)$13,110 $108,537

Potential SSI Cost Avoidance (based on CY2006 numbers):

5 SSI cases at $40,0002 = $200,0002 Engemann, Clin.Inf.Dis 2003;36:592-598.

Nicholson, AJIC 2006;34:44-48.

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SLH MRSA BundleSLH MRSA BundleSLH MRSA BundleSLH MRSA Bundle

Nasal cultures on all surgical patients in pre-admission testing (PAT) and hospital-based OB patients at 36-week visit

All pre-admission surgical patients given 2% CHG (chlorhexadine) bathing cloths for use the day of surgery; expecting mothers have 2% CHG cloths applied prior to delivery

If patient is MRSA positive, 2% Mupirocin is applied to both nares prior to surgery

MRSA (+) patients are provided with educational brochure – “Living with MRSA”1

1 Resource created by Washington State Public Health Department

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Implementing the MRSA BundleImplementing the MRSA BundleImplementing the MRSA BundleImplementing the MRSA Bundle

Nasal swab training for PAT and hospital-based OB staff

Coordination w/ lab Coordination w/ pharmacy Communication plan for result notification Data tracking and monitoring Patient education Staff education Physician education

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TimelineTimelineTimelineTimeline

Review of existing best practices; clinical and financial impact analyses completed

October 2006

CA-MRSA is noted to be

impacting SSI rates

November-December

2006

Proposed MRSA Bundle presented to various clinical committees

December 2006-January

2007

MRSA Bundle standing orders

approved by Medical Executive Committee

January 2007

Letters are sent to Medical Staff proposing MRSA Bundle

protocol

February 2007

All pre-admission testing and hospital-based OB patients are

screened for MRSA

March 2007

Surgery Committee proposes single dose of Mupirocin for

patients whose lab results are not available prior to surgery

May 2007

1 MRSA-related SSI in initial nine months

of program

November 2007

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All Elective Surgical Patients

Pt. Arrives toPAT

Pt. is nasal swabbedand given 2% CD

waschloth pack per MDstanding orders

Lab analyzesculture

Is pt. positivefor MRSA?

Lab resultscommunicated back

to MD; pt. useswashcloth prior toarriving for surgery

No

Yes

Lab notifies MDabout positive

culture

MD prescribesMupirocin

Lab notifies ICP ofpositive culture

YesICP flags pt. for

contact isolation inLastWord

Pt. arrives forsurgery

Physicians for Women Expecting Mothers

Pt. Arrives at MD office for36-week visit

Nasal swab isperformed

Is pt. positivefor MRSA?

No

Lab resultscommunicated back

to MD

Yes

Lab notifies MDabout positive

culture

Lab notifies ICP ofpositive culture

Yes

MD prescribesMupirocin

ICP flags pt. forcontact isolation in

LastWord

Lab analyzesculture

Pt. useswashcloth prior toarriving for surgery

St. Luke HospitalsMRSA Bundle Process

Pt. arrives tothe hospitalfor delivery

Pt. uses washclothprior to deliery

Note: Patients whose MRSA lab results are notcompleted prior to surgery will receive a single dose ofMupirocin prior to surgery.

SLH MRSA Bundle ProcessSLH MRSA Bundle ProcessSLH MRSA Bundle ProcessSLH MRSA Bundle Process

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Results and ImpactResults and ImpactResults and ImpactResults and Impact

Screening of all surgery patients who go through pre-admission testing (~ 65 % of all surgeries)

Screening of all OB patients from St. Luke Physicians for Women Service (~ 60% of all deliveries)

Percentage of surgery patients with positive MRSA culture: 3.9%

March – December Two Surgical Site Infections

• One MRSA SSI (C-Section)

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Results and ImpactResults and ImpactResults and ImpactResults and Impact

Month MRSA (+) Cultures Total Cultures % MRSA (+)Mar-07 23 537 4.3%Apr-07 20 526 3.8%May-07 24 457 5.3%Jun-07 21 476 4.4%Jul-07 21 508 4.1%Aug-07 22 506 4.3%Sep-07 14 434 3.2%Oct-07 20 477 4.2%Nov-07 16 487 3.3%Dec-07 11 404 2.7%Total 192 4812 3.9%

St. Luke Hospitals CombinedSurgical MRSA Culture Activity

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Barriers and ChallengesBarriers and ChallengesBarriers and ChallengesBarriers and Challenges

Regular cultures have 2 day turn-around time Patients having pre-admission testing less than

48 hours prior to surgery (culture results not available) Investigation into current lab collection and transport

processes Timely communication with physician about

positive results Questions about treatment for colonized MRSA

Some physicians wanting to treat all colonization with vancomycin

Patient’s reaction to positive culture results

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Where Do We Go From Here?Where Do We Go From Here?Where Do We Go From Here?Where Do We Go From Here?

Ongoing analysis of impact Continue to educate physicians about treating their

patients with MRSA Continued education to patients and community

about preventing and living with MRSA Expand scope of program to include inpatient and

emergent surgery cases with possible expansion to all new admissions

Consider utilization of a rapid screen test Evaluation and consideration of protocol revisions

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Our Goal…Our Goal…Our Goal…Our Goal…

Drive to Zero!!

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QuestionsQuestionsQuestionsQuestions

Ginny Lipke

(859) 572-3688

Virginia.Lipke@healthall.com