The Joint Commission Center for Transforming Healthcare (CTH)

Surgical Site Infections in Colorectal Surgeries Project: 2012

Sasha Madison, MPH, CICDirector Infection Prevention & Control Dept.

May 14, 2014

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PROJECT #4: SURGICAL SITE

INFECTION • Collaborate with American College of Surgeons & NSQIP measurement system leveraged.

• Seven participating hospitals:1. Mayo Clinic, MN2. Cleveland Clinic, OH3. Stanford Hospital & Clinics,

CA 4. OSF Saint Francis, IL5. Northwestern Memorial

Hospital, IL6. North Shore LIJ, NY7. Cedars-Sinai Medical Center,

CA

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Systematic Approach to Problem Solving – Surgical Site Infections (1)

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The Center worked with the American College of Surgeons to determine the scope of the SSI project, since there is a wide range of surgeries and procedures that can develop SSIs – each with its own unique set of complications and challenges.

To help narrow the scope of the project, the following criteria were used to identify a specific procedure that:

Is common across different types of hospitalsHas significant complications with an adverse clinical

impactHospitals have significant opportunities to improve

performanceHas high variability in performance across hospitals

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Collaborative Project Definition

Problem Statement: The incidence of Surgical Site Infections in colorectal surgery is

high, variable, and represents opportunity for improvement.

Goal: Reduce colorectal surgical site infections by 50% (Observed and

Observed/Expected)

Scope: Process Begins: Pre-Operative Processes (Pre-Op Clinic with

Surgeon) Process Ends: 30 Days Post-Surgery Includes: All emergent & elective surgical procedures Excludes: Trauma and Transplant patients & Patients under 18

years of age

Timeline:

August 2010 – March 2012

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2009 Metrics:Observed & O/E Baseline Performance

Metric 1- Observed Colorectal SSIsBaseline: 18.5% Target: 9.3%(50% reduction)

Note: Observed/Expected / Index ValueExpected Value is Dependent on “Expected” influence/calculation

Metric 2- O/E* Ratio for Colorectal SSIs Baseline: 1.49 Target: 0.74(50% reduction)

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Average SSI Cases / Month = 3

SHC SSI Project Phases & ElementsMilestone

Key Elements

Define Incidence of Surgical Site Infections in colorectal surgery is high, variable, and represents opportunity for improvement.

Measure

Reduce colorectal surgical site infections by 50% (Observed and Observed/Expected)

Analyze(Based on statistical analysis of SHC data)

Improve

Focus on identified causes, target solutions, patient outcomes

Control Correlate interventions with SSI outcomes and create sustainability plans for any intervention that successfully decreased SSIs

Statistically Significant Variables(Potential Risk Factors for SSI)

Potential Identified Variables /Opportunities

Wound Disruption (0.003) OR Duration (0.066) ASA Class > 2 (0.015) Open/Laparoscopic Procedure (0.054) Total Hospital LOS (0.036)

Lowest Patient Intra-Operative Temperature

Post-Operative Wound Care Hand Hygiene Dressing Removal at 48hrs Post-Operative Bathing

Surgical Closure Glove Change Prior to Closing

Fascia Separate Colorectal Closure Tray Tissue Irrigation - Irrigation Solution Type

Note: Actual Interventions in blue & Monitoring in green

Note: Above variables found to be statistically significant, however not entirely modifiable.- No Interventions Made

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Improvement Baseline Target & Measurement Tools

Implementation Month-Year

Glove Changes Standardize closing process

59% of clinicians responded “No” to changing gloves before closure

100% glove changes before closing fascia

MIDAS Focus Audit

February 2011

Colorectal Closure Tray Standardize major set closing tray

No separate closing tray

100% separate and clean closing instruments

MIDAS Focus Audit

April 2011

Patient and Room Temperature Guidelines Given to OR & ASC

No baseline measurement

Per SCIP & AORN Guidelines:

Patient temperature should be equal to or greater than 36 Degrees Celcius

Ambient OR room temperature should be 68-72 Degrees Fahrenheit

MIDAS Focus Audit

August 2011

Post Op Wound Care Protocol (Collaborative best practice) Dressing marked by surgical team Dressing Removal Goal = 48

hours

No baseline measurement

100% Dressing marked by surgical team

100% Dressing Removal: Goal = 48 hours

MIDAS Focus Audit

August 2011

Project Interventions & Monitoring

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NHSN Publicly Reported Cases- MIDAS Focus Study

MIDAS Focus Objectives:

• Detailed abstraction of elements with identified areas of opportunity

• Data will be analyzed for any potential trends and to serve as a guide for further interventions

• Surgeon specific SSI rates

• Surgical Quality Council Dashboard will include SSI outcomes

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Antibiotic Stewardship Program

• Dosing of Ertapenem for patients with BMI greater than 30

• Assessment of empiric therapy recommendations for contaminated and dirty cases

• Measuring timing of prophylactic antibiotics prior to incision: 0-15 minutes 16-30 “ ” 31-45 “ ” 46-60 “ ”

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Improvement ‘Bundle’

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• Interventions across the episode of care

• Multi-disciplinary

• Engage staff, patient, and families

• Standardize as many processes as possible

• Ensure high compliance with elementso Quick audits

• Build the elements into the system

• Frequent feedback and communication

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Pre-operative Interventions

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Pre-operative Chlorhexidine packets

o Provided to all patients preoperatively with instructions

o Use monitored morning of admission

o If not reported as not being used, SAGE wipes used on the entire body

Patients with BMI > 30 (Mayo)

o SAGE wipes applied even if preoperative bath performed

o Procedure listing software automatically identifies patients with BMI > 30

Pre-op antibiotic ordering (Mayo)Procedure scheduling software automatically provides SCIP appropriate choicesWeight-based dosing Software automatically orders intra-operative re-dosing dose if historical data for the specific procedure and surgeon demonstrated an average case duration >3 hours

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Pre-Operative Interventions (cont’d)

Hair removal by electric clipper− Outside of the operating room

Standardized to Chlorhexidine-Alcohol (Chloraprep™) skin preparation for all abdominal cases− Surgical assistant applies skin preparation

All in-serviced on appropriate application

− Must dry for 3 minutes before drapes applied

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Intra-Operative Interventions

Pre-procedural pause includes confirming appropriate antibiotics administered and documented

Re-dosing of cefazolin for cases longer than 3 hours. (Mayo)

−Circulating nurse has the preop order and pulls medication at the beginning of the case

−Reminder window on anesthesia provider’s computer screen

Triggered off time of first dose administration

−Appropriate weight-based dosing

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“Closing” Process− At the time of fascia closure

All staff change gloves

Gowns if soiled

Field re-blocked with sterile towels

Instruments used during case removed and “closing tray” brought onto the field

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Intra-Operative Interventions (cont’d)

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All order-sets discontinue SCIP compliant antibiotics after two postop doses or single dose when appropriate (Mayo)o Pharmacist part of team and queries service

Hand hygiene essential on flooro Physician/Nursing initiativeo Patient and Family initiative

Sterile dressing on until morning of POD 2o Document removal

Chlorhexidine shower/wipes daily after dressing removal (Mayo)

Standard postop order-sets orders urinary catheter removal at 8am the morning after surgery (Mayo)

Dismiss with chlorhexidine soap bottle for use at home (Mayo)

Post-Operative Interventions

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Important Lessons: Multidisciplinary approach is essential

o Physicians, nursing (pre, intrao-p, floor), pharmacy, CST, SA, administration, supply chain, quality, S&P, IT, Patient Education, Infection Control, WOCN, NSQIP team

Address the entire surgical episode of care

o Pre, intra, and postoperative elements may influence SSI rates

o Interventions designed for each phase

Introduce elements of change and audit compliance

Build ‘clues’ into the process to ensure better compliance: convenient hand hygiene supplies (Purell wipes, Hibiclens bottles), signage, Hibiclens packets, etc.

Build process improvements into the system to ensure task completion

No evidence for which of element(s) makes a difference in the “bundle”: the outcome is all that matters

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Challenges Encountered

Learnings: Reduction of our SSI rates continue to be challenging.

Questions 2012: Could we learn more by studying the elements of the National Healthcare Safety

Network(NHSN) colorectal SSI cases? Could we focus our efforts on the ‘bulk’ of our infections; Organ Space (asked in

2012) Focused our efforts on organ space infections beginning after this collaborative –

later part of 2102 Decrease seen in 2013 (decrease seen in colo-rectal SIR) Found part of the issue was appropriate classification of cases: major educational

focus later part 2012/2013

Experienced & Foreseeable Challenges: Strategies for preventing infections are different based on culture, environment,

surgeon practice, patient pre-existing conditions Lag time in collection and receipt of data to assess improvements Nursing time for documentation of audits takes away from patient care Insufficient and incomplete audits Resources needed for this improvement projectBest Practice: Standardization of approach was sequential and we may not see full term change

yet (glove changing, closing trays, etc. occurred in sequence not parallel) Best practices identified elsewhere may not have same level of impact in our

organization

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Next Steps & Opportunities

Based on best practice learnings through collaborative, continue glove changes & separate/clean closing instruments

MIDAS Focus Study on Publicly Reported Cases− Infection Control SSI surveillance in July/Aug 2011 identified an opportunity

in colorectal surgery− Data collection focused on elements which are not captured elsewhere− Need for individual physician communication of infections identified− Opportunity for Physician review of case with abstracted data elements

Antibiotic Stewardship− Instituted February 2012− Review of current prophylaxis guidelines and empiric therapy

SSI Deep/Organ Space and Sepsis commonalities− Drill down on each Organ/Space and Deep SSI− Leaks (i.e. CT scans, physician documentation, abscessogram results)− Antibiotic prophylaxis dosing for patients with BMI greater than 30 − Empiric therapy and treatment protocols

Pursue Pre-Operative Warming Improvements− Preoperative strategies for surgery admission unit− Potential partnership with vendors to pilot new interventions

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