The Cardiac Surgery Translational Study (“CSTS”) The Quality And Safety Research Group

Surgical Site Infection Prevention

Elizabeth Martinez, MD, MHSemartinez10@partners.org

March 18, 2011 Immersion Calls

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Immersion call ScheduleImmersion call Schedule

Title Date /Time 13:00 EST

Presented by

Program Overview Feb 18, 2011 Peter Pronovost MD PhD

Science Of Safety February 25, 2011 Jill Marsteller, PhD, MPP

Comprehensive Unit-Based Safety Program CUSP

March 4, 2011 Christine Goeschel MPA MPS ScD RN

Central Line Blood Stream Infection Elimination

March 11, 2011 David Thompson DNSC, MS

Surgical Site Infection Elimination March 18, 2011 Elizabeth Martinez, MD, MHS

Ventilator-Associated Pneumonia Reduction

March 25, 2011 Sean Berenholtz, MD

Hand-Offs: Transitions in Care April 1, 2011 Ayse Gurses, PhD

Data we Can Count on April 8, 2011 Lisa Lubomski, PhD.

Team Building April 15, 2011 Jill Marsteller, PhD, MPP

Physician Engagement April 22, 2011 Peter Pronovost, MD, PhD

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CSTS TimelineCSTS Timeline

• Planned Roll-out

– CLABSI Prevention interventions and monthly data collection: June, 2011

– SSI Prevention interventions and monthly data collection: Approximately September 2011

– VAP Prevention and monthly data collection: After December 2011

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Learning Objectives

•To understand the model for translating evidence into practice

•To explore how to implement evidence-based behaviors to prevent SSI

•To understand strategies to engage, educate, execute and evaluate

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Proportion of Adverse EventsMost Frequent Categories

Brennan. N Engl J Med. 1991;324:370-376

Non-surgical

Surgical

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Introduction• Over 300,000 CABG annually• SSI rates 3.51% (10,500 annually)

– 25% mediastinitis– 33% saphenous vein site– 6.8% multiple sites

• Increased mortality:17.3% v. 3.0% (p<0.0001)• Increased LOS: 47% v 5.9% with LOS>14days

(p<0.0001)• Increased cost: $20,000 to $60,000

Fowler et al..Circ, 2005:112(S), 358.

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Background: An Example of Surveillance Methodology

National Healthcare Safety Network (NHSN)•Formerly NNIS•National Healthcare Safety Network surveillance•CDC program that reports aggregated surveillance data from ~thousands of US hospitals

• hospitals/mandated for certain infections in order to receive full Medicare payment

•Standard case-finding (by ICD-9 code), definitions for infection, and risk-stratification methodology•Pooled mean and standard deviation reported for surgical procedures•SSIs can develop up to 1-year postop

• ‘hardware’ = sternal wires

CABG SSI Risk Model*

Preop• Age• Obesity• Diabetes• Cardiogenic shock• Hemodialysis• Immunosuppression

Intraop• Perfusion time• Placement of IABP• ≥ 3 anastomoses

*Did not include known best practices (e.g. SCIP)Fowler et al..Circ, 2005:112(S), 358.

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Traditional SSI Risk FactorsIntrinsic-Patient Related

• Age• Nutritional status• Diabetes• Smoking• Obesity• Remote infections• Endogenous mucosal microorganisms• Altered immune system• Preoperative stay-severity of illness• Wound class

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Translating EvidenceTranslating Evidenceinto Practiceinto Practice

Pronovost, Berenholtz, Needham. BMJ 2008

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Evidence Based Practices Evidence Based Practices that Reduce risk of SSIs*that Reduce risk of SSIs*

• Appropriate prophylactic antibiotics– Selection– Timing (and redosing)– Discontinuation

• Appropriate hair removal as close to time of surgery as possible:– Don’t remove hair unless necessary; If you remove hair -Don’t

shave. Can use clipper/depilatory (AVOID razors)

• Normothermia in non CPB cases• Appropriate glycemic control*********************************************************

****• Chlorhexidine surgical skin prep (used appropriately)

*SCIP measures

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Your Hospitals’ Your Hospitals’ Performance*Performance*

www.hospitalcompare.hhs.gov;Accessed 3/5/2011

*summarized (estimate) data for all surgical procedures from all participating Institutions as of 3/31/2011

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Ensure Patients ReliablyEnsure Patients ReliablyReceive EvidenceReceive Evidence

  Senior TeamStaff

leaders leaders

Engage How does this make the world a better place?

Educate What do we need to do?

ExecuteWhat keeps me from doing it?How can we do it with my resources and culture?

Evaluate How do we know we improved safety?

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TRiP: Model to Improve• Pick an important clinical area

• Identify what should we do– principles of evidence-based medicine

• Measure if you are doing it

• Ensure patients get what they should– Education– Create redundancy– Reduce complexity/standardize

• Evaluate whether outcomes are improved

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Systems Approach

• Every system is perfectly designed to get the results that it gets.

- Bataldan

• If you want to change performance you need to change the system.

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Science of Safety• Accept that we will make mistakes

• Focus on systems, including interpersonal communication, rather than people

• Largest barrier is lack of awareness evidence exists

• Standardize to reduce complexity

• Create independent checks

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Eliminating SSI• Apply best practices

– If hair is removed, use clippers or depilatory– Appropriate antibiotics

• Choice• Timing• Discontinuation

– Perioperative normothermia– Glycemic control

• Decrease complexity• Create redundancy

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Tips for Success• Engage

– Make the problem real– Publicly commit that harm is untenable

• Educate• Execute

– Culture, complexity and redundancy – Regular team meetings

• Evaluate – Measurement and feedback – Recognition and visibility– Celebrate your successes

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Engage• Make the problem real

– Share local infection rates– Share local compliance with process measures– Share a story of a patient with SSI

• Have the patient share their story

• Publicly commit that harm is untenable– Institutional commitment– Champions within the OR and the ICU and floor teams– Partnership with Infection Preventionist

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Educate

– Develop an educational plan to reach ALL members of the caregiver team

– Educate on the evidence based practices AND the data collection plan and other steps of the process.

– Use posters to educate the teams about the evidence-based process measures

Avoid Razors

Avoid Hypothermia

Give Correct Antibiotics

Give Antibiotics at the Right Time

Redose Antibiotics Appropriately

Antibiotics at 24 Hours

*Within 60 minutes prior to incision

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Perioperative SSI Process MeasuresPerioperative SSI Process Measures

Quality Indicator Numerator Denominator

Appropriate antibiotic choice Number of patients who received the appropriate prophylactic antibiotic

All patients for whom prophylactic antibiotics are indicated

Appropriate timing of prophylactic antibiotics

Number of patients who received the prophylactic antibiotic within 60 minutes prior to incision

All patients for whom prophylactic antibiotics are indicated

Appropriate discontinuation of antibiotics

Number of patients who received prophylactic antibiotics and had them discontinued in 24 hours

All patients who received prophylactic antibiotics

Appropriate hair removal Number of patients who did not have hair removed or who had hair removed with clippers

All surgical patients

Perioperative normothermia Number of patients with postoperative temperature ≥36.0oC

Patients undergoing surgery without CPB/planned hypothermia

Perioperative glycemic control Number of cardiac surgery patients with glucose control at 6AM pod 1 and 2

Patients undergoing cardiac surgery

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Execute• Culture

– Develop a culture of intolerance for infection• Standardize/Reduce complexity of the process

– Checklists -Confirm abx administration during briefing– Utilize glycemic control protocol– Local antibiotic guidelines posted in Ors– Standardize surgical skin prep

• Redundancy– Add best practices to briefing/debriefing checklist– Post reminders in the OR (White board)– Antibiotic timer program for redosing

• Regular team meetings– Develop a project plan– Identify barriers

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EvaluateEvaluate• Track compliance with SCIP measures

– Performance measures already being tracked by hospitals as part of SCIP participation*

– Post performance on monthly basis• Post in the OR, ICU and floor• Investigate non-compliant cases on a monthly basis

– Use Learning from Defect (LFD) tool

• Post SSI rates on a monthly/quarterly basis– Investigate each SSI with the CUSP team to identify

areas for improvement using the LFD tool

• Audit performance with skin prep methodology (at a minimum) and goal is conversion to chlorhexidine *based on data availability on

Hospital compare

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Share ResultsShare Results

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Acknowledgements

Deborah Hobson, BSNPamela Lipsett, MDSara Cosgrove, MDLisa Maragakis, MDTrish Perl, MSMatthew Huddle, BSNicole Errett, BSJustin Henneman, BSThe Johns Hopkins SSI Prevention Collaborative teams

Thank You!

Elizabeth Martinez, MD, MHS

Massachusetts General Hospital, Harvard University

emartinez10@partners.org

QUESTIONS?