Tough Stuff: Reducing Colorectal SSI
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Transcript of Tough Stuff: Reducing Colorectal SSI
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Reducing Colorectal Surgical Site Infections
Dr. Tom WallaceNSQIP Surgeon ChampionRoyal Inland HospitalKamloops, BC
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Disclosures
None
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How Many F’s?
FINISHED FILES ARE THERESULT OF YEARS OF SCIENTIFICSTUDY COMBINED WITH THEEXPERIENCE OF YEARS
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Kamloops and TCSPopulation / Geography of Community
Served Kamloops 112,549 TCS 225, 813 (2011/2012)
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Royal Inland Hospital (RIH)
5
216 In-patient bed hospital
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RIH Operating Room Quality Initiatives
NSQIP ERACS Culture Checklist QIPS Unit Leader LEAN
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NSQIP at RIH
Date Started – April 2011
Team Composition SCRs Clerk Quality Surgeon Champion Administration
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NSQIPData Sharing
Display Boards Patient Safety Leadership
Walkrounds Monthly Reports Non Risk Adjusted
Reports Quarterly Risk Adjusted Reports IH Collaborative Presentations Physician Letters
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Projects to date
Catheter Associated Urinary Tract Infections – Gynecology
Surgical Site Infections - Colorectal
NS PQI
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NSQIP
UTI Success
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Month Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan -13 Feb 13 Mar 13 April 13 May 13 June 13
Occurrence 3 5 6 5 4 2 6 4 2 2 1 0 2 0 2 0 2 3 1 0 1 2
# of Surgeries 94 137 159 138 159 161 156 106 70 120 119 143 129 169 99 120 158 160 96 151 160 158
0%
2%
4%
6%
8%
10%
12%
14%
RIH Post Op Catheter Associated Urinary Tract Infection Rates(Non Risk Adjusted Data)
CA UTI Occurrence Rate RIH Mean NSQIP Mean UCL
CA UTI Improvementproject initial intervention implemented
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Identifying Opportunities for Improvement
Question:Please describe howyou think your next patientmay be harmed?
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NSQIPOpportunities Identified
All Cases Morbidity: 96 observed events and 1680 total casesAll Cases SSI: 46 observed events and 1679 total cases
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SSI Data
0%
5%
10%
15%
20%
25%
2%
22%
5%
1% 1% 1% 0%
5%
2%
Wound Occurrence by SubspecialtyJuly 2012 - June 2013
N=306 N=92 N=507 N=117 N=184 N=76 N=82 N=195N=9120 Occurrences
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SSI Data
RIH SQAN NSQIP0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
22%
17.7%
11.2%
Colorectal SSI Occurrence Rate comparison between RIH, SQAN and NSQIP
July 2012 - June 2013(Non Risk Adjusted)
Colorectal SSI Occurrence Rate
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Patient Profiles
< 2 > 30
10
20
30
40
50
60
70
80
90
72.4
27.6
82.8
17.2
81.9
18.2
Comparison of Risk Factors for Colectomy Patients between RIH, SQAN and NSQIP
(Non Risk Adjusted Data)O/E period July 2012 - June 2013
RIH SQAN NSQIP
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Why rob a bank…
Because that’s where the money is!
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Our Goal
Aim Statement:Decrease Colorectal Surgical Site
Infections 30% by March 31, 2014
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Our SSI Plan Why re-invent the wheel?
Dellinger U of W Wick JH Cima Mayo Laflamme Joint Commission Edminston
Literature Review
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RIH NSQIP SSI BundlePre-OpPatient received pre op scrub Optimal Hair Removal (Clippers or None)Appropriate antibiotic Timing (0-60 min pre cut time)
Appropriate antibiotic givenPre Op BGM ValuePre op Bowel Prep & Oral AntibioticIntra- OpAppropriate Isolation techniqueWound barrier usedAntimicrobial sutures usedAntibiotic re-dosing for surgeries > 4 hrsNormothermiaIntra Op fluid volumeIntra Op BGM ValuePost - OpNormothermiaTotal Fluid volume in PARHigh O2 for 1 hr in PARBGM in PARStandardized wound care orders given (Remove POD 2)
Care for your surgical site information sheet given : Post Op outcome? If yes identify outcome
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SSI Bundle Driver Diagram
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SSI Bundle Driver Diagram
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Baseline AuditWhat is our current practice?
Data Sources Custom Fields Procedure Targeted
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Can we get this Process Data?
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Pre Op Scrub
Yes No0%
10%
20%
30%
40%
50%
60%
70%
80%
90%78%
22%
Pre Operative Scrub done on patients admitted day of surgery
N=18
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Pre Op Scrub
Yes No0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
14%
86%
Pre Operative Scrub done on patients admitted prior
to surgeryN=7
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Pre Op Albumin
Yes No0%
10%
20%
30%
40%
50%
60%
70%
36%
64%
Pre Operative Albumin TakenN=25
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Antibiotic Timing
Yes No0%
10%
20%
30%
40%
50%
60%
70%60%
40%
Appropriate Abx TimingGiven within 0-60 cut time
N=25
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Appropriate Antibiotic
Yes No0%
10%
20%
30%
40%
50%
60%
70%
80%
68%
32%
Appropriate Abx givenN=25
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Pre Op Bowel Prep
Yes No0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
8%
92%
Pre Operative Bowel PrepN=25
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Pre op Oral Antibiotics
Yes No0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0%
100%
Pre Operative Oral Abx givenN=25
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Surgical Site Infection Rates following Elective Colectomy
The Michigan Surgical Quality Collaborative
Englesbe. Ann Surg 2010;252: 514–520
n=195
All patientsGet I.V. antibiotics
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Per
cent
of
patie
nts
* P < 0.05
*
*
Oral Antibiotics with a Bowel Preparation
A Propensity Matched Analysis (n=740)
*
Englesbe. Ann Surg 2010;252: 514–520
All patientsGet I.V. antibiotics
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Containment Technique
Yes No0%
10%20%30%40%50%60%70%80%90%
100%
Appropriate Containment TechniqueN=25
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Wound Barrier
Yes No0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Wound Barrier UsedN=25
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New Technology
Yes No0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Antimicrobial Sutures UsedN=25
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Anaesthesia
Yes No0%
10%
20%
30%
40%
50%
60%
44%
56%
Intra Operative Warming (Bair Huggers) doc-umented
N=25
Yes No45%
46%
47%
48%
49%
50%
51%
52%
53%52%
48%
Intra Operative Temperature taken and doc-umented
N=25
Yes No0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0%
100%
Intra Operative BGM TakenN=25
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Anaesthesia
Average Time: 2:55 hrs (175 min)Average Crystalloid 1504 mlAverage Colloid 841 ml
Average Crystalloid over time: 515.7 ml / hrAverage Colloid over time: 288.3 ml / hr
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Standardize Post Operative Wound Care
Yes No0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
16%
84%
Standardized Wound Care Orders Given (Removal POD 2)
N=25
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Standardize Post Operative Wound Care
Yes No0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Surgical Site Incision Info Sheet ProvidedN=25
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Our Journey Continues….
Early in the process Information gathering
phase
Auditing Post implementation process Measures Correspond to outcome
measures
Share, Share, Share the data
42
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The future state…
43
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Stay Tuned ……..
Questions?
44