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Building your SSI Prevention Bundle
Armstrong Institute for Patient Safety and QualityPresented by: Elizabeth C. Wick, M.D. /Brad Winters, M.D.
DRAFT – final pending AHRQ approval
Learning Objectives
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Develop and implement an SSI reduction goal and prevention bundle that addresses up to three surgical care processes that your team feels needs to be improved to address SSIs
Understand how to use the results of your staff safety assessment to build a bundle
Review how to initiate audits of your processes
Create a performance goal (improvement in outcome) for your team
Learn how to proceed with improvements that do not have a strong evidence base
Locate SUSP resources on the project website
DRAFT – final pending AHRQ approval
Background
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SSI is the most common nosocomial infection in the surgical patient
SSI is the most common complication after colorectal abdominal surgery (3-30%)
SSI is associated with increased mortality, length of stay, and re-admission
An SSI costs between $6,200-$15,000/per patient (superficial-organ space)
DRAFT – final pending AHRQ approval
SSI Definitions
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Superficial-Purulent drainage from wound
-Positive wound culture
-Pain, redness swelling
-Diagnosis by Surgeon
Deep-Purulent drainage from deep aspect of the wound
-Dehiscence
-Abscess on exam or CT scan
Organ Space-Infection in the surgical cavity (abdomen)
DRAFT – final pending AHRQ approval
Colorectal Surgery Readmissions/Johns Hopkins Hospital
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Readmission rate 17.6% (2009-12)
DRAFT – final pending AHRQ approval
Pathogenesis of SSI
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Bacteria
Procedure
Host
DRAFT – final pending AHRQ approval
No single SSI prevention bundle
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Deeper dive into SCIP measures to identify local defects
Emerging evidence– Abx redosing and weight based dosing – Maintenance of normogylcemia– Mechanical bowel preparation with oral abx – Standardization of skin preparation
Capitalize on frontline wisdom– CUSP/Staff Safety Assessment
DRAFT – final pending AHRQ approval
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Deeper Dive Into SCIP Measures to Identify Local Defects
DRAFT – final pending AHRQ approval
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Does SCIP give us enough information?
Johns Hopkins HospitalMay 2010 SCIPHospital Comparewww.medicare.gov
DRAFT – final pending AHRQ approval
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NSQIP Report 2009
DRAFT – final pending AHRQ approval
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CUSP Step 2:Safety Issue Identified
CUSP Steps 4 & 5:Opportunities to improve
Infection Control • Skin preparation• Hypothermia• Contamination of bowel contents into the wound• Antibiotic timing• Selection and redosing • Length of case
Coordination of Care • Increase utilization of preoperative evaluation center,• Improve surgical posting accuracy (case name and duration)• Computer assistance for antibiotic selection and redosing
Communication and Teamwork • Improve communication throughout perioperative period • Empower team members to speak up • Improve compliance with briefings/debriefings• Implement teamwork tools
Equipment/ Supplies • Accurate temperature probes• Point of care glucose monitoring• Under body warmers • Sanitizing wipes near anesthesia machine
Policies/Protocols • Standardize care/protocols/policies• Monitor sterile technique policies
Education/Training • Ongoing education (with supportive data)• Development of a SSI prevention checklist
Wick, et al. 2012.
Peri-operative Antibiotic Compliance:Michigan Surgical Quality Collaborative2
12 DRAFT – final pending AHRQ approval
Auditing Your Practice
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Evaluate a sample of patients undergoing your procedure of interest for compliance with processes your team identified as potential areas to improve– (i.e: the next 10-20 patients)
Adapt tool from SUSP website or develop new tool
Practical and feasible strategy to evaluate performance and surface defects
Empowers frontline staff
DRAFT – final pending AHRQ approval
How do we conduct audits?
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Retrospective chart review
Concurrent review– Place audit tool on chart – Complete over continuum of care
We recommend auditing 5-10 patients– Larger samples yield better estimates of performance
Your data does not need to be submitted
DRAFT – final pending AHRQ approval
Gentamicin
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Despite a 95% compliance on SCIP
Interventions-
Increased amount of gentamicin available in room
Added dose calculator in anesthesia record
Educated surgery, anesthesia, and nursing
DRAFT – final pending AHRQ approval
SUSP Antibiotic Audit Tool
16 DRAFT – final pending AHRQ approval
Normothermia
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Interventions-
Confirmed that temperature probes were accurate (trial comparing foley and esophageal sensors)
Initiated forced air warming in the pre-operative area
DRAFT – final pending AHRQ approval
SUSP Normothermia Audit Tool
18 DRAFT – final pending AHRQ approval
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What about interventions with no data to support them?
DRAFT – final pending AHRQ approval
Separation of “Dirty” and “Clean” Instruments
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Intervention-
Built separate tray of instruments used for bowel anastomosis
Extra suction and bovie tip and gloves opened and changed after anastomosis
Educational sessions with scrub techs and nurses about instrument separation
Audits and education on the spot
DRAFT – final pending AHRQ approval
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Bringing Emerging Evidence for SSI Prevention to Your Patients
DRAFT – final pending AHRQ approval
Emerging Evidence for SSI Prevention
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Antibiotic Usage
-Redosing
-Weight based dosing of cephalosporins
Utilization of mechanical bowel preparation with oral antibiotics
Normoglycemia/Prevention of hyperglycemia
Standardization of skin preparation
DRAFT – final pending AHRQ approval
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Available on SUSP website
https://armstrongresearch.hopkinsmedicine.org/susp/ssi/resources.aspx
DRAFT – final pending AHRQ approval
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Bowel Prep
Redosing and Weight Based Dosing
JHU Antibiotic Poster
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Entire document available on SUSP website
https://armstrongresearch.hopkinsmedicine.org/susp/ssi/resources.aspx
DRAFT – final pending AHRQ approval
Additional Interventions to Improve Antibiotic Efficacy
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Weight-based dosing of cephalosporins
Antiobiotic Re-Dosing
- Maintain therapeutic antibiotic serum levels during the entire procedure- If using cefoxitin consider changing because of short redosing interval
• Audit your practice!!• Develop standard selections for based on procedure for your hospital• Engage surgery, nursing and anesthesia to implement standard protocol• Consider integrating into EMR if available• Audit your results and share success
DRAFT – final pending AHRQ approval
Hyperglycemia and Infection
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Background-
-Hyperglycemia is common in hospitalized patients
-38% of medical and surgical patients had hyperglycemia (26% diabetic and 12% non-diabetic)
-In cardiac surgery, degree of post operative hyperglycemia correlates with SSI, adopted as SCIP measures
Goal-Glucose <180mg/dl in all hospitalized patients
DRAFT – final pending AHRQ approval
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University of Washington/Glucose Control
Johns Hopkins Glucose Control
29 DRAFT – final pending AHRQ approval
Could you do better with glycemic management?
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Audit your current practice
Do you have a policy?
Consider gathering a multidisciplinary team (endocrinology, surgery, anesthesiology, nursing (ward and pre-op)) to develop a protocol for your hospital
Look at SUSP website for examples from other hospitalshttps://armstrongresearch.hopkinsmedicine.org/susp/ssi/resources.aspx
DRAFT – final pending AHRQ approval
Preparation of the Surgical Site
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Background-
-1012 bacteria reside on the skin
-Staphlococcus and streptococcus species among others
Goal of skin preparation-
-Reduce bacterial burden on skin prior to incision
Best practice-
-Dual agent skin preparation (Chlorhexidine + alcohol +, providone- iodine + alcohol)
-Skin prep should include alcohol to increase durability of sterilization
-Prep should be applied to specification (duration and amount)
-Prep must be dry before incision
DRAFT – final pending AHRQ approval
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Chloraprep better than Betadine
Chloraprep and Duraprep better than Betadine
DRAFT – final pending AHRQ approval
Is Skin Prep an Area You Could Improve?
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Audit your practices
- what is being used for what cases?
- who is doing the prep?
-how long are they taking for the prep?
Develop an educational plan, engaging frontline providers, for standardization
-? In-services
-? Video education
-? Change doctor preference cards
Audit again after your interventions…. How well did you do? Share the results!
DRAFT – final pending AHRQ approval
Summary
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No single SSI prevention bundle– Need to identify local defects
Auditing is a practical and feasible strategy to evaluate performance and surface defects
Tools are adaptable to local environment
The CUSP method empowers frontline staff
DRAFT – final pending AHRQ approval
Resources to find the information that you need for SUSP
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Armstrong Institute for Patient Safety and Quality
https://armstrongresearch.hopkinsmedicine.org/susp.asp
DRAFT – final pending AHRQ approval
Action Items
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Review staff safety assessment results
Pick 2-3 audit tools based on frontline feedback, SCIP measures and emerging evidence
Find tools on our website-https://armstrongresearch.hopkinsmedicine.org/susp/ssi/resources.aspx
Audit 5-10 patients with each tool
Create a performance goal for each intervention for your team
Develop your bundle
Develop system changes to implement interventions
Share your tools and ideas for new tools
DRAFT – final pending AHRQ approval
References
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1. Merriam-Webster Dictionary. “Auditing.” Merriam-Webster Dictionary web site. http://www.merriam-webster.com/dictionary/auditing. Accessed September 1, 2013.
2. Hendren S, Englesbe MJ, Brooks L, et al. Prophylactic antibiotic practices for colectomy in Michigan. Am J Surg. 2011;201(3):290-293.
3. Hospital Compare. Medicare: the official U.S. government site for medicare. Medicare.gov Website.
http://www.medicare.gov/hospitalcompare/profile.html#profTab=2&ID=210009&loc=21287&lat=39.2962372&lng=-76.5928888&name=johns%20hopkins%20hospital. Accessed May 30, 2010
4. Wick EC, Hobson DB, Bennett JL, et al. Implementation of a Surgical Comprehensive Unit-Based Safety Program to Reduce Surgical Site Infections. JACS. 2012; 215(2):193-200.
DRAFT – final pending AHRQ approval
Content Call Evaluation
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We want to ensure that the content calls provide useful and pertinent information for the SUSP teams. For this reason we request that you complete a brief evaluation following each call. The evaluation may be found at the following link:
https://www.surveymonkey.com/s/SUSP_Cohort4
DRAFT – final pending AHRQ approval
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