Surgical Site Infection Prevention Collaborative MCIC March 2006

1. Surgical Site Infection Prevention CollaborativeMCIC March 2006

2. Background: NNIS • National Nosocomial Infection Surveillance (NNIS) System • CDC program that reports aggregated surveillance data from ~300 US hospitals • Standard case-finding (by ICD-9 code), definitions for infection, and risk-stratification methodology • Pooled mean and standard deviation reported for surgical procedures, including craniotomy, laminectomy, spinal fusion, C-section, and CABG

3. Background: Methodology • HEIC surveillance methodology • Monthly denominator data from case-mix data base (all NNIS procedures by ICD-9 code) • Complete chart review of all procedures performed to assess for infection • Risk stratification • Length of procedure (1 point) • ASA score (1 point) • Wound class (assuming all procedures are clean because CANNOT get wound class) • Generation and distribution of standardized rates quarterly or semi-annually (if denominator < 50/quarter)

4. Background: Reporting • HEIC reporting strategies • Rates with NNIS benchmarking • Weekly evaluation of numbers of infections (includes non-NNIS procedures)

5. Present your local NNIS infection data here

6. Surgical Site Infections GOALS • Define and identify risk factors for SSI • Discuss strategies for prevention • Discuss antibiotic prophylaxis principles Pamela A. Lipsett, MD Professor Departments of Surgery,Anesthesiology, Critical Care Medicine, Nursing Johns Hopkins University Schools of Medicine and Nursing

7. Proportion of Adverse EventsMost Frequent Categories Non-surgical Surgical Brennan. N Engl J Med. 1991;324:370-376

8. INTRODUCTION • 40 million operations annually • 20% experience infection • Surgical site infections (SSI) prolong hospital stay by 6.5 to 7.4 days and comprise 42% of extra charges

9. Age Nutritional status Diabetes Smoking Obesity Remote infections Endogenous mucosal microorganisms Altered immune system Preoperative stay-severity of illness SSI:RISK FACTORSINTRINSIC-PATIENT RELATED

10. Duration of surgical scrub Skin antisepsis Preop shaving Preop skin prep Surgical attire Sterile draping Surgical technique Duration of operation Prophylaxis Ventilation Sterilization of equipment Wound class Drains SSI:RISK FACTORSEXTRINSIC-OPERATION RELATED

11. Length of pre-operative stay Pre-operative shaving Length of operation Use of abdominal drains Pre-operative showering Presence of remote infections Normothermia Increased oxygenation Glucose control NON-ANTIBIOTIC FACTORS

12. Temperature and SSI Following Colectomy • Mechanical bowel prep • Parenteral antibiotics at induction x 4 d • Standard anesthetic-isoflurane • Randomized after inductionT>36.5 ºorT>34.5 º • Supplemental O2 in PACU x 3h • Aggressive fluid resuscitation Kurz. NEJM 1996;334:1209

13. Temperature and SSI Following Colectomy Normo (104)Hypo(96)P SSI 6 18 .009 Collagen 328 254 .04 Time to eat 5.6d 6.5d <.006 Kurz. NEJM 1996;334:1209

14. Hyperglycemia and Infection RiskAbdominal and Cardiovascular Operations Glucose POD#1 <220 mg%>220 mg% Any Infection 12% 31% “Serious” Infection 5.7-fold increase for any glucose > 220 mg% Pomposelli. JPEN 1998;22:77

15. Diabetes, Glucose Control, and SSIsAfter Median Sternotomy Latham. ICHE 2001; 22: 607-12

16. Insulin Treatment in SICU Patients Treatment Group ConventionalIntensive Death in ICU 63/783 (8%) 35/765 (5%) Van den Berghe. NEJM 2001;345:1359

17. Preoperative Recommendations: Category 1A • If hair is removed, remove immediately before the operation, preferably with electric clippers

18. Influence of Shaving on SSI No Hair GroupRemoval Depilatory Shaved Number 155 153 246 Infection rate 0.6% 0.6% 5.6% Seropian. Am J Surg 1971; 121: 251

19. Shaving, Clipping and SSI Cruse. Arch Surg 1973; 107: 206

20. Hair Removal Techniques and SSI Alexander. Arch Surg 1983; 118: 347

21. GUIDELINES FOR ANTIBIOTIC PROPHYLAXIS 1. The procedure should carry a significant risk of infection and/or cause significant bacterial contamination.

22. Relative Benefit from Antibiotic Surgical Prophylaxis OperationProphylaxis (%)Placebo (%)NNT* Colon 4-12 24-48 3-5 Other (mixed) GI 4-6 15-29 4-9 Vascular 1-4 7-17 10-17 Cardiac 3-9 44-49 2-3 Hysterectomy 1-16 18-38 3-6 Craniotomy 0.5-3 4-12 9-29 Total joint 0.5-1 2-9 12-100 Breast & hernia ops 3.5 5.2 58 * Number Needed to Treat

23. GUIDELINES FOR ANTIBIOTIC PROPHYLAXIS 2.The antibiotic selected must be active against the major contaminating organisms and should have previously been shown to be effective prophylaxis. It is NOT necessary to cover ALL organisms present.

24. GUIDELINES FOR ANTIBIOTIC PROPHYLAXIS 3. The antibiotic chosen must achieve concentrations higher than the minimal inhibitory concentration (MIC) of the suspected pathogens in the wound siteat the time of incision.

25. GUIDELINES FOR ANTIBIOTIC PROPHYLAXIS 4. The shortest possible course of the most effective least toxic antibiotic must be used for prophylaxis. Must consider distribution and half-life of individual agents.

26. GUIDELINES FOR ANTIBIOTIC PROPHYLAXIS 5. The newer broader spectrum agents must be saved for therapy of resistant organisms and should not be used for prophylaxis.

27. Antimicrobial Prophylaxis: Category IB • Do not routinely use vancomycin for antimicrobial prophylaxis

28. WHEN (TIMING) OF PROPHYLACTIC AGENTS • Antibiotic levels of the individual agents must be higher than the MIC at the time of incision • Individual agents must be considered • Cefazolin has a Vd of 10-12 L can can be pushed within minutes of incision • Additional doses dependent on half-life and blood loss

29. Timing Analysis Burke JP. CID. 2001;33;s78-s82

30. Appropriate Use:LDS Burke JP. CID. 2001;33;s78-s82

31. Antibiotic Timing Related to Incision Bratzler DW, Houck PM, et al. Arch Surg 2005:140:174-182

32. Discontinuation of Antibiotics Patients were excluded from the denominator of this performance measure if there was any documentation of an infection during surgery or in the first 48 hours after surgery. Bratzler DW, Houck PM, et al. Arch Surg 205:140:174-182

33. Cefazolin 1 gram is not the correct dose for everyone At incision and closure 1g , blood and tissue levels all lower than “normal” weight Below MIC for gram pos cocci and gram neg rods Cefazolin 2gm good blood and tissue levels Wound infection rates from 16.5% to 5.1% Forse et al:surgery 1989:106,751-767 SPECIAL CONSIDERATION: MORBID OBESITY

34. CONCLUSIONS • Must be familiar with principles of prophylaxis and CDC recommendations • Morbidly obese patients should receive larger doses of antibiotics

35. CONCLUSIONS:Beyond CDC • Maintenance of normothermia maybe important (Level II) • Glucose control perioperatively

36. Improving Safety and Quality:Five Step Model for Improvement

37. Why do we need to improve care? In U.S. Healthcare system • 44,000- 98,000 preventable deaths • $50 billion in total costs IOM report “To err is human” Similar results in UK and Australia

38. Why do we need to improve care? • Patients – Do the right thing! • Purchasers • Leapfrog group • Insurers • Regulators • JCAHO ICU measurement set • CMS surgical care improvement project

39. Outline • Review 5 step model for improvement • Provide practical examples • How will we prevent SSI?

40. 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 • Evaluate whether outcomes are improved

41. Important Clinical Areas • Eliminating CR-BSIs • Ventilator Associated Pneumonia • Sepsis Bundle • Perioperative Beta Blockers • VTE Prophylaxis • Decreasing SSI

42. 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 • Evaluate whether outcomes are improved

43. 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 • Evaluate whether outcomes are improved

44. Process full barrier precautions DVT and PUD prophylaxis Appropriate abx timing Adv/Disadvantages short cycle feedback meaningful no risk-adjustment Outcome mortality catheter-related BSI SSI Adv/Disadvantages long cycle feedback difficult important to patients Outcome vs. Process Measures McGlynn, Jt Comm J Qual Improv 1988

45. 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 • Evaluate whether outcomes are improved

46. Systems Approach • Every system is perfectly designed to get the results that it gets Berwick • If you want to change performance you need to change the system

47. All improvement is local: we can provide concepts; you need to design interventions

48. 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

49. 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 • Evaluate whether outcomes are improved

50. Eliminating SSI • Apply best practices • If hair is removed, use clippers • Appropriate antibiotics • Choice • Timing • Discontinuation • Perioperative normothermia • Glycemic control • Decrease complexity • Create redundancy