Best Practice in General Surgery A University of Toronto, Division of General Surgery Initiative to Improve Patient Car

1. Best Practice in General SurgeryA University of Toronto, Division of General Surgery Initiative to Improve Patient Care

2. Aim: To promote standardized evidence based practices in the adult teaching hospitals at the univeristy of toronto within general surgery. Rationale improve patient care improve resident education capitalize on expertise within our division possibly be “ahead of the game” if LHINs exert more influence foster collaboration in clinical research

4. An example of an initiative designed to improve practice by engaging physicians. BPIGS Mission Survey of general surgeons

5. SSI specifically: Baseline data – is there a problem? Survey of surgeons, chart review Creation of guideline Identification of stakeholders SSI workshop – where is the problem? Identification of champions at each hospital Educational rounds by local O.L. Engagement of Anaesthesia Plan for feedback.

6. Steering Committee: Robin McLeod (chair) Cagla Eskicioglu Darlene Fenech Shawn Forbes Anna Gagliardi Avery Nathens Marg McKenzie (coordinator)

7. Prioritization of Practice Improvements (Results of Survey n=76) SSI Prevention 86% Fast Track Surgery 83% VTE Prophylaxis 80% Bowel Prep 73% POI 71% Transfusion 69% Perioperative Steroids 65% Ventral Hernia Repair 60% Abdominal Wound Closure 60% Inguinal Hernia Repair 53%

8. SSI Prevention-first initiative Antibiotic Prophylaxis Hair Removal Temperature Control (Normothermia) Supplemental Oxygen

9. Beliefs and practices:- Survey distributed to all general surgeons and residents- Heads of divisions interviewed in person, quality managers interviewed by telephone- Documents at the individual hospitals assessed

10. Survey: antimicrobial prophylaxis Do you use antibiotic prophylaxis for SSI prevention? 97.4% yes (similar for staff and resident surgeons) Where is antibiotic prophylaxis delivered? 11.8% ward, 23.7% preop holding, 60.5% OR In what way is antibiotic prophylaxis delivered? 82.9% IV, 11.8% oral, 6.6% combo

11. Survey: antimicrobial prophylaxis In what % of cases is it initiated within 1hr of incision? no responses Who is responsible for decisions about antibiotic and dose? 59.2% surgeon, 31.6% resident, 26.3% anaesthetist, 7.9% ward nurse, 6.6% surgical nurse, 2.6% pharmacist

12. Survey: antimicrobial prophylaxis What influences your decisions about antibiotic prophylaxis? 100% type of surgery 90.7% published guidelines 88.0% personal judgement 74.7% hospital policy or protocol 46.7% decision-making tool What influences the timing/duration antibiotic prophylaxis? 83.8% forgetting 75.7% lack team communication 55.7% responsibility unclear

13. Survey: preop hair removal Do you use preop shaving for SSI prevention? 17.1% yes (27.8% residents, 7.5% staff) Do you use preop clipping for SSI prevention? 77.6% yes (75.0% residents, 80.0% staff) Do you use no hair removal for SSI prevention? 44.7% yes (52.8% residents, 37.5% staff)

14. Perioperative Hyperoxia Do you use perioperative hyperoxia for SSI prevention? 42.1% yes (50.0% residents, 35.0% staff)

15. Survey: beliefs about evidence

16. Chart Review Results To determine what the current practice is at the University of Toronto for reducing SSI’s To determine whether these practices are adequately documented in the chart.

17. Methods Retrospective chart review Each of the 7 teaching hospitals >50 charts per hospital Elective colorectal surgery Consecutive charts prior to April 30, 2007.

18. Demographics Charts per hospital (48-83) 97.7% inpatients 52.5% male Overall >60% had CR neoplasm >55% had CRC 91.4% of patients no unusual findings at surgery

19. Pre Op ORAL Antibiotics?

20. Pre Op IV Antibiotics-Timing

21. Type of Pre Op IV Antibiotic given

22. Post OP IV Antibiotics-If administered - >24 hours?

23. Hair Removal

24. TemperatureProportion of Patients >36 C

25. FiO2

27. SSI Prevention Guideline–Process Guideline developed-Avery Nathens, Shawn Forbes Feedback sought from all GS, GS residents and key stakeholders Workshop held on November 16-multidisciplinary from all 7 hospitals Guideline modified and sent out for further feedback

33. Preoperative Hair Removal For the purpose of SSI prevention, hair removal should not be performed. If hair removal is required, clipping should be done rather than shaving

34. Maintenance of Normothermia The patient’s temperature should be maintained at or above 36 celsius This may be accomplished by pre operative warming measures, increasing the room temperature, warming devices and IV fluid warmers for cases longer than 1 hour.

35. Perioperative Hyperoxia Perioperative hyperoxia (FiO2 80%) should be considered as an adjunctive means to further reduced rates of SSI

36. Workshop Invited all heads of divisions of general surgery and 1-2 other surgeons from each hospital 1-2 anesthetists were invited Infectious Disease SSI nurses OR nuses Administrative persons involved in SSI prevention.

37. Workshop Introduction and endorsement The evidence The survey and perceptions Chart Review Guideline Discussion Small group sessions between hospitals

38. After the SSI workshop… Implementation of the Guideline will occur locally at hospitals Hospital champions – all surgeons Provided a slide deck for talks to the multidisciplinary team Normothermia Guideline

39. What Next? - teaching sessions with anaesthesia and GS residents laminated cards for residents Posters Checklist (modified WHO) Checklist for ascertaining PCN allergy Anaesthesia Survey Engaging champions and encouraging discussion between activities at each hospital Repeat audit next summer

40. Acknowledgements Guideline development: Avery Nathens and Shawn Forbes Interviews: Anna Gagliardi and Marg McKenzie Document Analysis: Anna Gagliardi and Cagla Eskicioglu Chart Review: Janet Chung, Darlene Fenech and Cagla Eskicioglu

41. Hospital Champions: Paul Bernick-TEGH Lorne Rotstein-TGH Allan Okrainec-TWH Robin McLeod-MSH Darlene Fenech-SB Avery Nathens-SMH David Lindsay-SJH