Building Your SSI Prevention Bundle: Slide Presentation

Slide 1: AHRQ Safety Program for Surgery—Onboarding

Building Your SSI Prevention Bundle

Slide 2: Learning Objectives

After this session, you will be able to–

• Develop and implement a surgical site infection (SSI) reduction goal and prevention bundle that addresses up to three surgical care processes.
• Build a bundle based on the results of your staff safety assessment.
• Review how to initiate audits of your processes.
• Create a team performance goal (improvement in outcome).
• Proceed with improvements without strong evidence base.
• Locate AHRQ Safety Program for Surgery resources on the project Web site.

Slide 3: Background¹

Surgical Site Infections–

• Are the most common nosocomial infections in the surgical patient.
• Are the most common colorectal abdominal surgery complications (3-30%).
• Are associated with increased length of stay, readmission, and mortality.
• Cost, depending on infection location, $6,200—$15,000 per patient  (superficial vs. organ space).

Slide 4: SSI Definitions²

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).

Image: Drawing of a surgical site infection. A vertical incision with small stitches shows signs of redness, warmth, tenderness and drainage (pus).

Slide 5: JHH Colorectal Surgery Readmissions

Readmission Rate: 17.6% (2009–12)

Image:  Table depicting readmission rates in 2009-2012 Columns are labeled Characteristics, readmitted patients, non-readmitted patients, p value, odds ratio. The rows are labeled intraoperative: ostomy present or ostomy not present; length of operation, mean hours. Postoperative surgical site infection (superficial incisional SSI, deep incisional SSI, organ space SSI), length of stay, 30-day mortality.

Slide 6: Pathogenesis of SSI

Image: Venn diagram illustrating interplay between bacteria, host, and procedure interactions, which can contribute to surgical site infections. Each component is shown as a separate but overlapping circle.

Slide 7: No Single SSI Prevention Bundle

• Deeper dive into SCIP measures to identify local defects.
• Emerging evidence:
  • Antibiotics redosing and weight-based dosing.
  • Maintenance of normoglycemia.
  • Mechanical bowel preparation with oral antibiotics.
  • Standardization of skin preparation.
• Capitalize on frontline wisdom:
  • Comprehensive Unit-based Safety Program (CUSP).
  • Staff Safety Assessment (SSA).

Slide 8: Deeper Dive into SCIP Measures to Identify Local Defects

Deeper Dive into SCIP Measures to Identify Local Defects

Slide 9: Does SCIP Provide Enough Information?³

Image: Table compares Johns Hopkins (JH) and Comparison Hospitals (Other):

• Surgery patients who were given an antibiotic at the right time (within 1 hour before surgery) to help prevent infection; JH - 98%, Other - 97%.
• Surgery patients who were given the right kind of antibiotic to help prevent infection; JH - 98%, Other - 98%.
• Surgery patients whose preventive antibiotics were stopped at the right time (within 24 hours after surgery); JH - 100%, Other - 96%.
• Surgery patients who had hair removed from the surgical area before surgery using a safer method (electric clippers or hair removal cream instead of a razor); JH - 100%, Other - 100%.
• Surgery patients who were actively warmed in the operating room or whose body temperature was near normal by the end of surgery; JH - 98%, Other - 99%.

Slide 10: Observed to Expected Outcome Ratio

Image: Graph depicting NSQIP report 2009; 30 day morbidity observed to expected (o/e) ratios for colectomy. The X-axis is labeled with report identification numbers. The Y-axis is a range of 0 to 3. This graph is an unpublished report from the NSQIP database in 2009.

Sample 2009 NSQIP report (American College of Surgeons National Surgical Quality Improvement Program).

Slide 11: Safety Issues & Improvement Opportunities⁴

Image: Table with two columns. The first column shows applying CUSP Step 2 to identify safety issues. Rows beneath this column show examples of different types of safety issues. The second column shows applying CUSP steps 4 and 5 with opportunities to improve. Rows beneath this column list opportunities to improve related to the categories of safety issues identified.

Reference: Wick EC, Hobson D, Bennett J, Demski R, Maragakis L, Gearhart SL, et al. Implementation of a Surgical Comprehensive Unit Based Safety Program (CUSP) to Reduce Surgical Site infections. J. Am Coll Surg  2012; 215(2):193-200. PMID: 22632912.

Slide 12: Perioperative Antibiotic Compliance

Image: Table shows data from the Michigan Surgical Quality Collaborative.⁵ The table includes four columns. The first column titled Antibiotics Practices includes rows that describe different antibiotic practices. Column 2 shows the numbers of cases in which a particular practice identified in column 1 was applied. Column 3 shows the number of nonemergency cases in which the practice identified in column 1 was applied. Column 4 shows the number of emergency cases in which the practice identified in column 1 was applied.  The number of cases and emergency cases for some different practices are highlighted. A SCIP-compliant antibiotic was chosen in 2,431 or 81.4% of cases (n=3002). It was chosen in 130 or 52.4% of emergency cases. Antibiotics were weight-adjusted in 552 or 56.8% of cases (n=972). Antibiotics were redosed in 24 or 6% of cases (n=3002).

Reference: Hendren et al. Am. J Surg 2011.

Slide 13: Auditing Your Practice

• Evaluate a sample of patients undergoing your targeted procedure for compliance with processes your team identified as potential areas to improve.
  • For example, the next 10­–20 patients.
• Adapt tool from AHRQ Web site or develop new tool.
• Develop practical and feasible strategy to evaluate performance and identify defects.
• Empower frontline staff.

Slide 14: How Do We Conduct Audits?

• Retrospective chart review.
• Concurrent review:
  • Place audit tool on chart.
  • Complete over continuum of care.
• Audit of 5–10 patients is recommended:
  • Larger samples yield better estimates of performance.
• Data collection for internal purposes only.

Slide 15: Intervention: Gentamicin Antibiotic Dosing

Interventions

• Increased amount of gentamicin available in room.
• Added dose calculator in anesthesia record.
• Educated surgery, anesthesia, and nursing staff.

Despite 95% compliance on SCIP!

Image: Bar chart highlighting the percentage of patients receiving the correct dose of gentamicin before and after intervention. Before the intervention, only 33% of patients received the correct dose of gentamicin, despite 95% compliance on SCIP measures. After the intervention, 92% of patients received the correct, evidence-based dosing of gentamicin.

Slide 16: Antibiotic Audit Tool

Image: Example Antibiotic Audit tool with two columns: the first is labeled "Questions" and the second is labeled "Data." The data column has space provided for fill-in responses, yes/no checkboxes, or drug, dose and time details. 

1. Patient name.
2. Medical record number.
3. Date of operation.
4. Procedure Type:  Colorectal.
5. Was the correct antibiotic used, based on the procedure (example: Cefotetan OR Ciprofloxacin and Metronidazole)?
6. Was patient allergic to cephalosporins? If NO, skip to question 8
7. If patient cephalosporin allergic, were both Ciprofloxacin and Metronidazole given?
8. Was the correct prophylactic antibiotic dose administered? Correct dosing:
   1. Cefotetan 2 gm OR
   2. Ciprofloxacin 400 mg AND
   3. Metronidazole 500 mg
9. If you answered NO to question 8, what was the defect?
10. Antibiotic infusion stop time.
11. Anesthesia stop time.
12. Was Cefotetan used as antibiotic prophylaxis?  If NO, skip to question 16.
13. Was blood loss during the case >1500 cc?
14. Was the length of time between first Antibiotic infusion stop and Anesthesia stop ≥6 hours? 
15. If YES to question 13 AND/OR 14, was Cefotetan redosed? 
16. If YES, was redosing given < 6 hours after the first dose of Cefotetan?
17. Time of surgical incision?
18. Was the first antibiotic infusion completed < 60 minutes BEFORE incision?

Slide 17: Intervention: Normothermia

Interventions

• Confirmed that temperature probes were accurate first:
  • Needed surgeons to accept temperature data.
  • Compared indwelling urinary catheter and esophageal sensors in local trial.
• Initiated forced air warming intervention in the pre-operative area after temperature accuracy established.

Slide 18: Normothermia Audit Tool

Image: Sample of Normothermia Audit Tool (1 of 2). Table lists the following parameters:

1. Patient name.
2. Medical record number.
3. Date of operation.
4. Procedure.
5. Surgeon.
6. Anesthesiologist or CRNA.
7. Temperature (°C) on arrival to preoperative area.
8. Temperature (°C) in preoperative area prior to going to operating room.
9. Convective warmer used in preoperative area? (i.e.,  Bair Hugger)
10. First temperature (°C) in operating room.
11. Temperature (°C) at or just prior to time of incision.

Slide 19: Normothermia Audit Tool

Image: Sample of Normothermia Audit Tool (2 of 2). Table lists the following parameters:

12. Final temperature (°C) in the operating room.
13. Convective warmer used intra-operatively?
14. Patient temperature (°C) on arrival to PACU/ICU.
15. Was the patient’s temperature maintained at 36°C or above during the entire perioperative period?
16. If the patient’s temperature was documented below 36°C, where was the patient located at that time? [pre-op, at incision, case stop, PACU/ICU]
17. Length of Case (Anesthesia start to stop time)

Slide 20: Separation of Clean and Dirty Instruments

Interventions

• Separate tray of instruments used for bowel anastomosis.
• Extra suction along with both bovie tip and gloves opened and changed after anastomosis.
• Educational sessions with scrub techs and nurses about instrument separation.
• Real-time audits.

Images: Clean surgical instruments on a sterile table. Along with the next image of used instruments, this image shows the physical separation between used and unused surgery implements. Instruments used in surgery stored in a separate bowl marked "dirty." Along with the preceding image of sterile instruments, this image shows the physical separation between used and unused surgery implements.

Slide 21: Bringing Emerging Evidence for SSI Prevention to your Patients

Bringing Emerging Evidence for SSI Prevention to your Patients

Slide 22: Emerging Evidence for SSI Prevention

• Antibiotic usage:
  • Redosing.
  • Weight-based dosing of cephalosporins.
• Utilization of mechanical bowel preparation with oral antibiotics.
• Normoglycemia/prevention of hyperglycemia.
• Standardization of skin preparation.

Slide 23: Emerging Literature Excerpt

Image: Screenshot of an ASHP article entitled “Clinical Practice Guidelines for Antimicrobial Prophylaxis in Surgery.”

Slide 24: Antimicrobial Prophylaxis in Surgery

Image: A table depicting recommended doses and redosing intervals for commonly used antimicrobials for surgery prophylaxis for adults and pediatrics.

Slide 25: Johns  Hopkins Hospital Antibiotic Poster

Image: A table depicting perioperative antibiotic prophylaxis to prevent surgical site infection.

Slide 26: Interventions To Improve Antibiotic Efficacy

• Standardize weight-based dosing of cephalosporins.
• Standardize antibiotics redosing:
  • Maintain therapeutic antibiotic serum levels throughout procedure.
  • Reconsider the use of cefoxitin due to its short redosing interval.
• Audit your practice!
• Standardize selections based on your hospital procedures.
• Engage surgery, nursing, and anesthesia areas to implement a standard protocol.
• Consider integrating into electronic medical records.
• Audit your results and share success.

Slide 27: Hypoglycemia and Infection

Background

• Hyperglycemia is common in hospitalized patients.
• 38% of medical and surgical patients had hyperglycemia.
  • 26% diabetic.
  • 12% nondiabetic.
• In cardiac surgery, degree of post-operative hyperglycemia correlates with SSI, adopted as SCIP measures.

Goal

• Glucose <180mg/dl in all hospitalized patients.

Postoperative hyperglycemia is associated with an increased risk of SSI in general surgery patients.

Image: Line graph shows the correlation between infection rate and Post-Op Glucose levels. Post-operative hyperglycemia is associated with increased risk of SSI in general surgery patients.

Reference: Ramos, et al. 2008.

Slide 28: University of Washington/Glucose Control

Image:  A glucose-auditing tool used by the University of Washington.

Slide 29: Could You Improve Glycemic Management?

• Audit your current practice.
• Do you have a policy?
• Consider gathering a multidisciplinary team to develop a protocol for your hospital:
  • Endocrinology.
  • Surgery.
  • Anesthesiology.
  • Nursing (ward and preoperative).

Slide 30: Preparation of the Surgical Site

Background

• More than a thousand bacteria types reside on the skin.
• Staphylococcus and streptococcus species, among many others.

Goal of skin preparation

• Reduce bacterial burden on skin prior to incision.

Best practice skin preparation

• Dual agent skin preparation:
  • Chlorhexidine + alcohol OR
  • Povidone + iodine + alcohol
• Include alcohol to increase durability of sterilization.
• Apply to specification, both in duration and amount.
• Must be dry before incision.

Slide 31: Literature Excerpts

Images:  An image of a journal article from the New England Journal of Medicine. An image of a journal article from Infection Control Hospital Epidemiology. Text notes next to each article read "ChloraPrep better than Betadine" and "ChloraPrep and DuraPrep better than Betadine."

Slide 32: Is Skin Prep an Area You Could Improve?

Audit your practices

• What is being used for what cases?
• Who is doing the prep?
• How long are they taking for the prep?

Develop standardized educational plan for frontline providers

• In-service training sessions.
• Video education.
• Change doctor preference cards.

Audit again after implementing your interventions.

How well did you do? Share the results!

Slide 33: Key Takeaways

• No single SSI prevention bundle exists.
  • You need to identify the LOCAL defects.
• Auditing is a practical and feasible strategy to evaluate performance and identify defects.
• Tools provide a guideline and are adaptable to your local environment.
• CUSP methodology empowers frontline staff.

Slide 34: Action Items

• Review staff safety assessment results.
• Pick 2–3 audit tools based on frontline feedback, SCIP measures and emerging evidence.
• Audit 5–10 patients with each tool.
• Create a performance goal for each intervention.
• Develop your bundle.
• Implement interventions for system changes.
• Share your tools, ideas for new tools, and results.

Slide 35: References

1. 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. PMID: 22632912.
2. National Healthcare Safety Network. CDC/NSHN Surveillance definitions for specific types of infections. In: NSHN Patient Safety Component Manual. Atlanta: Centers for Disease Control and Prevention; January  2014:chapter 17. www.cdc.gov/nhsn/PDFs/pscManual/17pscNosInfDef_current.pdf. Accessed June 11, 2014.
3. Centers for Medicare & Medicaid Services. Hospital Compare. www.medicare.gov/hospitalcompareprofile.html#profTab=2&ID=210009&loc=21287&lat=39.2962372&lng=-76.5928888&name=johns%20hopkins%20hospital. Accessed May 30, 2010.

Slide 36: References

4. Johns Hopkins Medicine, Health Library. Surgical Site Infections.http://www.hopkinsmedicine.org/healthlibrary/conditions/surgical_care/surgical_site_infections_134,144/ Accessed September 14, 2014.
5. Hendren S, Englesbe MJ, Brooks L, et al. Prophylactic antibiotic practices for colectomy in Michigan. Am J Surg 2011;201(3):290-293. PMID: 21367365.
6. American Society of Health-System Pharmacists. Clinical practice guidelines for antimicrobial prophylaxis in surgery. www.ashp.org/surgical-guidelines. Accessed September 14, 2014. doi:10.2146/ajhp120568. Also note: Bratzler DW, Dellinger EP, Olsen KM, et al. American Journal of Health-System Pharmacy 2013 Feb 1;70(3): 195-283,582. PMID:23327981.