The Joint Commission Center for Transforming Healthcare (CTH) Surgical Site Infections in Colorectal Surgeries Project: 2012 Sasha Madison, MPH, CIC Director Infection Prevention & Control Dept. May 14, 2014

Project #4: Surgical Site Infection Collaborate with American College of Surgeons & NSQIP measurement system leveraged. Seven participating hospitals: Mayo Clinic, MN Cleveland Clinic, OH Stanford Hospital & Clinics, CA OSF Saint Francis, IL Northwestern Memorial Hospital, IL North Shore LIJ, NY Cedars-Sinai Medical Center, CA Siew Lee will go over the list of participants for the project and point out the video available at the website. Siew Lee will play the video for 2 +minutes.

Systematic Approach to Problem Solving – Surgical Site Infections (1) The Center worked with the American College of Surgeons to determine the scope of the SSI project, since there is a wide range of surgeries and procedures that can develop SSIs – each with its own unique set of complications and challenges. To help narrow the scope of the project, the following criteria were used to identify a specific procedure that: Is common across different types of hospitals Has significant complications with an adverse clinical impact Hospitals have significant opportunities to improve performance Has high variability in performance across hospitals Siew Lee will explain the kick off experience of working with ACS and participating hospitals in coming out with the criteria to narrow down the scope for the project and how we landed on colorectal as the focus.

Collaborative Project Definition DMAIC Problem Statement: The incidence of Surgical Site Infections in colorectal surgery is high, variable, and represents opportunity for improvement. Goal: Reduce colorectal surgical site infections by 50% (Observed and Observed/Expected) Scope: Process Begins: Pre-Operative Processes (Pre-Op Clinic with Surgeon) Process Ends: 30 Days Post-Surgery Includes: All emergent & elective surgical procedures Excludes: Trauma and Transplant patients & Patients under 18 years of age Timeline: August 2010 – March 2012 Kinjal

2009 Metrics: Observed & O/E Baseline Performance DMAIC Metric 1- Observed Colorectal SSIs Baseline: 18.5% Target: 9.3% (50% reduction) Metric 2- O/E* Ratio for Colorectal SSIs Baseline: 1.49 Target: 0.74 (50% reduction) Kinjal 1st graph (left): P= Overall Rate of CY 09’ 2nd graph (right): X= Mean O/E Average SSI Cases / Month = 3 Note: Observed/Expected / Index Value Expected Value is Dependent on “Expected” influence/calculation

SHC SSI Project Phases & Elements DMAIC Milestone Key Elements Define Incidence of Surgical Site Infections in colorectal surgery is high, variable, and represents opportunity for improvement. Measure Reduce colorectal surgical site infections by 50% (Observed and Observed/Expected) Analyze (Based on statistical analysis of SHC data) Improve Focus on identified causes, target solutions, patient outcomes Control Correlate interventions with SSI outcomes and create sustainability plans for any intervention that successfully decreased SSIs Statistically Significant Variables (Potential Risk Factors for SSI) Potential Identified Variables /Opportunities Wound Disruption (0.003) OR Duration (0.066) ASA Class > 2 (0.015) Open/Laparoscopic Procedure (0.054) Total Hospital LOS (0.036) Lowest Patient Intra-Operative Temperature Post-Operative Wound Care Hand Hygiene Dressing Removal at 48hrs Post-Operative Bathing Surgical Closure Glove Change Prior to Closing Fascia Separate Colorectal Closure Tray Tissue Irrigation - Irrigation Solution Type Note: Actual Interventions in blue & Monitoring in green Note: Above variables found to be statistically significant, however not entirely modifiable. - No Interventions Made Kinjal

Project Interventions & Monitoring DMAIC Improvement Baseline Target & Measurement Tools Implementation Month-Year Glove Changes Standardize closing process 59% of clinicians responded “No” to changing gloves before closure 100% glove changes before closing fascia MIDAS Focus Audit February 2011 Colorectal Closure Tray Standardize major set closing tray No separate closing tray 100% separate and clean closing instruments April 2011 Patient and Room Temperature Guidelines Given to OR & ASC No baseline measurement Per SCIP & AORN Guidelines: Patient temperature should be equal to or greater than 36 Degrees Celcius Ambient OR room temperature should be 68-72 Degrees Fahrenheit August 2011 Post Op Wound Care Protocol (Collaborative best practice) Dressing marked by surgical team Dressing Removal Goal = 48 hours 100% Dressing marked by surgical team 100% Dressing Removal: Goal = 48 hours Kinjal

MIDAS Focus Objectives: DMAIC NHSN Publicly Reported Cases- MIDAS Focus Study MIDAS Focus Objectives: Detailed abstraction of elements with identified areas of opportunity Data will be analyzed for any potential trends and to serve as a guide for further interventions Surgeon specific SSI rates Surgical Quality Council Dashboard will include SSI outcomes Sasha

Antibiotic Stewardship Program DMAIC Dosing of Ertapenem for patients with BMI greater than 30 Assessment of empiric therapy recommendations for contaminated and dirty cases Measuring timing of prophylactic antibiotics prior to incision: 0-15 minutes 16-30 “ ” 31-45 “ ” 46-60 “ ” Sasha

DMAIC Sasha

Improvement ‘Bundle’ Interventions across the episode of care Multi-disciplinary Engage staff, patient, and families Standardize as many processes as possible Ensure high compliance with elements Quick audits Build the elements into the system Frequent feedback and communication

Pre-operative Interventions Pre-operative Chlorhexidine packets Provided to all patients preoperatively with instructions Use monitored morning of admission If not reported as not being used, SAGE wipes used on the entire body Patients with BMI > 30 (Mayo) SAGE wipes applied even if preoperative bath performed Procedure listing software automatically identifies patients with BMI > 30 Pre-op antibiotic ordering (Mayo) Procedure scheduling software automatically provides SCIP appropriate choices Weight-based dosing Software automatically orders intra-operative re-dosing dose if historical data for the specific procedure and surgeon demonstrated an average case duration >3 hours

Pre-Operative Interventions (cont’d) Hair removal by electric clipper Outside of the operating room Standardized to Chlorhexidine-Alcohol (Chloraprep™) skin preparation for all abdominal cases Surgical assistant applies skin preparation All in-serviced on appropriate application Must dry for 3 minutes before drapes applied

Intra-Operative Interventions Pre-procedural pause includes confirming appropriate antibiotics administered and documented Re-dosing of cefazolin for cases longer than 3 hours. (Mayo) Circulating nurse has the preop order and pulls medication at the beginning of the case Reminder window on anesthesia provider’s computer screen Triggered off time of first dose administration Appropriate weight-based dosing

Intra-Operative Interventions (cont’d) “Closing” Process At the time of fascia closure All staff change gloves Gowns if soiled Field re-blocked with sterile towels Instruments used during case removed and “closing tray” brought onto the field

Post-Operative Interventions All order-sets discontinue SCIP compliant antibiotics after two postop doses or single dose when appropriate (Mayo) Pharmacist part of team and queries service Hand hygiene essential on floor Physician/Nursing initiative Patient and Family initiative Sterile dressing on until morning of POD 2 Document removal Chlorhexidine shower/wipes daily after dressing removal (Mayo) Standard postop order-sets orders urinary catheter removal at 8am the morning after surgery (Mayo) Dismiss with chlorhexidine soap bottle for use at home (Mayo)

Important Lessons: Multidisciplinary approach is essential Physicians, nursing (pre, intrao-p, floor), pharmacy, CST, SA, administration, supply chain, quality, S&P, IT, Patient Education, Infection Control, WOCN, NSQIP team Address the entire surgical episode of care Pre, intra, and postoperative elements may influence SSI rates Interventions designed for each phase Introduce elements of change and audit compliance Build ‘clues’ into the process to ensure better compliance: convenient hand hygiene supplies (Purell wipes, Hibiclens bottles), signage, Hibiclens packets, etc. Build process improvements into the system to ensure task completion No evidence for which of element(s) makes a difference in the “bundle”: the outcome is all that matters

Challenges Encountered DMAIC Learnings: Reduction of our SSI rates continue to be challenging. Questions 2012: Could we learn more by studying the elements of the National Healthcare Safety Network(NHSN) colorectal SSI cases? Could we focus our efforts on the ‘bulk’ of our infections; Organ Space (asked in 2012) Focused our efforts on organ space infections beginning after this collaborative – later part of 2102 Decrease seen in 2013 (decrease seen in colo-rectal SIR) Found part of the issue was appropriate classification of cases: major educational focus later part 2012/2013 Experienced & Foreseeable Challenges: Strategies for preventing infections are different based on culture, environment, surgeon practice, patient pre- existing conditions Lag time in collection and receipt of data to assess improvements Nursing time for documentation of audits takes away from patient care Insufficient and incomplete audits Resources needed for this improvement project Best Practice: Standardization of approach was sequential and we may not see full term change yet (glove changing, closing trays, etc. occurred in sequence not parallel) Best practices identified elsewhere may not have same level of impact in our organization Kinjal

Next Steps & Opportunities DMAIC Based on best practice learnings through collaborative, continue glove changes & separate/clean closing instruments MIDAS Focus Study on Publicly Reported Cases Infection Control SSI surveillance in July/Aug 2011 identified an opportunity in colorectal surgery Data collection focused on elements which are not captured elsewhere Need for individual physician communication of infections identified Opportunity for Physician review of case with abstracted data elements Antibiotic Stewardship Instituted February 2012 Review of current prophylaxis guidelines and empiric therapy SSI Deep/Organ Space and Sepsis commonalities Drill down on each Organ/Space and Deep SSI Leaks (i.e. CT scans, physician documentation, abscessogram results) Antibiotic prophylaxis dosing for patients with BMI greater than 30 Empiric therapy and treatment protocols Pursue Pre-Operative Warming Improvements Preoperative strategies for surgery admission unit Potential partnership with vendors to pilot new interventions Sasha