Evaluation of the CDC Guideline for Prevention of Surgical Wound Infection Presented by Sujha Subramanian, PhD, Lucy Savitz, PhD, Linda Pucci, MA, Shulamit Bernard, PhD, and Michele A. Pearson, MD, MPH 411 Waverley Oaks Road, Suite 330 · Waltham, MA Phone: · Fax:

2 Research Motivation n CDC has developed and disseminated consensus guidelines in 1999 to prevent and reduce surgical site infections (SSIs). n Despite these efforts, SSIs remain a significant cause of patient morbidity and mortality. n The objective of this research is two-fold: 1) To assess adherence with guideline recommendations 2) To evaluate practitioner/institutional barriers to and facilitators of implementing prevention strategies.

3 Methods: Objective 1 n Quantitative assessment of adherence - data collected via chart abstraction at three hospitals: academic medical center, teaching community hospital and a non-teaching community hospital (Veterans administration hospital to be added). n Four target procedures were selected: CABG, joint procedures, vascular procedures, general surgery n Sample size: 50 patients per procedure were randomly selected (200 per hospital) n Timeframe: Jan 1, 2002 through Dec 31, 2002

4 Objective 1: Measures n Perioperative Antimicrobial Prophylaxis l Antibiotics administered within 1 hour of surgical incision l Antibiotic agent consistent with guidelines l Antibiotics discontinued within 24 hours of surgery end time n Perioperative Glucose Control l Patients tested for serum glucose level l Serum glucose level maintained in normal range during the perioperative and postoperative period. n Warming peri-op; Oxygen intra & post-op

5 Methods: Objective 2 n Qualitative assessment of barriers/facilitators through focus groups and key informant interviews l Focus group - 2 w/ surgeons; 2 w/ nurses u Society of Thoracic Surgeons/AATS u American Society of PeriAnesthesia Nurses l Key informant interviews - same 3 sites selected for quantitative data collection n Qualitative content analysis framework: Awareness, Agreement, Adoption, Adherence

6 Findings: Guideline Adherence Procedure Type CABG General Joint Vascular Antibiotics Start time 68% (42-98) 62% (51-69) 58% (20-84) 49% (45-56) Agent 99% (96-100) 71% (29-96) 99% (88-98) 93% (88-96) End time 33% (14-81) 62% (39-88) 76% (43-100) 20% (57-100) Glucose level Tested 43% (18-82) 21% (20-24) 21% (18-26) 29% (24-36) Hyperglycemia 39% (14-82) 16% (12-18) 9% (0-14) 15% (14-16) Warming 100% (100) 96% (96) 86% (68-94) 77% (62-100)

7 Comparison with National Estimates (CMS/CDC National SSI Prevention: Medicare Quality Improvement Project) Procedure Type CABG General Joint Vascular Antibiotic administered with 1 hour Current Study 68% 62% 58% 49% CDC/CMS 45% 47% 52% 40% Correct Antibiotic Current Study 99% 71% 99% 93% CDC/CMS 96% 84% 97% 92% Antibiotic stopped within 24 hours Current Study 33% 62% 76% 20% CDC/CMS 34% 60% 36% 44%

8 Barriers/Facilitators to SSI Recommendation Adherence Barriers n Tradition/habit n Absence of an implemented protocol n Lack of awareness/exposure n Conflicting cultures n Facility layout n Inconsistent care process re- engineering Facilitators: n Leadership buy-in n Adequate resources n Training (with refreshers) n Local reinforcing activities (signs, meetings, role models) n Feedback data n Evidence to support

9 Emergent Themes and Challenges n Disconnect between cost and infections n Education on SSI should be for anyone who touches the patient, hospital wide, including family members n Hospitals are not aware of superficial SSI after discharge (unless patient is re-admitted) n There is some confusion and/or overlap of various staff roles in task activity n Surgeons may practice at multiple facilities that have differing SSI prevention practices/protocols n Compelling data drives quality improvement n Multidisciplinary teams/task forces for quality improvement are key to successful implementation of targeted initiatives

10 Conclusions n Overall, adherence with SSI guidelines recommendations is not high (except for antibiotic agent). n Significant barriers exist to adoption but approaches to improving adherence can be identified. n Need to identify key facilitators to increasing adherence with guideline recommendation (objective of final focus groups w/ experts).

11 Implications for Monitoring Hospital Quality n Antibiotic administration is influenced by patients risk factors (renal failure, compromised immune system) n Adherence with recommendations could differ by type of surgery n Significant data collection challenges l Antibiotic end times are generally not available l Difficult to identify antibiotics given as prophylaxis versus treatment l Assessing appropriate use of vancomycin requires detailed information on choice of antibiotics