1. Oklahoma Foundation for Medical Quality Performance Improvement for the Surgeon: SIPP and SCPP Twelfth G. Rainey Williams Surgical Symposium September 29 th, 2005

2. Oklahoma Foundation for Medical Quality Performance Improvement for the Surgeon: SIPP and SCPP Surgical Infection Prevention Project  National program funded by CMS  Can be used as JCAHO PI project  Oklahoma collaborative project

3. Oklahoma Foundation for Medical Quality Performance Improvement for the Surgeon: SIPP and SCPP Why SIPP?

4. Oklahoma Foundation for Medical Quality Public Health Importance n SSI occurs in 2-5% of extra abdominal surgeries and up to 20% of intra-abdominal surgeries n SSI patients are 60% more likely to spend time in the ICU 5x more likely to be re-admitted 2x the incidence of mortality

5. Oklahoma Foundation for Medical Quality Impact of SSI’s Case Control* Study of 255 Pairs Infected Uninfected Mortality7.8%3.5% ICU admission29%18% L.O.S.11d6d Median direct cost$7531$3844 Readmission41%7% Kirkland. Infect Control Hosp Epidemiol 1999; 20: 725 * matched for procedure, NNIS index, age

6. Oklahoma Foundation for Medical Quality Most Common Hospital- acquired Infections, 1995 Urinary tract infections Bloodstream infections Surgical site infections Pneumonia Other

7. Oklahoma Foundation for Medical Quality Estimated Annual Impact of SSIs After Specific Procedures

8. Oklahoma Foundation for Medical Quality SSI Surveillance SSI Surveillance NNIS Risk Index

9. Oklahoma Foundation for Medical Quality SSI Rates* by Surgery Type and NNIS Risk Score *Infections per 100 procedures †Risk index categories 2 and 3 combined

10. Oklahoma Foundation for Medical Quality SSI Risk Factors n Age n Obesity n Diabetes n Malnutrition n Prolonged pre- operative stay n Infection at a remote site n n Shaving site n n Duration of surgery n n Surgical technique n n Presence of drains n n Inappropriate use of antimicrobial prophylaxis Newly Identified: Hyperglycemia, hypothermia, and tissue hypoxemia

11. Oklahoma Foundation for Medical Quality

12. Surgical Procedures of Interest National Surgical Infection Prevention Project n Cardiac n Coronary Artery Bypass Graft (CABG) n Colon n Hip & Knee Arthroplasty n Hysterectomy (abdominal and vaginal) n Vascular Surgery: Aneurysm repair Thromboendarterectomy Vein Bypass These procedures are being evaluated in the Medicare project because there is no controversy over the use of antibiotics for these operations. This does not imply that antibiotic prophylaxis should not be used for other procedures.

13. Oklahoma Foundation for Medical Quality Quality Indicators Quality Indicators National Surgical Infection Prevention Project n Quality Indicator #1 Proportion of patients who receive antibiotics within 1 hour before surgical incision Because of the longer required infusion time, vancomycin, when indicated for beta-lactam allergy, may be started within 2 hours before the incision.

14. Oklahoma Foundation for Medical Quality Impact of Timing of Antibiotic Prophylaxis Classen DC, et al. N Engl J Med. 1992.

15. Oklahoma Foundation for Medical Quality Classen, et al. N Engl J Med. 1992;328:281. Perioperative Antibiotics Timing of Administration Infections (%) Hours From Incision 14/369 5/699 5/1009 2/180 1/81 1/41 1/47 15/441

16. Oklahoma Foundation for Medical Quality Prophylactic Antibiotics Timing Cefoxitin Incision 2 hours 3 hours 34 11 7 99 22 11 On CallInduction Serum Levels DiPiro JT, et al. Arch Surg. 1985;120:829-832. Blood levels at the time of the incision are important to reduce infection!

17. Oklahoma Foundation for Medical Quality Dose of Antibiotic for Prophylaxis n Always give at least a full therapeutic dose of antibiotic n Consider the upper range of doses for large patients and/or long operations n Consider repeating doses for long operations

18. Oklahoma Foundation for Medical Quality Quality Indicators Quality Indicators National Surgical Infection Prevention Project n Quality Indicator #2 Proportion of patients who receive prophylactic antibiotics consistent with current recommendations

19. Oklahoma Foundation for Medical Quality Appropriate Antibiotics Appropriate Antibiotics National Surgical Infection Prevention Project n Cardiac and vascular surgery cefazolin, cefuroxime, cefamandole (vancomycin only if documented beta- lactam allergy) n Hip and knee arthroplasty cefazolin, cefuroxime (vancomycin only if documented beta- lactam allergy)

20. Oklahoma Foundation for Medical Quality Appropriate Antibiotics Appropriate Antibiotics National Surgical Infection Prevention Project n Hysterectomy cefazolin, cefotetan, cefoxitin, or cefuroxime (fluoroquinolone + clindamycin if documented beta-lactam allergy)

21. Oklahoma Foundation for Medical Quality Appropriate Antibiotics Appropriate Antibiotics National Surgical Infection Prevention Project n Colorectal surgery Oral (after effective mechanical bowel prep) administered for 18 hours preop –neomycin sulfate + erythromycin base, or –neomycin sulfate + metronidazole Parenteral –cefoxitin, cefotetan, cefmetazole, or cefazolin + metronidazole –(fluoroquinolone + clindamycin if documented beta-lactam allergy)

22. Oklahoma Foundation for Medical Quality Antibiotic Recommendation Sources n American Society of Health System Pharmacists n Infectious Diseases Society of America n The Hospital Infection Control Practices Advisory Committee n Medical Letter n Surgical Infection Society n Sanford Guide to Antimicrobial Therapy 2001

23. Oklahoma Foundation for Medical Quality Quality Indicators Quality Indicators National Surgical Infection Prevention Project n Quality Indicator #3 Proportion of patients whose prophylactic antibiotics were discontinued within 24 hours of surgery end time

24. Oklahoma Foundation for Medical Quality Duration of Prophylaxis Gastrointestinal Author Drug Duration Infection Strachan 1977cefazolin1 dose3% (biliary)5 days6% placebo17% Stone 1979cefamandole3 doses0 (mixed)5 days3% cephaloridine5 days4% Hall 1989moxalactam1 dose5% (mixed)2 days6%

25. Oklahoma Foundation for Medical Quality Duration of Prophylaxis Cardiac Author Drug Duration Infection Conte 1972cephalothin1 dose10% 4 days9% Goldmann 1977 cephalothin 2 days4% 6 days6% Austin 1980 cephalothin 2 doses11% 3 days9% Geroulanos 1986cefuroxime2 days1.1% cefazolin4 days2.5%

26. Oklahoma Foundation for Medical Quality Duration of Prophylaxis Duration of Prophylaxis Joint Replacement Author Drug Duration Infection Pollard 1979cephaloridine12 hours1.4% (hips)flucloxacillin14 days1.3% Heydemann 1986cefazolin1 dose0 (hips and knees)24 hours1% 48 hours0 7 days 1.5%

27. Oklahoma Foundation for Medical Quality Impact of Prolonged Antibiotic Prophylaxis n 2,641 CABG patients Grp 1 - < 48 hours of antibiotics Grp 2 - > 48 hours of antibiotics n SSI Rates Grp 1 - 8.7% (131/1502) Grp 2 - 8.8 % (100/1139) n Antibiotic resistant pathogen - Grp 2 Odds Ratio 1.6 (95% CI: 1.1-2.6) Harbarth S, et al. Circulation. 2000.

28. Oklahoma Foundation for Medical Quality Antibiotic Prophylaxis Antibiotic Prophylaxis Duration n In summary - Most studies have confirmed efficacy of  12 hrs of prophylactic antibiotics Many studies have shown efficacy of a single dose Whenever compared, the shorter course has been as effective as the longer course and results in less antibiotic resistance

29. Oklahoma Foundation for Medical Quality Surgical Infection Prevention n Besides appropriate antibiotic selection, what else reduces infection?

30. Oklahoma Foundation for Medical Quality HICPAC - SSI Prevention Guidelines - 1999 Category 1 No prior infections15 air changes/hr in O.R. Do not shave in advance 1 Keep O.R. doors closed Control glucose in D.M. ptsUse sterile instruments Stop tobacco useWear a mask* Shower with antiseptic soapCover hair* Prep skin with approp. agentWear sterile gloves* Surgeon’s nails shortGentle tissue handling Surgeons scrub handsDPC for heavily contaminated Exclude infected surgeonswounds Give prophylactic antibioticsClosed suction drains (when used) Pos pressure ventilation in O.R.Sterile dressing x 24-48 hr SSI surveillance with feedback to surgeons 1 Every published study of razor shaving has shown increased infection rates!

31. Oklahoma Foundation for Medical Quality Enhanced Perioperative Glucose Control in Diabetics n 2,467 diabetic patients undergoing cardiac surgery Control group - subcutaneous insulin Treatment group - IV insulin infusion n Results Controls - 2.0% SSI rate (19/968) Treatment- 0.8% SSI rate (12/1499), P=0.01 Furnary AP, et al. Ann Thorac Surg. 2000.

32. Oklahoma Foundation for Medical Quality Perioperative Glucose Control n 1,000 cardiothoracic surgery patients n Diabetics and non-diabetics with hyperglycemia Patients with a blood sugar > 300 mg/dL during or within 48 hours of surgery had more than 3X the likelihood of a wound infection! Latham R, et al. Infect Control Hosp Epidemiol. 2001.

33. Oklahoma Foundation for Medical Quality Temperature Control n 200 colorectal surgery patients control - routine intraoperative thermal care (mean temp 34.7°C) treatment - active warming (mean temp on arrival to recovery 36.6°C) n Results control - 19% SSI (18/96) treatment - 6% SSI (6/104), P=0.009 Kurz A, et al. N Engl J Med. 1996. Also: Melling AC, et al. Lancet. 2001. (preop warming)

34. Oklahoma Foundation for Medical Quality Supplemental Perioperative O 2 n 500 colorectal surgery patients control - 30% FiO 2 intra- and post-op* treatment - 80% FiO 2 intra- and post-op* n Results control - 11.2% SSI (28/250) treatment - 5.2% SSI (13/250), P=0.01 *2 hours postoperatively Greif R, et al. N Engl J Med. 2000.

35. Oklahoma Foundation for Medical Quality Reducing Surgical Infections Reducing Surgical Infections Summary n In addition to usual infection control: Appropriate antibiotic treatment –timing, selection, duration (intra-op dosing for long cases or excess blood loss) Avoid shaving and other HICPAC recommendations Blood glucose control (diabetics and non-diabetics) Temperature control (goal 37°C) Supplemental O 2

36. Oklahoma Foundation for Medical Quality Website Resource www.surgicalinfectionprevention.org

37. Oklahoma Foundation for Medical Quality Performance Improvement for the Surgeon: SIPP and SCPP Surgical Complication Prevention Project  New project being piloted now  More broad than SIPP  Will probably become routine PPI project

38. Oklahoma Foundation for Medical Quality Performance Improvement for the Surgeon: SIPP and SCPP What does this mean for you?  It will improve your patient outcomes  It may satisfy MOC requirements  It may become your hospital’s PPI project  Surgeons should remain quality leaders