1. Surgical Site Infection SUSP Armstrong Institute for Patient Safety and Quality Presented by: Elizabeth C. Wick, M.D. and Deborah B. Hobson, R.N.

2. Understand pathogenesis, monitoring and prevention of SSIs To explore how to implement evidence-based behaviors to prevent SSIs Learning Objectives 2

3. BACKGROUND 3

4. Proportion of Adverse Events Most Frequent Categories Brennan. N Engl J Med. 1991;324:370-376 Non-surgical Surgical 4

5. SSI is the most common nosocomial infection in the surgical patient SSI is the most common complication after colorectal abdominal surgery (3-30%) SSI is associated with increased mortality, length of stay and readmission An SSI costs between $6,200 - $15,000/per patient (superficial- organ space) Background Smith et al, Ann Surg, 2004 Wick et al, Arch Surg, 2011 5

6. 6 Pathogenesis of SSI Bacteria Procedure Host

7. Superficial –purulent drainage from wound –positive wound culture –pain, redness swelling –diagnosis by surgeon Deep –purulent drainage from deep aspect of wound –dehiscence –abscess on exam or CT scan Organ Space –infection in surgical cavity (abdomen) 7 SSI Definitions

8. NEW MANDATORY Monitoring: colon and hysterectomy Rate will be risk adjusted based on age and ASA Deep incisional and organ space rates for colon and hysterectomy will be reported to CMS (required for full payment) Data to be transmitted to CMS late 2012, 2013 Hospital specific standardized infection ratios will be generated for colon and hysterectomy 8 Monitoring: NHSN (CDC-National Healthcare Safety Network) http://www.cdc.gov/nhsn/PDFs/FINAL-ACH-SSI-Guidance.pdf

9. Data –Robust preoperative risk factors for risk adjustment –30-day postoperative mortality and morbidity Program –Costs approximately $30K/year; infection only one of many outcomes studied –Requires full time RN dedicated to data collection AND surgeon champion –Includes annual audit by NSQIP and risk adjusted reports –Option to collect all colon and rectal procedures vs. random sample of surgical procedures 9 Monitoring: NSQIP (National Surgical Quality Improvement Program)

10. SCIP PROCESSES TO PREVENT SSI 10

11. SCIP DataJohns Hopkins Comparison Hospitals Surgery patients who were given an antibiotic at the right time (within one hour before surgery) to help prevent infection 98%97% Surgery patients who were given the right kind of antibiotic to help prevent infection 98% Surgery patients whose preventive antibiotics were stopped at the right time (within 24 hours after surgery) 97%96% Surgery patients needing hair removed from the surgical area before surgery, who had hair removed using a safer method (electric clippers or hair removal cream – not a razor) 100% Patients having surgery who were actively warmed in the operating room or whose body temperature was near normal by the end of surgery. 98%99% Johns Hopkins Hospital. May 2010 SCIP, Hospital Compare, www.medicare.gov Does SCIP Give Us Enough information? 11

12. Problem : Penicillin-allergic patients undergoing colorectal surgery were not receiving proper prophylactic antibiotics (Clindamycin and Gentamycin). Johns Hopkins CUSP Experience: Room for Improvement in SCIP Compliance 12

13. Antibiotic Compliance Project Johns Hopkins Interventions Increased amount of gentamicin available in the room Added dose calculator in anesthesia record Educated surgeons, anesthesia, and nursing in Wick et al, JACS 2012 (in press) 13

14. Antibiotics practices All cases (n = 3002) number (%) Nonemergency (n = 2743) number (%) Emergency cases (n = 248) number (%) Was an SCIP-compliant antibiotic chosen? 2,431 (81.4%)2,293 (83.6%)130 (52.4%) Was antibiotic given within 1 h before incision? 2,712 (90.8%)2,544 (92.7%)159 (64.1%) Antibiotics weight-adjusted (n = 972)552 (56.8%) Antibiotics redosed (n = 398)24 (6.0%) Total surgical site infection269 (9.0%)245 (8.9%)24 (9.7%) 14 Perioperative Antibiotic Compliance: Michigan Surgical Quality Collaborative Hendren et al. Am. J Surg 2011

15. Problem: Patients arrive in the recovery room with temperature < 36°C despite having a forced air warmer during surgery Johns Hopkins CUSP Experience: Room for Improvement in SCIP Compliance 15

16. Normothermia Project Johns Hopkins Interventions Confirmed that temperature probes were accurate (trial comparing foley and esophageal sensors) Initiated forced air warming in the pre-operative area Heightened awareness 16 Wick et al, JACS 2012 (in press)

17. EMERGING EVIDENCE FOR SSI PREVENTION 17

18. 1.Antibiotic Usage –Redosing –Weight based dosing of cephalosporins 2.Maintenance of normogylcemia 3.Utilization of mechanical bowel preparation with oral antibiotics 4.Standardization of skin preparation 18 Emerging Evidence for SSI Prevention

19. Antibiotic Redosing –Maintain therapeutic antibiotic serum levels during entire procedure 19 Additional Interventions to Improve Antibiotic Efficacy Consensus Guidelines, in press IDSA/SIS/SHEA/AHPS

20. BACKGROUND: Hyperglycemia is common in hospitalized patients 38% of medical and surgical patients had hyperglycemia (26% diabetic and 12% non-diabetic In cardiac surgery, degree of post- operative hyperglycemia correlates with SSI; adopted as SCIP measures GOAL: Glucose <180mg/dl in all hospitalized patients 20 Hyperglycemia and Infection Ramos. Ann Surg 2008

21. BACKGROUND 10 12 Bacteria reside on the skin Staphlococcus and Streptococcus species among others GOAL OF SKIN PREPARATION Reduce bacterial burden on skin prior to incision BEST PRACTICE Dual-agent skin preparation (chlorhexidine + alcohol, providone-iodine +alcohol) Skin prep should include alcohol to increase durability of sterilization Prep should be applied to specification (duration and amount) Prep must dry before incision 21 Preparation of the Surgical Site Darouiche RO et al. N Engl J Med. 2010 Swenson BR et al. Infect Control Hosp Epidemiol. 2009

22. Oral antibiotics for prevention of SSI was first described in the 1940’s 1973 Nichols and Condon FAVORABLE 1974 Washington et al randomized trial FAVORABLE 1990’s-2000’s oral antibiotics fell out of favor in US –Patients not tolerant of preparation (nausea, dehydration) 2002 Lewis et al –Randomized controlled trial –Oral neomycin and metronidazole plus systemic antibiotics vs systemic antibiotics alone (5% neomycin and metronidazole vs 17% placebo) 22 Bowel Preparation: A Brief History Reviewed in Fry, 2011.

23. Bowel Preparation: A Brief History Rigorous studies of IV antibiotics did not include oral antibiotics 1990’s-2000’s oral antibiotics fell out of favor in US –Patients not tolerant of preparation (nausea, dehydration) –Patients no longer admitted to hospital pre-operatively Lewis et al (2002) –Randomized controlled trial –Oral neomycin and metronidazole plus systemic antibiotics vs systemic antibiotics alone (5% neomycin and metronidazole vs 17% placebo) 2012 –AHPSA guidelines on antimicrobial prophylaxis endorse use of oral antibiotics with mechanical bowel preparation plus IV antibiotics to prevent SSIs 23 Reviewed in Fry, 2011.

24. Cochrane Review: Oral Antibiotics + Bowel Preparation is Associated with Lowest SSI Rate 24 1 Guenega, Cochrane Database Syst Rev,2009 2 Nelson, Cochrane Database Syst Rev,2009 Slide adapted from Patch Dellinger, MD University of Washington SSI Rate Nelson Study 1 Guenaga Study 2 SSI Rate MBP + oral + parenteral MBP - no oral + parenteral MBP + + parenteral No MBP + + parenteral MBP = Mechanical Bowel Preparation

25. Appropriate prophylactic antibiotics –Selection* –Weight-based dosing of cephalosporins –Timing* –Redosing –Discontinuation* Appropriate hair removal as close to time of surgery as possible* Temperature management* Appropriate glycemic control Dual agent (with alcohol) surgical skin prep Mechanical bowel prep and oral antibiotics Summary of SCIP and Emerging Evidence to Prevent Colorectal SSIs *SCIP measures 25

26. Review current colorectal SSI bundles at your hospital (policy and practice) Review hospital process measure data With assembled CUSP team, plan for administration of staff safety assessment Next Steps 26

27. Who’s on the call? 27 Poll

28. Does your hospital have a colorectal SSI bundle in place? 28 Poll

29. If your hospital has a colorectal SSI bundle in place, what’s in it? 29 Poll

30. On-boarding Call Evaluation We want to ensure that the on-boarding calls provide useful and pertinent information for the SUSP teams. For this reason we request that you complete a brief evaluation following each call. The evaluation may be found at the following link: https://www.research.net/s/susp_cohort_3 If you are not able to reach the link from the slide, please cut & past the URL into your browser. Armstrong Institute for Patient Safety and Quality 30