1. The Cardiac Surgery Translational Study (“CSTS”) The Quality And Safety Research Group Surgical Site Infection Prevention Elizabeth Martinez, MD, MHS emartinez10@partners.org March 18, 2011 Immersion Calls

2. Slide 2 Immersion call Schedule TitleDate /Time 13:00 EST Presented by Program Overview Feb 18, 2011Peter Pronovost MD PhD Science Of Safety February 25, 2011Jill Marsteller, PhD, MPP Comprehensive Unit-Based Safety Program CUSP March 4, 2011Christine Goeschel MPA MPS ScD RN Central Line Blood Stream Infection Elimination March 11, 2011David Thompson DNSC, MS Surgical Site Infection Elimination March 18, 2011Elizabeth Martinez, MD, MHS Ventilator-Associated Pneumonia Reduction March 25, 2011Sean Berenholtz, MD Hand-Offs: Transitions in Care April 1, 2011Ayse Gurses, PhD Data we Can Count on April 8, 2011Lisa Lubomski, PhD. Team Building April 15, 2011Jill Marsteller, PhD, MPP Physician Engagement April 22, 2011Peter Pronovost, MD, PhD

3. Slide 3 CSTS Timeline Planned Roll-out – CLABSI Prevention interventions and monthly data collection: June, 2011 – SSI Prevention interventions and monthly data collection: Approximately September 2011 – VAP Prevention and monthly data collection: After December 2011

4. Slide 4 Learning Objectives To understand the model for translating evidence into practice To explore how to implement evidence-based behaviors to prevent SSI To understand strategies to engage, educate, execute and evaluate

5. Slide 5 Proportion of Adverse Events Most Frequent Categories Brennan. N Engl J Med. 1991;324:370-376 Non-surgical Surgical

6. Slide 6 Introduction Over 300,000 CABG annually SSI rates 3.51% (10,500 annually) – 25% mediastinitis – 33% saphenous vein site – 6.8% multiple sites Increased mortality:17.3% v. 3.0% (p<0.0001) Increased LOS: 47% v 5.9% with LOS>14days (p<0.0001) Increased cost: $20,000 to $60,000 Fowler et al..Circ, 2005:112(S), 358.

7. Slide 7 Background: An Example of Surveillance Methodology National Healthcare Safety Network (NHSN) Formerly NNIS National Healthcare Safety Network surveillance CDC program that reports aggregated surveillance data from ~thousands of US hospitals hospitals/mandated for certain infections in order to receive full Medicare payment Standard case-finding (by ICD-9 code), definitions for infection, and risk-stratification methodology Pooled mean and standard deviation reported for surgical procedures SSIs can develop up to 1-year postop ‘hardware’ = sternal wires

8. CABG SSI Risk Model* Preop Age Obesity Diabetes Cardiogenic shock Hemodialysis Immunosuppression Intraop Perfusion time Placement of IABP ≥ 3 anastomoses *Did not include known best practices (e.g. SCIP) Fowler et al..Circ, 2005:112(S), 358.

9. Slide 9 Traditional SSI Risk Factors Intrinsic-Patient Related Age Nutritional status Diabetes Smoking Obesity Remote infections Endogenous mucosal microorganisms Altered immune system Preoperative stay-severity of illness Wound class

10. Slide 10 Translating Evidence into Practice Pronovost, Berenholtz, Needham. BMJ 2008

11. Slide 11 Evidence Based Practices that Reduce risk of SSIs* Appropriate prophylactic antibiotics – Selection – Timing (and redosing) – Discontinuation Appropriate hair removal as close to time of surgery as possible: – Don’t remove hair unless necessary; If you remove hair - Don’t shave. Can use clipper/depilatory (AVOID razors) Normothermia in non CPB cases Appropriate glycemic control ************************************************************* Chlorhexidine surgical skin prep (used appropriately) *SCIP measures

12. Slide 12 Your Hospitals’ Performance* www.hospitalcompare.hhs.gov; Accessed 3/5/2011 *summarized (estimate) data for all surgical procedures from all participating Institutions as of 3/31/2011

13. Slide 13 Ensure Patients Reliably Receive Evidence SeniorTeam Staff leaders Engage How does this make the world a better place? Educate What do we need to do? Execute What keeps me from doing it? How can we do it with my resources and culture? Evaluate How do we know we improved safety?

14. Slide 14 TRiP: Model to Improve Pick an important clinical area Identify what should we do – principles of evidence-based medicine Measure if you are doing it Ensure patients get what they should – Education – Create redundancy – Reduce complexity/standardize Evaluate whether outcomes are improved

15. Slide 15 Systems Approach Every system is perfectly designed to get the results that it gets. - Bataldan If you want to change performance you need to change the system.

16. Slide 16 Science of Safety Accept that we will make mistakes Focus on systems, including interpersonal communication, rather than people Largest barrier is lack of awareness evidence exists Standardize to reduce complexity Create independent checks

17. Slide 17 Eliminating SSI Apply best practices –If hair is removed, use clippers or depilatory –Appropriate antibiotics Choice Timing Discontinuation –Perioperative normothermia –Glycemic control Decrease complexity Create redundancy

18. Slide 18 Tips for Success Engage –Make the problem real –Publicly commit that harm is untenable Educate Execute –Culture, complexity and redundancy –Regular team meetings Evaluate –Measurement and feedback –Recognition and visibility –Celebrate your successes

19. Slide 19 Engage Make the problem real –Share local infection rates –Share local compliance with process measures –Share a story of a patient with SSI Have the patient share their story Publicly commit that harm is untenable –Institutional commitment –Champions within the OR and the ICU and floor teams –Partnership with Infection Preventionist

20. Slide 20 Educate –Develop an educational plan to reach ALL members of the caregiver team –Educate on the evidence based practices AND the data collection plan and other steps of the process. –Use posters to educate the teams about the evidence-based process measures

21. Avoid Razors Avoid Hypothermia Give Correct Antibiotics Give Antibiotics at the Right Time Redose Antibiotics Appropriately Antibiotics at 24 Hours *Within 60 minutes prior to incision

22. Slide 22 Perioperative SSI Process Measures Quality IndicatorNumeratorDenominator Appropriate antibiotic choiceNumber of patients who received the appropriate prophylactic antibiotic All patients for whom prophylactic antibiotics are indicated Appropriate timing of prophylactic antibiotics Number of patients who received the prophylactic antibiotic within 60 minutes prior to incision All patients for whom prophylactic antibiotics are indicated Appropriate discontinuation of antibiotics Number of patients who received prophylactic antibiotics and had them discontinued in 24 hours All patients who received prophylactic antibiotics Appropriate hair removalNumber of patients who did not have hair removed or who had hair removed with clippers All surgical patients Perioperative normothermiaNumber of patients with postoperative temperature ≥36.0 o C Patients undergoing surgery without CPB/planned hypothermia Perioperative glycemic controlNumber of cardiac surgery patients with glucose control at 6AM pod 1 and 2 Patients undergoing cardiac surgery

23. Slide 23 Execute Culture – Develop a culture of intolerance for infection Standardize/Reduce complexity of the process – Checklists -Confirm abx administration during briefing – Utilize glycemic control protocol – Local antibiotic guidelines posted in Ors – Standardize surgical skin prep Redundancy – Add best practices to briefing/debriefing checklist – Post reminders in the OR (White board) – Antibiotic timer program for redosing Regular team meetings – Develop a project plan – Identify barriers

24. Slide 24 Evaluate Track compliance with SCIP measures – Performance measures already being tracked by hospitals as part of SCIP participation* – Post performance on monthly basis Post in the OR, ICU and floor Investigate non-compliant cases on a monthly basis – Use Learning from Defect (LFD) tool Post SSI rates on a monthly/quarterly basis – Investigate each SSI with the CUSP team to identify areas for improvement using the LFD tool Audit performance with skin prep methodology (at a minimum) and goal is conversion to chlorhexidine *based on data availability on Hospital compare

25. Slide 25 Share Results

26. Slide 26 Acknowledgements Deborah Hobson, BSN Pamela Lipsett, MD Sara Cosgrove, MD Lisa Maragakis, MD Trish Perl, MS Matthew Huddle, BS Nicole Errett, BS Justin Henneman, BS The Johns Hopkins SSI Prevention Collaborative teams

27. Thank You! Elizabeth Martinez, MD, MHS Massachusetts General Hospital, Harvard University emartinez10@partners.org QUESTIONS?