1. The Bundle Approach to Reducing Surgical Site Infections Virginia Lipke, RN, BS, ACRN, CIC Infection Control Practitioner The St. Luke Hospitals Ft. Thomas and Florence, Ky. September 9, 2008

2. S T. L U K E H O S P I T A L S OutlineOutline  Introduction to St. Luke Hospitals  Standardizing Care  Bundles in general are evidence based  Impact of IHI 100,000 Lives Campaign  Surgical Site Infection Risks & Considerations  Surgical Volume  Targeted Infection Control Surveillance  MRSA Bundle as an example  Focus on Value of Bundle and Process

3. S T. L U K E H O S P I T A L S About St. Luke Hospitals  St. Luke Hospital – East: 310 bed facility located in Ft. Thomas, KY  St. Luke Hospital – West: 177 bed facility located in Florence, KY St. Luke Hospitals, Inc. (SLH) consist of two community facilities:

4. S T. L U K E H O S P I T A L S Standardizing Care  General agreement that standardization of care will improve efficiency of care and result in better outcomes  IHI (Institute of Health Improvement) 100,000 Lives Campaign  Directed standardization of care Rapid Response Teams Medication Reconcilliation Ventilator-Associated Pneumonia Bloodstream Infections AMI SSI  Creation and implementation of bundles or care paths facilitated care for these initiatives

5. S T. L U K E H O S P I T A L S Methodology for Bundle Development  Identify need and create clinical and business case  Secure administrative support and medical staff buy-in through communication at various clinical committees  Define the process and protocol for the bundle  Complete implementation of the bundle  Continued monitoring and evaluation

6. S T. L U K E H O S P I T A L S Leveraging Findings for Organizational change  Present findings to all committees  Suggest protocol and practice changes  Secure physician champions  Bring in local talent to help  Do your own study and share results  Know the community standard

7. S T. L U K E H O S P I T A L S Sustaining Impact and Results  Ongoing monitoring  Quantify results clinically and financially  Communication of results to all stakeholders  Reinforce education  Physicians, clinical staff & patients  Revisit community and national data

8. S T. L U K E H O S P I T A L S Adoption of Protocols and Bundles at St. Luke Hospitals  Employing a systematic approach and following a set methodology for protocol and bundle implementations resulted in success and credibility  Pneumococcal Vaccination  IHI 100,000 Lives Campaign Initiatives  Mentor status for 4 of the initiatives  Significant decrease in non-ICU codes  No Ventilator Associated Pneumonia in 34 months  IHI 5 Million Lives Campaign  DVT Protocol implementation December 2008

9. S T. L U K E H O S P I T A L S Surgical Site Infections (SSIs): Magnitude of the Problem  1996: 28.4M ambulatory surgery procedures in the U.S.(CDC, National Center for Health Statistics)  2003: 30.8M inpatient surgical procedures and 9.7M (37%) of those performed on patients >65 years (CDC,National Center for Health Statistics)  NNIS: SSIs occur in 2.6%¹ of all surgeries = 1.5M SSIs annually  Attributable cost: $25,5246 (range $1,783 - $134,602)² 1.Mangram,AJ,et al.,Guidelines for the Prevention of Surgical Site Infections,1999,CDC. 2.Stone,PW et al.,Am J Infect Control,2005 2.Stone,PW, et al.,Am.J.Infect.Control,2005;33(9):501-9

10. S T. L U K E H O S P I T A L S SSI Risk Factors for the Patient  Age  Nutritional Status  Diabetes  Nicotine Use  Obesity  Coexisting Infection  Altered Immune Response  Long Preoperative Stay

11. S T. L U K E H O S P I T A L S Risk Factors for SSI: Pre-and Intraoperative  Inappropriate use of antibiotic prophylaxis  Infection at remote site  Shaving versus clipping or no hair removal  Improper skin preparation  Improper hand antisepsis by operating room team  Long duration of surgery  Surgical attire and drapes  Environment of room, (ventilation & sterilization)  Surgical technique: homeostasis, sterile field, O2

12. S T. L U K E H O S P I T A L S Surgical Care at St. Luke Hospitals  Routine monitoring and surveillance  Identification of risk associated with MRSA  Business case for MRSA bundle  Implementation of bundle  Evaluating impact of bundle

13. S T. L U K E H O S P I T A L S Surgical Volume and Infection Control Monitoring  Total Surgeries  Over 10,000 cases per year  Targeted Surveillance  C-Sections  Total Hips  Total Knees  Gastric By-pass and Bandings  Fusions  Craniotomies  Overall infection rates are low

14. S T. L U K E H O S P I T A L S SLH SSI Rate

15. S T. L U K E H O S P I T A L S Internal & External Data  Lab reports and testing methods  Past years IC report compared to NNIS  Antibiograms for the past years  Literature searches-beware of old data and be open to new data  What is our current practice?  What new surgical services are we adding?  What are the risks?

16. S T. L U K E H O S P I T A L S Why Should Hospitals Place Greater Emphasis on How Skin is Prepped?  When we consider pathogenesis of SSI, it has been accepted for decades that most SSI are endogenous in nature.  Usual Suspects  S. aureus  Co Ag Negative Staph  E.coli  K.oxytoca  S.pneumonaie  P.aeruginosa  S.marcescens

17. S T. L U K E H O S P I T A L S St. Luke Hospitals Emergency Department visits where MRSA was noted for skin and soft tissue infections:  8 MRSA-related Surgical Site Infections (SSIs) in CY2006 (47% of total SSIs); 0 in previous years  Increased awareness by Emergency, Obstetrics, and Surgery Practitioners Community & Hospital Impact 2003200420052006 173244504660

18. S T. L U K E H O S P I T A L S Projected Cost of MRSA Bundle Site CY2006 Elective Surgical Volume via PAT Lab Test and CHG Costs Mupirocin Costs (based on 5% MRSA(+) rate) Total Annual Projected Costs St. Luke East3400 $13.83 ($12.00+$1.83) $6,460$53,482 St. Luke West3500 $13.83 ($12.00+$1.83) $6,650$55,055 St. Luke Hospitals 6900 $13.83 ($12.00+$1.83) $13,110$108,537 Potential SSI Cost Avoidance (based on CY2006 numbers): 5 SSI cases at $40,000 2 = $200,000 2 Engemann, Clin.Inf.Dis 2003;36:592-598. Nicholson, AJIC 2006;34:44-48.

19. S T. L U K E H O S P I T A L S SLH MRSA Bundle  Nasal cultures on all surgical patients in pre-admission testing (PAT) and hospital-based OB patients at 36-week visit  All pre-admission surgical patients given 2% CHG (chlorhexadine) bathing cloths for use the day of surgery; expecting mothers have 2% CHG cloths applied prior to delivery  If patient is MRSA positive, 2% Mupirocin is applied to both nares prior to surgery  MRSA (+) patients are provided with educational brochure – “Living with MRSA” 1 1 Resource created by Washington State Public Health Department

20. S T. L U K E H O S P I T A L S Implementing the MRSA Bundle  Nasal swab training for PAT and hospital-based OB staff  Coordination w/ lab  Coordination w/ pharmacy  Communication plan for result notification  Data tracking and monitoring  Patient education  Staff education  Physician education

21. S T. L U K E H O S P I T A L S TimelineTimeline Review of existing best practices; clinical and financial impact analyses completed October 2006 CA-MRSA is noted to be impacting SSI rates November- December 2006 Proposed MRSA Bundle presented to various clinical committees December 2006- January 2007 MRSA Bundle standing orders approved by Medical Executive Committee January 2007 Letters are sent to Medical Staff proposing MRSA Bundle protocol February 2007 All pre-admission testing and hospital-based OB patients are screened for MRSA March 2007 Surgery Committee proposes single dose of Mupirocin for patients whose lab results are not available prior to surgery May 2007 1 MRSA-related SSI in initial nine months of program November 2007

22. S T. L U K E H O S P I T A L S SLH MRSA Bundle Process

23. S T. L U K E H O S P I T A L S Results and Impact  Screening of all surgery patients who go through pre-admission testing (~ 65 % of all surgeries)  Screening of all OB patients from St. Luke Physicians for Women Service (~ 60% of all deliveries)  Percentage of surgery patients with positive MRSA culture: 3.9%  March – December  Two Surgical Site Infections One MRSA SSI (C-Section)

24. S T. L U K E H O S P I T A L S Results and Impact St. Luke Hospitals Combined Surgical MRSA Culture Activity

25. S T. L U K E H O S P I T A L S Barriers and Challenges  Regular cultures have 2 day turn-around time  Patients having pre-admission testing less than 48 hours prior to surgery (culture results not available)  Investigation into current lab collection and transport processes  Timely communication with physician about positive results  Questions about treatment for colonized MRSA  Some physicians wanting to treat all colonization with vancomycin  Patient’s reaction to positive culture results

26. S T. L U K E H O S P I T A L S Where Do We Go From Here?  Ongoing analysis of impact  Continue to educate physicians about treating their patients with MRSA  Continued education to patients and community about preventing and living with MRSA  Expand scope of program to include inpatient and emergent surgery cases with possible expansion to all new admissions  Consider utilization of a rapid screen test  Evaluation and consideration of protocol revisions

27. S T. L U K E H O S P I T A L S Our Goal… Drive to Zero!!

28. S T. L U K E H O S P I T A L S QuestionsQuestions Ginny Lipke (859) 572-3688 Virginia.Lipke@healthall.com