1. 1 CDS PROJECT ASSURING APPROPRIATE ADHERENCE AND REPORTING OF ANTIBIOTIC SURGICAL SCIP MEASURE Dave Robbins Lisa Heavilon Wendelyn Bradley Bonnie Livingston

2. Hospital Acquired Infections HAIs in American hospitals: 1.7 million infections and 99,000 deaths each year Of these infections, 22 percent are surgery-related Post-operative infections: Prior to the mid 19th century “irritative fever” common – purulent incisional drainage, sepsis, and often death 1860s - Joseph Lister’s work radically changed surgery from an activity associated with infection and death to a discipline that could eliminate suffering and prolong life

3. GENERAL BACKGROUND Surgical site infection prevention Surgical site infections account for 15% of all hospital- acquired infections Patients who develop surgical site infections are twice as likely to die as other surgical patients Preoperative antibiotics given within 1 hour of incision optimize drug levels in the tissues and are more effective than prophylactic antibiotics administered during or after the operation Appropriately chosen antibiotics provide effective protection against bacteria common at surgical sites without giving excessively broad coverage.

4. Negative Outcome Poorer patient outcomes Increased length of stay Need for additional health care (MD visits, home care, medications) Development of organism resistance Costs HAIs cost up to $45 billion per year Infection control interventions could save approx $31 billion per year CMS refusing reimbursement for post-operative infections Public Perception Published results i.e. Hospital Compare Word-of-mouth

5. PROBLEM DEFINITION Hospital 80% compliant with SCIP Core Measure for antibiotic administration prior to surgical procedures CMS diminished payment due to current compliance number Tedious and time consuming chart review for report generation and submission to CMS Physician frustration IC concern over potential increase of post operative infection rate

6. Goal DEFINITION Improve compliance with antibiotic surgical SCIP measures from 80% to 100% within one year of CDS implementation Reduce CMS non-reimbursable HAI ’ s Automated data, analysis, and presentation reporting Stay current with relevant regulations, standards and benchmarks. –Facilitate HAI mandatory reporting to NHSN –Achieve TJC 2009 National Patient Safety Goals

7. MODEL UTILIZED Alert System [at two clinical junctures] –Use of data elements to include Transactional Temporal Text Data repository for reporting to include –Data Management –Model Management –Knowledge Engine –User Dashboard

8. MODEL KNOWLEDGE Transactional Data Elements Antibiotic Algorithm for Surgical Type Over-ride transaction message CPT/ICD-9=Surgical Type MR # Account # Surgery/Admit Date NDC Antibiotic Administration Date Discharges with an ICD-9-CM Principal Procedure Code or ICD-9-CM Other Temporal Data Elements Antibiotic Administration TimeAntibiotic Administration Time Surgical Incision Time Database Elements Data Base Management Model Management Knowledge engine User Dashboard

9. MODEL KNOWLEDGE Included Populations: ICD-9-CM Principal Procedure Code or ICD-9-CM Other Procedure Code for selected surgical types. Discharges with an ICD-9-CM Principal Procedure Code or ICD-9-CM Other Excluded Populations: Admission DX suggestive of preoperative infectious diseases Antibiotics within 24 hours prior to arrival (except colon surgery patients taking oral prophylactic antibiotics). Readmissions of patients with MDRO history Post-surgical re-admits Micro lab confirmation of reportable diseases Denominator Statement: All selected surgical patients with no prior evidence of infection

10. MODEL-SX-ABX Algorithm HIP/KNEE ARTHROPLASTY Preferred: –Cefazolin (Ancef Æ ) High-risk for MRS (documented) –Vancomycin If Beta-lactam-allergy: –Vancomycin –Clindamycin CV-VASCULAR SURGERY Preferred: –Cefazolin (Ancef Æ ) High-risk for MRS (documented) –Vancomycin If Beta-lactam-allergy: –Vancomycin –Clindamycin Use of Vancomycin for surgical prophylaxis, in the absence of a documented beta-lactam allergy, requires physician documented rationale in the medical record.

11. MODEL-SX-ABX Algorithm COLORECTAL SURGERY-GENERAL SURGERY Cefotetan (Cefotan Æ ) or Cefazolin (Ancef Æ ) and Metronidazole (Flagyl Æ ) Or Ampicillin-sublactam (Unasyn Æ ) Or Ertapenem (Invanz Æ ) as a single dose If Beta-lactam allergy: –Clindamycin combined with Gentamicin or parenteral Fluroquinolone –or AztreonamorMetronidazole (Flagyl Æ ) with Gentamicin or parenteral Fluroquinolone (Levaquin Æ )

12. MODEL FRAMEWORK

13. System Description Key components HIS AIS/OR CPOE (with predefined order templates) PIS ADC (with antibiotic compliance alerts) LIS HAI Monitoring Data Warehouse Integration made possible via HL7 Standard codes CPT, NDC

14. Functional Overview

15. Specialized Antibiotic Alert At the time of dispense the ADC presents an alert if the prescribed antibiotic (based in NDC) does not match the surgical procedure (based on CPT) Anesthesiologist or Nurse may override the alert to dispense the ordered or alternate antibiotic System log is maintained with date/time, user id, NDC and reason for override whenever the alert is triggered

16. Specialized Antibiotic Alert All overrides must be accompanied by a justification Non-conforming antibiotics must be chosen from a predefined list AIS/OR system records date and time of medication administration for comparison against cut time

17. Non-conforming Antibiotic Alert

18. Alert Override Justification

19. Evaluation Overview Core Evaluation Goals – Goal 1: Functional Integrity Assess the CDS to make sure it is functioning as intended. – Goal 2: Intervention Performance Evaluate the performance of the intervention against organizational objectives and industry benchmarks. – Goal 3: Continuous Product Improvement Refine the intervention, keep it up to date, evaluate it in context. 19

20. Goal 1: Functional Integrity Verification: Was the Intervention Built Correctly? –Confirm PFO is displayed under right conditions. –Alerts are fired 100% at correct time, 0% at incorrect time. Validation: Was the Right Intervention Built? –Staff interviews, workshops and surveys. –Observation.

21. 21 Example Industry Benchmarks

22. Goal 2: Intervention Performance Direct Objectives: Increase Compliance with SCIP Guidelines –Appropriate Antibiotic Selection Automated data collection, monthly reporting Compare to monthly trend and industry benchmarks –Timeliness of Antibiotic Administration Automated data collection, monthly reporting Compare to monthly trend and industry benchmarks Indirect Objectives: Decrease Surgical Site Infections –Trend surgical site infections over time –Differentiate from overlapping interventions

23. Goal 3: Continuous Improvement Currency: Keep knowledge up to date Annual knowledge expiration date SCIP Program listserv Receive updates from vendor Refinement: Improve and extend Assess ways to improve efficiency and efficacy with workshops and surveys Evaluate ways to extend the system capabilities to deliver additional value Portfolio Management: Evaluate in Context Evaluate high level goals across specific interventions Plan for future interventions in coordinated fashion

24. CONCLUSION We’ve presented An overview The Model System Description Evaluation Are there any questions?

25. Thanks! Thanks to Gary Larson