1. Surgical Infection Prevention Team Members: Anesthesia: W. Scott Jellish - chair, Maureen Kawka, Joe Rinehart Infectious Disease: Paul O’Keefe, Chris Schriever Surgical Services: Jeri Katsaros, Margaret Vorrier Labor & Delivery: Maureen Davey Quality Resource Management: Mary Altier, Carmen Barc, Vada Grant Infection Control: Jayne Haake CCE: William Barron, LuAnn Vis, Michael Wall

2. Opportunity Statement Surgical site infections are a major complication after surgery, resulting in considerable morbidity, mortality, and resource utilization. Proper use of antibiotics – giving the right drug at the right time – is effective in preventing infections after surgery Project Goals: To achieve 100% compliance for the following measures: 1.Administer antibiotics within one hour before surgical incision 2.Administer the appropriate antibiotic 3.Stop antibiotics within 24 hours after surgery

3. Targeted Surgeries  Abdominal and Vaginal Hysterectomy  Hip and Knee Replacement  Cardiac Bypass  Other Cardiac Surgery  Vascular Surgery  Colon Surgery

4. Solutions Implemented in 2005  Data collection processes completely overhauled  Restructured data collection to CMS/JCAHO specifications  Monthly chart audits (50-70/month) by RN Quality Specialists  Forwarded data to UHC for “practice” and benchmarking  Began abstracting additional SIP measures – glucose control, hair removal, normothermia  Communication with key stakeholders  Overall results available on luhs.org  Department specific results available on internal website

5. Barriers Addressed  Adjusted post-operative orders for antibiotic discontinuation  Focused efforts with Orthopaedic NP to improve SIP-3  Shared patient/MD level data  Forwarded endorsement from American Academy of Orthopaedic Surgeons  Engaged colon surgery physician leader  OR management team focused on appropriate hair removal  Improved access to clippers  Removed razors from OR – only available through case carts

6. LUMC patients who receive prophylactic antibiotics within 60 minutes prior to surgical incision UHC Rate: 77%

7. LUMC patients who receive prophylactic antibiotics consistent with current CMS guidelines UHC Rate: 89%

8. LUMC patients who have prophylactic antibiotics discontinued within 24 hours after surgery end Orthopedic NP involvement and order changes UHC Rate: 61%

9. Next Steps: Where do we go from here?  SIP-1:  Individual feedback (letters) concerning protocol noncompliance to Anesthesiologists, Residents, & CRNA’s  Incorporate prompt for antibiotic administration during the time- out  Signage prompts at OR doors and Pharmacy  SIP-2:  Awaiting response for Vancomycin use in CV valve cases  SIP-3:  Collect CV data for 48 hour discontinuation  Brainstorm improvement opportunities with CV Nurse Practitioners and General surgeons (colon surgeries)

10. Next Steps: Where do we go from here?  Engage Operating Room staff and OR Pharmacy in improvement efforts  Initiate use of UHC online tool and sampling process to assist with data collection of the extended measure set  Glucose control  Hair removal  Normothermia  SSI rates  Submit SIP-1 measure to CMS