1. Implementing Evidenced Based Practices to Reduce Surgical Site Infections Mary R. Nicholson RN, BSN CIC The Christ Hospital Cincinnati, Ohio

2. THE CHRIST HOSPITAL CINCINNATI, OHIO

3. TCH Statistics 555 bed tertiary care hospital 25,840 admissions year 44 ICU beds; ADC of 36 Services: Cardiac surgery (CVS), Orthopedic, Oncology, Neurosurgery, OB-Gyn, Renal Transplant, Medicine, and Pulmonary Internal Medicine Residency Program US News and World Report rankings (2006) Cardiac = 21st Neurological/Neurosurgery = 36 th Respiratory disorders = 38th Digestive Disorders = 50 th

4. Pre-operative Nasal Screening

5. Staphylococcus aureus The most common pathogen causing SSI is Staphylococcus aureus (S.aureus) S.aureus is endogenous to the human body with the primary site of colonization the anterior nares; and ~ 25-30% of the population may be colonized with S.aureus at any given time. Weinstein (1959) noted there was a correlation between S.aureus and all types of SSI. Kluytmans et.al., (1996) showed a study, preoperative nasal carriage was the most important risk factor of SSI. Carriers of S aureus are 2-9 times more likely as non- carriers to have SSI

6. Mupirocin usage Perl et. al., (2002) conducted a randomized double blinded placebo controlled trial to determine whether intranasal mupirocin reduces the rate of S. aureus infections at surgical sites and prevents other nosocomial infections 4030 patients were enrolled who underwent CVS, general surgery, neurosurgery, gynecologic procedures. 891 patients who had S aureus in their anterior nares, 444 received mupirocin and 447 placebo Among the patients with S aureus nasal carriage 4.0% who received mupirocin had nosocomial S.aureus infections as compared with the 7.7% who received placebo Concluded mupirocin significantly reduced the rate of nosocomial infections due to S aureus, specifically among patients with nasal carriage of S aureus, the group expected to be at increased risk

7. Cardiac surgery (CVS) population Prior to the study period ( Jan 02- April 03), the overall CVS SSI rate was 1.89% (18 infections per 954 procedures performed); MRSA non-surgical isolates occurred in ~ 11 patients each year Total joint patients In 2004, there was an increase in total joint SSIs with an associated rate of 1.49% (8/543). We determined: 5/8 of the SSI were deep infections and were caused by S. aureus (with 3/5 of the isolates MRSA). The patients and OR team members underwent nasal cultures to rule out S. aureus nasal colonization. 4 patients and one OR team member were identified as nasal carriers Hospital Stats

8. Culture method For the study, patient anterior nares were cultured preoperatively using the Oxoid Penicillin Binding Protein Latex agglutination test This screening test selects for S aureus and reports both methicillin sensitive and resistant isolates

9. Patient Protocols CVS patients Cultured as they entered the Surgery Followed by an intranasal mupirocin application to each nares. The mupirocin application is continued every 12 hours until the culture results were available. If the culture is positive for S. aureus, mupirocin is continued for a total of 14 doses; If the culture is negative, mupirocin is discontinued. Orthopedic patients Cultured at the time of Preadmission testing (PAT) Culture results were reviewed and only SAS/MRSA carriers are treated with mupirocin

10. Treatment of Orthopedic carriers: S. aureus sensitive patients Receive intranasal mupirocin BID for 7 days IV cephazolin or clindamycin is administered as pre- operative surgical antimicrobial prophylaxis Methicillin resistant S. aureus (MRSA) patients Receive intranasal mupirocin BID for 7 days Patients are instructed to shower with CHG soap IV vancomycin is administered as the pre-operative surgical antimicrobial prophylaxis Patients are placed in Contact isolation upon admission to the hospital and continues until patient’s culture results return negative after completing treatment. Follow-up cultures are obtained in surgeon’s office

11. CVS Patient Statistics During the study period, a total of 1077 procedures were performed including coronary bypass (CABG), internal mammary artery (IMA), heart valve and vascular procedures. Antimicrobial prophylaxis included cefazolin, cefuroxime and vancomycin

12. CVS Infections: Pre and post mupirocin Since implementation of mupirocin: Seen an 80 % reduction in S.aureus associated SSI 1.67% vs 0.34% (p<0.001) Seen an 79% reduction in deep sternal infections 1.15% vs 0.25% (p<.002) Elimination of MRSA in non-surgical isolates

13. Orthopedic Patient Culture Results (Dec 04 – Dec 05) 27% of patients were identified as S aureus carriers at the time of PAT

14. Orthopedic Infections Pre-mupirocin and Post-mupirocin We observed zero (0) deep S. aureus associated SSI and one superficial SSI over a 19-month period as compared with the historical rate of 1.64% (p< 0.05).

15. Pre-operative Antibiotic Prophylaxis Timing

16. In the fall 2003, in Cincinnati, there was a 10 hospital city wide Patient Safety Project initiated spearheaded by Dr. Marta Render (VA hospital). A grant was awarded by the Agency for Healthcare Research and Quality (AHRQ). The focus of the grant was to reduce nosocomial infections by implementing evidenced based practices in high risk areas (OR and ICUs) and to measure relevant outcomes including compliance with practice standards, reduction in infections and economic benefits. This project involved multi- disciplinary teams at each hospital. Phase 2 of the project focused on improving the timing of pre-operative antibiotics at our hospital Our baseline antibiotic timing data ranged from 49-80% compliance with meeting the recommended time frames Patient Safety Initiative

17. New Change Model - Repeated Use of the PDSA Cycle (plan, do, study results and then act) Starting with Hunches Theories Ideas Changes That Result in Improvement AP SD A P S D AP SD D S P A DATA Very Small Scale Test Follow-up Tests Wide-Scale Tests of Change Implementation of Change ©2001 Institute for Healthcare Improvement

18. Patient Safety Initiative At the Kick-Off meeting the team members: Developed an aim statement Developed measures Planned 1 st two tests of change and developed timeline AIM STATEMENT: We will achieve 100% compliance with timely administration of recommended antibiotic prophylaxis administration by the end of 2005, in an effort to decrease SSI for our patients

19. Patient Safety Initiative SDS staff completes SDS part of data form, hangs and begins the antibiotic based on start time of the procedure and sends patient to OR OR staff completes OR part of form and notes incision time. Form is taken to front desk for pick-up and tabulation by infection control dept. At BEST – administration of antibiotic within 60 minutes of the incision time was about 75% 1 st test: SDS nurses giving ATB

20. Patient safety initiative Monthly the hospitals came together at the GCHC Sharing of data at the monthly hospitals meeting Discovered most successful teams involved the collaboration between OR staff/anesthesia in the administration of the antibiotics Took information back to the OR/SDS groups

21. Patient Safety Initiative SDS nurses primed and hung the ATB but did not administer the ATB (except Vanco and those needed to be infused over 60 minutes) Pharmacy verified infusion times OR nurses began the antibiotic as the patient entered the OR suite; then record the dose and return form to front desk Significant findings: There were patients whose time between ATB dose and cut time was >50 minutes Positioning and Prepping patients does impact the start time of the cases 2 nd TEST: OR nurses give the ATB

22. Patient Safety Initiative Continued with tests of changes as we rolled out the process thru the specific surgical services Data was tabulated and shared with the OR staff by posting compliance outside each specialty’s rooms There were also brief 10-15 minute weekly meetings to discuss successes and challenges Continued to meet monthly with other hospitals involved in the safety initiative

23. Patient Safety Initiative Data was taken back to OR to show higher success rates with Circulating RN administered the antibiotic Continue two more time periods before moving on to other rooms Having OR nurses administer antibiotic appears to be the most successful ( 2 weeks at 100% for Orth rooms) Shared the results via graphs with SDS and OR team members Planned next service to implement the practice change. Learnings

24. Patient Safety Initiative Celebrations and incentives: luncheons, awards, gift certificates, tee-shirts Goal was to roll–out to all of the OR rooms (main unit) by end of August; Sept 05- practice change began in the Gyn surgery unit (8N) Began to address in-patients and deleting “on-call dosing” orders Attended nsg leadership meetings to present the progress Developed education and hospital policy: OR nurse to start all other antibiotics. By October 2005, project was implemented in the entire OR – 2 months ahead of schedule NaviCare system went “live” to document electronically and forms eventually eliminated

25. Patient Safety Initiative June 05 –Dec 06 Data includes antibiotic dosing for over 13K patients Antibiotic Timing compliance thru December 2006

26. Impact on SSIs

27. What we learned Engaging front line staff makes new processes successful Using the PDSA cycle to roll the process out was helpful Frequent reporting/display of results keep the focus on the goals Developing a policy based on successes ensures higher compliance

28. Awards and Publication 2004 Sodexho Health Care Services Honorable Mention :Spirit of Excellence Award JCAHO: Codman Award for GCHC Patient Safety Initiative Nicholson, MR and Huesman LA. Controlling the usage of intranasal mupirocin does impact the rate of Staphylococcus aureus deep sternal wound infections in cardiac surgery patients. Am J Infect Control 2006; 34(1):44-48. Midwest Nursing Research Society Annual Meeting April 2006 Poster presentation: Milwaukee APIC Blue Ribbon Abstract Award 2006: Tampa American Society of Orthopedic Surgeons Annual Conference: February 2007 Anthem’s Meritorious Award March 2007