1. Building your SSI Prevention Bundle
Armstrong Institute for Patient Safety and Quality
Presented by: Elizabeth C. Wick, M.D. /Brad Winters, M.D.
DRAFT – final pending AHRQ approval

2. Learning Objectives
Develop and implement an SSI reduction goal and prevention bundle that addresses up to three surgical care processes that your team feels needs to be improved to address SSIs
Understand how to use the results of your staff safety assessment to build a bundle
Review how to initiate audits of your processes
Create a performance goal (improvement in outcome) for your team
Learn how to proceed with improvements that do not have a strong evidence base
Locate SUSP resources on the project website
DRAFT – final pending AHRQ approval

3. Background
SSI is the most common nosocomial infection in the surgical patient
SSI is the most common complication after colorectal abdominal surgery (3-30%)
SSI is associated with increased mortality, length of stay, and re-admission
An SSI costs between $6,200-$15,000/per patient (superficial-organ space)
DRAFT – final pending AHRQ approval

4. SSI Definitions Superficial Deep Organ Space
-Purulent drainage from wound
-Positive wound culture
-Pain, redness swelling
-Diagnosis by Surgeon
Deep
-Purulent drainage from deep aspect of the wound
-Dehiscence
-Abscess on exam or CT scan
Organ Space
-Infection in the surgical cavity (abdomen)
DRAFT – final pending AHRQ approval

5. Colorectal Surgery Readmissions/Johns Hopkins Hospital
Readmission rate 17.6% ( )
DRAFT – final pending AHRQ approval

6. Pathogenesis of SSI Host Bacteria Procedure
DRAFT – final pending AHRQ approval

7. No single SSI prevention bundle
Deeper dive into SCIP measures to identify local defects
Emerging evidence
Abx redosing and weight based dosing
Maintenance of normogylcemia
Mechanical bowel preparation with oral abx
Standardization of skin preparation
Capitalize on frontline wisdom
CUSP/Staff Safety Assessment
DRAFT – final pending AHRQ approval

8. Deeper Dive Into SCIP Measures to Identify Local Defects
DRAFT – final pending AHRQ approval

9. Does SCIP give us enough information?
Johns Hopkins Hospital
May 2010 SCIP
Hospital Compare
DRAFT – final pending AHRQ approval

10. NSQIP Report 2009
DRAFT – final pending AHRQ approval

11. Identifying Safety Issues and Opportunities for Improvement
CUSP Step 2:
Safety Issue Identified
CUSP Steps 4 & 5:
Opportunities to improve
Infection Control
Skin preparation
Hypothermia
Contamination of bowel contents into the wound
Antibiotic timing
Selection and redosing
Length of case
Coordination of Care
Increase utilization of preoperative evaluation center,
Improve surgical posting accuracy (case name and duration)
Computer assistance for antibiotic selection and redosing
Communication and Teamwork
Improve communication throughout perioperative period
Empower team members to speak up
Improve compliance with briefings/debriefings
Implement teamwork tools
Equipment/ Supplies
Accurate temperature probes
Point of care glucose monitoring
Under body warmers
Sanitizing wipes near anesthesia machine
Policies/Protocols
Standardize care/protocols/policies
Monitor sterile technique policies
Education/Training
Ongoing education (with supportive data)
Development of a SSI prevention checklist
Wick, et al

12. Peri-operative Antibiotic Compliance: Michigan Surgical Quality Collaborative2
DRAFT – final pending AHRQ approval

13. Auditing Your Practice
Evaluate a sample of patients undergoing your procedure of interest for compliance with processes your team identified as potential areas to improve
(i.e: the next patients)
Adapt tool from SUSP website or develop new tool
Practical and feasible strategy to evaluate performance and surface defects
Empowers frontline staff
DRAFT – final pending AHRQ approval

14. How do we conduct audits?
Retrospective chart review
Concurrent review
Place audit tool on chart
Complete over continuum of care
We recommend auditing 5-10 patients
Larger samples yield better estimates of performance
Your data does not need to be submitted
DRAFT – final pending AHRQ approval

15. Gentamicin Interventions-
Increased amount of gentamicin available in room
Added dose calculator in anesthesia record
Educated surgery, anesthesia, and nursing
Despite a 95% compliance on SCIP
DRAFT – final pending AHRQ approval

16. SUSP Antibiotic Audit Tool
DRAFT – final pending AHRQ approval

17. Normothermia Interventions-
Confirmed that temperature probes were accurate (trial comparing foley and esophageal sensors)
Initiated forced air warming in the pre-operative area
DRAFT – final pending AHRQ approval

18. SUSP Normothermia Audit Tool
DRAFT – final pending AHRQ approval

19. What about interventions with no data to support them?
DRAFT – final pending AHRQ approval

20. Separation of “Dirty” and “Clean” Instruments
Intervention-
Built separate tray of instruments used for bowel anastomosis
Extra suction and bovie tip and gloves opened and changed after anastomosis
Educational sessions with scrub techs and nurses about instrument separation
Audits and education on the spot
DRAFT – final pending AHRQ approval

21. Bringing Emerging Evidence for SSI Prevention to Your Patients
DRAFT – final pending AHRQ approval

22. Emerging Evidence for SSI Prevention
Antibiotic Usage
-Redosing
-Weight based dosing of cephalosporins
Utilization of mechanical bowel preparation with oral antibiotics
Normoglycemia/Prevention of hyperglycemia
Standardization of skin preparation
DRAFT – final pending AHRQ approval

23. Available on SUSP website
DRAFT – final pending AHRQ approval

24. Redosing and Weight Based Dosing
Bowel Prep

25. JHU Antibiotic Poster
Entire document available on SUSP website
DRAFT – final pending AHRQ approval

26. Additional Interventions to Improve Antibiotic Efficacy
Weight-based dosing of cephalosporins
Antiobiotic Re-Dosing
- Maintain therapeutic antibiotic serum levels during the entire procedure
If using cefoxitin consider changing because of short redosing interval
Audit your practice!!
Develop standard selections for based on procedure for your hospital
Engage surgery, nursing and anesthesia to implement standard protocol
Consider integrating into EMR if available
Audit your results and share success
DRAFT – final pending AHRQ approval

27. Hyperglycemia and Infection
Background-
-Hyperglycemia is common in hospitalized patients
-38% of medical and surgical patients had hyperglycemia (26% diabetic and 12% non-diabetic)
-In cardiac surgery, degree of post operative hyperglycemia correlates with SSI, adopted as SCIP measures
Goal-
Glucose <180mg/dl in all hospitalized patients
DRAFT – final pending AHRQ approval

28. University of Washington/Glucose Control

29. Johns Hopkins Glucose Control
DRAFT – final pending AHRQ approval

30. Could you do better with glycemic management?
Audit your current practice
Do you have a policy?
Consider gathering a multidisciplinary team (endocrinology, surgery, anesthesiology, nursing (ward and pre-op)) to develop a protocol for your hospital
Look at SUSP website for examples from other hospitals
DRAFT – final pending AHRQ approval

31. Preparation of the Surgical Site
Background-
-1012 bacteria reside on the skin
-Staphlococcus and streptococcus species among others
Goal of skin preparation-
-Reduce bacterial burden on skin prior to incision
Best practice-
-Dual agent skin preparation (Chlorhexidine + alcohol +, providone- iodine + alcohol)
-Skin prep should include alcohol to increase durability of sterilization
-Prep should be applied to specification (duration and amount)
-Prep must be dry before incision
DRAFT – final pending AHRQ approval

32. Chloraprep better than Betadine
Chloraprep and Duraprep better than Betadine
DRAFT – final pending AHRQ approval

33. Is Skin Prep an Area You Could Improve?
Audit your practices - what is being used for what cases? - who is doing the prep? -how long are they taking for the prep? Develop an educational plan, engaging frontline providers, for standardization -? In-services -? Video education -? Change doctor preference cards Audit again after your interventions…. How well did you do? Share the results!
DRAFT – final pending AHRQ approval

34. Summary No single SSI prevention bundle
Need to identify local defects
Auditing is a practical and feasible strategy to evaluate performance and surface defects
Tools are adaptable to local environment
The CUSP method empowers frontline staff
DRAFT – final pending AHRQ approval

35. Resources to find the information that you need for SUSP
Armstrong Institute for Patient Safety and Quality
DRAFT – final pending AHRQ approval

36. Action Items Review staff safety assessment results
Pick 2-3 audit tools based on frontline feedback, SCIP measures and emerging evidence
Find tools on our website-
Audit 5-10 patients with each tool
Create a performance goal for each intervention for your team
Develop your bundle
Develop system changes to implement interventions
Share your tools and ideas for new tools
DRAFT – final pending AHRQ approval

37. References
Merriam-Webster Dictionary. “Auditing.” Merriam-Webster Dictionary web site. Accessed September 1, 2013.
Hendren S, Englesbe MJ, Brooks L, et al. Prophylactic antibiotic practices for colectomy in Michigan. Am J Surg. 2011;201(3):
Hospital Compare. Medicare: the official U.S. government site for medicare.  Medicare.gov Website.
Accessed May 30, 2010
4. Wick EC, Hobson DB, Bennett JL, et al. Implementation of a Surgical Comprehensive Unit-Based Safety Program to Reduce Surgical Site Infections. JACS. 2012; 215(2):
DRAFT – final pending AHRQ approval

38. Content Call Evaluation
We want to ensure that the content calls provide useful and pertinent information for the SUSP teams. For this reason we request that you complete a brief evaluation following each call. The evaluation may be found at the following link:
DRAFT – final pending AHRQ approval