Overview of SCIP measures Identify improvement strategies Identify successful processes

Transcription

1 Janette Biorn, RN Infection Prevention Services Consulting Minnetonka, MN 1 Overview of SCIP measures Identify improvement strategies Identify successful processes 2 1

2 Surgical Care Improvement Project - national quality partnership of 34 organizations focused on improving surgical care SCIP goal: reduce the incidence of surgical complications nationally by 25% by 2010 Surgical Site Infection Prevention Venous Thromboembolism Prophylaxis Beta Blockers for patients on Beta Blockers prior to admission IHI % of patients experience serious adverse events related to medical management. The top three causes were: Medication-related (19%) Wound infections (14%) Technical complications (13%) 58% of these events were preventable mistakes now called medical errors or patient safety failures An estimated 40-60% of SSIs are preventable. IHI

3 Antibiotics should be present in the tissue to be operated on at the time incision is made and throughout time the wound is open. Designate responsibility and accountability for administration Standardize administration / delivery process Standing orders delivery and discontinuation Educate Staff Provide outcome compliance 5 Appropriate use of prophylactic antibiotics Selection Timely administration Timely discontinuation Choose prophylactic antibiotic consistent with national guidelines Studies indicate optimum timing for prophylactic antibiotic is within one hour prior to incision Initiate protocol as a standard Nursing and/or pharmacy drives protocol No reliance on individual physician memory 2007 IHI 6 3

4 Most studies have confirmed efficacy of 12 hrs. Many studies have shown efficacy of a single dose. Whenever compared, the shorter course has been as effective as the longer course. There is no need to continue coverage beyond 24 hours even if a patient has tubes or drains postoperatively. Discontinuation of antibiotics automatic If doses required, times set by nursing or pharmacy to end within 24 hours 7 Identify owners clearly: who starts it and who documents it Set a narrower performance margin If goal is 0-60, strive for Take advantage of habits and patterns Trigger for when dose is given Verify prior to incision Reliable procedures take coordination between preoperative nursing and anesthesia services / OR staff. Discontinuation of antibiotics automatic 2007 IHI 8 4

5 Revised physician pre-op orders & develop order set to include antibiotic Global education to all clinician providing care to at risk population Reminders to Operating Room preference cards and in rooms Developed feedback report for physicians and OR staff Feedback specified whether prophylactic antibiotics were provided too early (greater than 60 minutes) or after incision Shared information regularly at weekly Anesthesia staff meetings and monthly QA meetings Prophylactic antibiotics primed and hung by Pre-op Holding areas staff Changed CPOE order sets to DC AB within 24 hours of surgery end time Drill down of misses preformed physician score cards developed and used to drive improvement (anesthesiologists and surgeons) Changed antibiotic from piggyback to IV push when appropriate Pharmacy assigned authority for discontinuing antibiotic after 24 hours Adding statement regarding antibiotic administration to the Pause for the Cause document 9 Appropriate: No hair removal at all Clipping Depilatory use Inappropriate: Razors 10 5

6 Group No Hair Removal Depilatory Razor Number Infection rate 0.6% 0.6% 5.6% Seropian. Am J Surg. 1971; 121: Number Infected (%) Razor (1.3%) Clipper (0.4%) p < 0.03 Ko. Ann Thorac Surg. 1992;53:

7 Perform hair removal only if hair interferes with wound closure Ensure adequate supply of clippers Establish protocol for when and how to remove hair Post signs and posters Staff and Patient Education 13 Remove all razors from operating room and supply areas No preoperative use of razors at the surgical site Stopped ordering razors Evaluated and purchased clippers Modified Prep Kits Global education of staff Surgical technician s advice and support for elimination of razors in operating room and all preoperative areas 14 7

8 Poor Glucose control is an independent risk factor for surgical site infection Degree of hyperglycemia correlates with the SSI rate Current measure is for cardiac surgery patients May be beneficial in other surgery populations 15 Type of Surgery Pre-Tight glycemic control Post_Tight Glycemic Control Cardiothoracic 4.6% 2.5% Vascular 1.9% 0.83% Hip replacement 1.0% 0.7% Knee replacement 1.1% 1.0% Bariatric 17.9% 5.3% Morris Brown MD, Henri Ford Hospital, International Anesthesia Research Society 16 8

9 Standardized glucose control protocol Develop Order sets Assess risk of hyperglycemia in all post operative patients Assign responsibility and accountability for monitoring and control Implement a glucose control protocol (sliding scale or insulin drip) Develop one protocol to be used for all surgical patients Regularly check preoperative blood glucose levels on all patients to identify hyperglycemia; this is best done early enough that the assessment of risk can be completed and treatment initiated if appropriate 17 Revised current insulin protocol to provide greater control over blood glucose levels throughout the patient stay Implemented the revised protocol in the peri-operative (vs. post-operative) environment Implemented daily insulin protocol rounds Adjusted process for ICU transfer orders to the step down unit to allow IV insulin to continue vs. a switch to subcutaneous insulin Established greater collaboration with diabetes educators in the patient process Implemented daily verbal reports of previous day's blood glucose levels to physicians during rounds Create/implement postoperative hyperglycemic patient management protocol Create/implement IV to SQ Insulin conversion protocols Standardized antibiotic type/dosage for cardiac surgery and vascular surgery patients Blood glucose testing on all cardiovascular surgery patients preoperative, intraoperative, with all blood gases and immediately postoperatively 18 9

10 MI cardiac events are the most common medical complication of surgery Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina, symptomatic arrhythmias, hypertension, or other ACC/AHA Class I guideline indications (ACC/AHA Practice Guidelines. JACC. 2006; 47(11); ) Patients on beta blockers preoperatively should be continued on beta blockers postoperatively Need reliable system to ensure process is continued 2007 IHI 19 Identify patients preoperatively who are on beta blockers Develop standard postoperative order sets or automatic protocols for provision of beta blockers to these patients Designate responsibility for postoperative ordering of preoperative medications Educate patients about importance of continuing beta blockers post-op: encourage them to remind surgeon and anesthesiologist that they take these 2007 IHI 20 10

11 Add beta blocker time and date to electronic surgical record Implemented use of a pre/intra/post-op beta blocker protocol Developed pre-printed/cpoe orders based on the ACCP Pre-admission evaluation screening by anesthesiologist Global education 21 Deep vein thrombosis (DVT) estimated at 10% - 40% of general surgical patients without prophylaxis American College of Chest Physicians (ACCP): autopsies of surgical patients who died within 30 days postoperatively 32% percent had PE and it was cause of death for most ACCP recommends routine prophylaxis for all patients in the targeted groups Lindblad B, Eriksson A, Bergqvist D. Br J Surg. 1991;78:

12 Defined by type of surgical procedure and patient risk Pharmaceutical Prophylaxis Low Molecular weight heparin Low-dose unfractionated heparin Mechanical Prophylaxis Intermittent pneumatic compression devices Documentation of not doing must be documented Specification Manual for National HospitL Inpatient Quality Measures 23 Develop standard order sets for prophylaxis Develop protocols for providing prophylaxis automatically, based on surgical procedure Provide education and training for staff on the importance Educate patients preoperatively about the prophylaxis they will receive and steps they can take to reduce risk Posters / Reminders 24 12

13 Implemented daily rounds to review VTE therapy Include in VAP bundle whenever possible Pre-admission evaluation screening by anesthesiologist Pre-checked pneumoboots on order sets Provide feedback on findings Global education million inpatient surgeries in the United States every year and a significant percentage result in preventable, often life-threatening complications Estimates of 2.5 to 3.5 million surgical patients per year experience unintended harm resulting from or contributed to by surgical care. Prevention and reducing complications can be achieved by applying evidence-based practices standardizing and simplifying core processes Success has already been achieved by many health care facilities across the nation Ongoing communication, education and collaboration with a multidisciplinary team is imperative for success IHI How to Guide - Reducing Surgical Complications 26 13

14 MedQIC Surgical Care Improvement Project &pagename=Medqic/Content/ParentShellTe mplate&parentname=topiccat&c=mqparents Institute for Healthcare Improvement Surgical Site Infections SiteInfections/ Institute for Healthcare Improvement Reduce Surgical Complications lcomplications.htm Institute for Healthcare Improvement Prevent Surgical Site Infections