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1 Infection Prevention Division Essentials EDU Learning Program Surgical Care Improvement Project (SCIP): Improving Safety of Surgical Care to Improve Patient Outcomes Dianne Rawson RN, MA Senior Director Periop Services Fairview University Medical Center June 14, 2011 Disclosure Dianne Rawson Sponsored by 3M Housekeeping Questions Mute feature (*7 = unmute, *6 = mute) Chat feature Technical difficulties CE credits Post session follow-up 1

2 How do I get a CE Certificate? Next week, all of today s meeting participants will be sent an containing instructions for obtaining a CE Certificate for today s meeting. The will be sent to the address you provided when you logged-in to today s meeting. If there are others listening with you today who did not log-on, you may forward the CE certificate to them. Session Description Surgical Care can be improved through better utilization of evidence-based practice guidelines and by using a systems approach when providing patient care. Healthcare personnel can help to lower the risk of surgical complications by supporting the use of evidence-based practice guidelines within their facility. Learning Objectives State the prevalence of surgical site infections Identify five SCIP project quality measures Describe potential complications of hypothermia Describe 2 nursing interventions for each quality measure 2

3 Introduction What is SCIP? National quality partnership to improve surgical care Sponsored by Centers for Medicare and Medicaid Services (CMS) Collaborating agencies Centers for Disease Control and Prevention (CDC) Institute for Healthcare Improvement (IHI) Joint Commission (JC) Introduction, continued 1999 ground-breaking report Institute of Medicine, To Err is Human Study of > 44,000 operations in large medical center from % (>2400)suffered complications half linked to medical error! Prevalence of Surgical Site Infections (SSIs) According to the CDC: 38% of healthcare-associated infections in surgical patients are SSIs¹ SSI increased length of stay (LOS) by 7.3 days - added cost of $3,152¹ (1992 analysis) Deep organs/space SSI VS incision SSI associated with greater cost and LOS¹ 1. Guideline for Prevention of Surgical Site Infection, 1999 ( 3

4 And, More Recently Studies differ considerably Median costs in the range of $ $12,900 Another study showed the adjusted mean at $2200 per SSI Source: ICHC, February 2011, Vol. 32, No. 2 Estimating the Proportion of Healthcare-Associated Infections That Are Reasonably Preventable and the Related Mortality and Costs. Umscheid, et al. Surgical Site Infections (SSIs) are the second leading cause of HAIs Klevens RM, et al. Estimating Health Care-Associated Infections and Deaths in US Hospitals, Public Health Reports 2007;122: What We Know Some surgical complications are unavoidable Surgical care can be improved Better adherence to evidence-based practice guidelines Using systems approach with safeguards Personnel support the use of evidence-based practice guidelines 4

5 SCIP INF: 1 Surgical Patients with Prophylactic Antibiotics Initiated Within One Hour Prior to Surgical Incision Target Population CABG, Other Cardiac Surgery, Hip Arthroplasty, Knee Arthroplasty, Colon Surgery, Hysterectomy, Vascular Surgery Vancomycin or fluoroquinolone 2 hours prior to incision Goal of Prophylaxis Establish bactericidal tissue and serum levels at the time of incision SCIP INF: 1 Guideline-based standing order/protocol for surgical antibiotic prophylaxis Place protocol in patient s chart when transferring to the OR Assign accountability for administering prophylactic antibiotic Incorporate antibiotic delivery check process into surgical time out Others visible reminders in the OR SCIP INF: 2 Prophylactic Antibiotic Selection for Surgical Patients Target Population CABG, Other Cardiac Surgery, Hip Arthroplasty, Knee Arthroplasty, Colon Surgery, Hysterectomy, Vascular Surgery Consistent with current guidelines for use of prophylactic antibiotics Goal of Prophylaxis Use an agent that is safe, cost-effective and has spectrum of action that covers most of the probable intraoperative contaminants for the procedure 5

6 SCIP INF: 2 P&T Committee Meet at least annually to review standard formulary for antimicrobial prophylaxis Create drug matrix pocket cards for OR staff/surgical team reference SCIP INF: 3 Prophylactic Antibiotics Discontinued within 24 Hours After Surgery End Time Target Population Hip Arthroplasty, Knee Arthroplasty, Colon Surgery, Hysterectomy, Vascular Surgery CABG/Other Cardiac Surgery 48 hours after surgery end time Rationale Need to provide therapeutic serum and tissue levels of antibiotic throughout procedure Intraoperative re-dosing may be needed for long procedures Administration of antibiotics for more than a few hours after incision closed offers no additional benefit to patient Prolonged antibiotic use increased the risk of developing antimicrobial-resistant pathogens SCIP INF: 3 Approve guideline-based, standing orders/protocol for automatic discontinuation of surgical antibiotic prophylaxis (Medical Staff Surgical Committee) Develop policy for pharmacy staff to automatically discontinue antibiotic prophylaxis within the appropriate timeframe Implement policy whereby physicians need to manually write an order to continue antibiotic prophylaxis with a reason (e.g. ongoing infection) Implement use of a care pathway that result in the routine discontinuation of prophylactic antibiotics within appropriate timeframe 6

7 SCIP INF 4: Cardiac Surgery Patients with Controlled 6 AM Postoperative Blood Glucose Target Population Cardiac surgery patients Controlled 6AM blood glucose < 200 mg/dl on post op days (POD) 1 and 2 Rationale Hyperglycemia associated with increased morbidity and mortality for multiple medical and surgical complications Risk of infection significantly higher for patients undergoing CABG (Zerr, et al, 1997) and infection risk controlled if mean blood glucose levels controlled below 200 mg/dl (Zerr, et al, 2001) Source: Specifications Manual for National Hospital Inpatient Quality Measures: Discharges 4/1/11 12/31/11 SCIP INF: 4 Approve use of standardized glucose management protocol for intra-operative and post-operative care: Cardiac surgery patients Diabetic surgical patients Implement process to identify all patients with hyperglycemia prior to surgery Assign accountability to individual staff or category of staff (e.g. nursing) for management of glucose levels SCIP INF: 6 Surgery Patients with Appropriate Hair Removal No hair removal, hair removal with clippers or depilatory is considered appropriate Shaving is not appropriate Rationale Shaving causes abrasions that later may become infected Several studies support rationale: Kjonniksen, et al (2002): Strong evidence to contraindicate use of razors for hair removal Ko, et al (1992): Randomized study of 1,980 patients undergoing CABG surgeries significant higher rate of infection in those that were shaved VS those that had hair removal by electric clippers Alexander, et al (1983): Reported clippers used AM of surgery resulted in reduced SSI and healthcare expenditures Source: Specifications Manual for National Hospital Inpatient Quality Measures: Discharges 4/1/11 12/31/11 7

8 SCIP INF: 6 Adopt a policy that does not allow pre-operative shaving with razors Hair removal will be performed with clippers or depilatory Educate surgeons and clinical staff Remove all razors from OR suites and surrounding patient support areas Request surgical prep kits without razors Purchase and place electric clippers throughout the holding and pre-op areas where hair removal occurs Implement the use of No Shave posters Modify documentation forms SCIP INF: 9 Urinary Catheter Removal on POD 1 or POD 2 Surgical patients with urinary catheter removed on POD 1 or 2 Sizable variation on duration of post op foley catheter use among hospitals Rationale Risk of urinary tract infection (UTI) increases with duration of indwelling foley catheter use Literature supports early removal of foley catheters SCIP INF: 9 Approve use of a standardized protocol for postoperative urinary catheter removal Consider the use of automatic stop orders for discontinuing foley catheters Adopt a bladder bundle for standardized practice Create patient/family education of FAQs on catheter-associated UTIs 8

9 SCIP INF: 10 Surgery Patients with Perioperative Temperature Management Surgical patients for whom either active warming used intraoperatively for the purpose of maintaining normothermia OR Who had at least one body temperature > 96.8 F/36 C recorded within the 30 minutes immediately prior to or the 15 minutes immediately after anesthesia end time Surgery Patients with Perioperative Temperature Management - Rationale Core temperatures outside the normal range pose a risk to all patients undergoing surgery Adverse outcomes can lead to prolonged hospital stays and increased hospital expenditures Unplanned Perioperative hypothermia can lead to: - Impaired wound healing, adverse cardiac events, altered drug metabolism and coagulopathies Literature supports maintaining normothermia SCIP INF: 10 Educate surgeons and nursing staff on the risks of hypothermia and benefits of maintaining normothermia Implement effective, evidence-based warming measures to help patients stay warm throughout the perioperative process 9

10 SCIP VTE: 1 Surgery Patients with Recommended Venous Thromboembolism (VTE) Prophylaxis Ordered VTE one of most common postop complications Prophylaxis most effective strategy to reduce morbidity and mortality often underused VTE includes DVT and pulmonary embolism Related to duration of surgery, patient risk factors, duration/extent of postop immobilization AND use/nonuse of prophylaxis Prophylaxis recommendations based on selected surgical procedures from 2008 American college of Chest Physicians Guidelines SCIP VTE: 2 Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis within 24 Hours Prior to Surgery to 24 Hours After Surgery Timing of prophylaxis based on type of procedure, prophylaxis selection, and clinical judgment regarding patient risk factors Optimal start of pharmacologic prophylaxis needs to be balanced with efficacy VS bleeding potential SCIP VTE: 1 and 2 Develop a policy for universal VTE risk assessment of all patients admitted to the hospital Assign accountability for which category of staff (e.g. nursing) will complete the risk assessment Implement a DVT awareness campaign and training for staff 10

11 Conclusion Develop a multidisciplinary team: Meet regularly Discuss successes and gaps in performance related to SCIP Reference 1. Specifications Manual for National Hospital Inpatient Quality Measures: Discharges 4/1/11 12/31/11 11