Download Performance Improvement for the Surgeon: SIPP and

Oklahoma Foundation for
Medical Quality
Performance Improvement for the
Surgeon: SIPP and SCPP
Twelfth G. Rainey Williams Surgical Symposium
September 29th, 2005
Oklahoma Foundation for
Medical Quality
Performance Improvement for the
Surgeon: SIPP and SCPP
Surgical Infection Prevention Project
 National program funded by CMS
 Can be used as JCAHO PI project
 Oklahoma collaborative project
Oklahoma Foundation for
Medical Quality
Performance Improvement for the
Surgeon: SIPP and SCPP
Why SIPP?
Oklahoma Foundation for
Medical Quality
Public Health Importance

SSI occurs in 2-5% of extra
abdominal surgeries and up to 20%
of intra-abdominal surgeries

SSI patients are
• 60% more likely to spend time in
the ICU
• 5x more likely to be re-admitted
• 2x the incidence of mortality
Impact of SSI’s
Oklahoma Foundation for
Medical Quality
Case Control* Study of 255 Pairs
Infected
Mortality
7.8%
ICU admission
29%
L.O.S.
11d
Median direct cost
$7531
Readmission
41%
Uninfected
3.5%
18%
6d
$3844
7%
* matched for procedure, NNIS index, age
Kirkland. Infect Control Hosp Epidemiol 1999; 20: 725
Oklahoma Foundation for
Medical Quality
Most Common Hospitalacquired Infections, 1995
Other 21%
Urinary tract
infections
30%
Pneumonia 15%
16%
Surgical site
infections
18%
Bloodstream
infections
Oklahoma Foundation for
Medical Quality
Estimated Annual Impact of
SSIs After Specific Procedures
CABG
# Procedures
Colorectal Hip Replace Knee Replace
383,000
250,000
293,000
324,000
# SSIs
14,975
15,075
4,109
3,726
# Deaths
11,107
11,500
3,809
648
$84
$127
$196
$63
Total Costs
(in millions)
SSI Surveillance
Oklahoma Foundation for
Medical Quality
NNIS Risk Index
Patient-Specific Risk Score
0-3 Points Possible
Patient Characteristic
Points
Wound class III or IV
1 point
ASA score 3, 4, or 5
1 point
Duration of surgery > cutpoint
1 point
Oklahoma Foundation for
Medical Quality
SSI Rates* by Surgery Type
and NNIS Risk Score
NNIS Risk Score
Duration
Cutpoint
(hours)
0
1
2
3
Abd Hyst
2
1.5
2.5
6.1
†
Total knee
2
0.9
1.2
2.0
†
Small bowel surgery
3
5.6
7.5
9.8
14.8
CABG (chest and leg)
5
0.7
3.5
5.8
17.5
Operation
*Infections per 100 procedures
†Risk index categories 2 and 3 combined
Oklahoma Foundation for
Medical Quality






SSI Risk Factors
Age
Obesity
Diabetes
Malnutrition
Prolonged preoperative stay
Infection at a
remote site





Shaving site
Duration of surgery
Surgical technique
Presence of drains
Inappropriate use of
antimicrobial
prophylaxis
Newly Identified:
Hyperglycemia, hypothermia, and tissue hypoxemia
Oklahoma Foundation for
Medical Quality
Surgical Procedures of Interest
Oklahoma Foundation for
Medical Quality
National Surgical Infection Prevention Project






Cardiac
Coronary Artery Bypass Graft (CABG)
Colon
Hip & Knee Arthroplasty
Hysterectomy (abdominal and vaginal)
Vascular Surgery:
• Aneurysm repair
• Thromboendarterectomy
• Vein Bypass
These procedures are being evaluated in the Medicare project because there is no controversy
over the use of antibiotics for these operations. This does not imply that antibiotic prophylaxis
should not be used for other procedures.
Quality Indicators
Oklahoma Foundation for
Medical Quality

National Surgical Infection Prevention Project
Quality Indicator #1
• Proportion of patients who receive
antibiotics within 1 hour before surgical
incision
Because of the longer required infusion time, vancomycin, when
indicated for beta-lactam allergy, may be started within 2 hours
before the incision.
Oklahoma Foundation for
Medical Quality
Impact of Timing of Antibiotic
Prophylaxis
Antibiotic Timing
SSI
Incidence
Relative
Risk
P value
2-24 hours preop
3.8%
--
--
< 2 hours preop
0.6%
0.15
<0.001
3 hours postop
1.4%
0.37
0.11
3-24 hours postop
3.3%
0.86
0.8
Classen DC, et al. N Engl J Med. 1992.
Perioperative Antibiotics
Timing of Administration
Oklahoma Foundation for
Medical Quality
4
14/369
15/441
Infections (%)
3
1/41
2
1/47
1/81
2/180
1
5/699
5/1009
0
≤-3
-2
-1
0
1
2
Hours From Incision
Classen, et al. N Engl J Med. 1992;328:281.
3
4
≥5
Prophylactic Antibiotics Timing
Oklahoma Foundation for
Medical Quality
Cefoxitin
Serum Levels
Incision
2 hours
3 hours
On Call
Induction
34
11
7
99
22
11
DiPiro JT, et al. Arch Surg. 1985;120:829-832.
Blood levels at the time of the incision are important to reduce infection!
Oklahoma Foundation for
Medical Quality
Dose of Antibiotic for Prophylaxis

Always give at least a full therapeutic
dose of antibiotic

Consider the upper range of doses
for large patients and/or long
operations

Consider repeating doses for long
operations
Quality Indicators
Oklahoma Foundation for
Medical Quality

National Surgical Infection Prevention Project
Quality Indicator #2
• Proportion of patients who receive
prophylactic antibiotics consistent with
current recommendations
Appropriate Antibiotics
Oklahoma Foundation for
Medical Quality

National Surgical Infection Prevention Project
Cardiac and vascular surgery
• cefazolin, cefuroxime, cefamandole
• (vancomycin only if documented betalactam allergy)

Hip and knee arthroplasty
• cefazolin, cefuroxime
• (vancomycin only if documented betalactam allergy)
Appropriate Antibiotics
Oklahoma Foundation for
Medical Quality

National Surgical Infection Prevention Project
Hysterectomy
• cefazolin, cefotetan, cefoxitin, or
cefuroxime
• (fluoroquinolone + clindamycin if
documented beta-lactam allergy)
Appropriate Antibiotics
Oklahoma Foundation for
Medical Quality

National Surgical Infection Prevention Project
Colorectal surgery
• Oral (after effective mechanical bowel
prep) administered for 18 hours preop
– neomycin sulfate + erythromycin base, or
– neomycin sulfate + metronidazole
• Parenteral
– cefoxitin, cefotetan, cefmetazole, or cefazolin +
metronidazole
– (fluoroquinolone + clindamycin if documented
beta-lactam allergy)
Oklahoma Foundation for
Medical Quality
Antibiotic Recommendation
Sources

American Society of Health System
Pharmacists

Infectious Diseases Society of America

The Hospital Infection Control Practices
Advisory Committee

Medical Letter

Surgical Infection Society

Sanford Guide to Antimicrobial Therapy 2001
Quality Indicators
Oklahoma Foundation for
Medical Quality

National Surgical Infection Prevention Project
Quality Indicator #3
• Proportion of patients whose
prophylactic antibiotics were
discontinued within 24 hours of surgery
end time
Duration of Prophylaxis
Oklahoma Foundation for
Medical Quality
Gastrointestinal
Author
Strachan 1977
(biliary)
Stone 1979
(mixed)
Hall 1989
(mixed)
Drug
Duration
Infection
cefazolin
1 dose
5 days
placebo
3%
6%
17%
cefamandole
3 doses
5 days
0
3%
cephaloridine
5 days
4%
moxalactam
1 dose
2 days
5%
6%
Duration of Prophylaxis
Oklahoma Foundation for
Medical Quality
Cardiac
Author
Drug
Duration Infection
Conte 1972
cephalothin
1 dose
4 days
10%
9%
Goldmann 1977
cephalothin
2 days
6 days
4%
6%
Austin 1980
cephalothin
2 doses
3 days
11%
9%
Geroulanos 1986
cefuroxime
cefazolin
2 days
4 days
1.1%
2.5%
Duration of Prophylaxis
Oklahoma Foundation for
Medical Quality
Joint Replacement
Author
Pollard 1979
(hips)
Heydemann 1986
(hips and knees)
Drug
Duration Infection
cephaloridine
flucloxacillin
12 hours
14 days
1.4%
1.3%
cefazolin
1 dose
24 hours
48 hours
7 days
0
1%
0
1.5%
Oklahoma Foundation for
Medical Quality

Impact of Prolonged Antibiotic
Prophylaxis
2,641 CABG patients
• Grp 1 - < 48 hours of antibiotics
• Grp 2 - > 48 hours of antibiotics

SSI Rates
• Grp 1 - 8.7% (131/1502)
• Grp 2 - 8.8 % (100/1139)

Antibiotic resistant pathogen - Grp 2
• Odds Ratio 1.6 (95% CI: 1.1-2.6)
Harbarth S, et al. Circulation. 2000.
Antibiotic Prophylaxis
Oklahoma Foundation for
Medical Quality

Duration
In summary • Most studies have confirmed efficacy of
12 hrs of prophylactic antibiotics
• Many studies have shown efficacy of a
single dose
• Whenever compared, the shorter course
has been as effective as the longer
course and results in less antibiotic
resistance
Oklahoma Foundation for
Medical Quality

Surgical Infection Prevention
Besides appropriate antibiotic
selection, what else reduces
infection?
Oklahoma Foundation for
Medical Quality
HICPAC - SSI Prevention
Guidelines - 1999
Category 1
No prior infections
Do not shave in advance1
Control glucose in D.M. pts
Stop tobacco use
Shower with antiseptic soap
Prep skin with approp. agent
Surgeon’s nails short
Surgeons scrub hands
Exclude infected surgeons
Give prophylactic antibiotics
15 air changes/hr in O.R.
Keep O.R. doors closed
Use sterile instruments
Wear a mask*
Cover hair*
Wear sterile gloves*
Gentle tissue handling
DPC for heavily contaminated
wounds
Closed suction drains (when
used)
Pos pressure ventilation in O.R.
Sterile dressing x 24-48 hr
SSI surveillance with feedback to surgeons
1Every
published study of razor shaving has shown increased infection rates!
Oklahoma Foundation for
Medical Quality

Enhanced Perioperative
Glucose Control in Diabetics
2,467 diabetic patients undergoing
cardiac surgery
• Control group - subcutaneous insulin
• Treatment group - IV insulin infusion

Results
• Controls - 2.0% SSI rate (19/968)
• Treatment- 0.8% SSI rate (12/1499), P=0.01
Furnary AP, et al. Ann Thorac Surg. 2000.
Oklahoma Foundation for
Medical Quality


Perioperative Glucose Control
1,000 cardiothoracic surgery patients
Diabetics and non-diabetics with hyperglycemia
Patients with a blood sugar > 300 mg/dL during or within 48 hours of surgery
had more than 3X the likelihood of a wound infection!
Latham R, et al. Infect Control Hosp Epidemiol. 2001.
Oklahoma Foundation for
Medical Quality

Temperature Control
200 colorectal surgery patients
• control - routine intraoperative thermal
care (mean temp 34.7°C)
• treatment - active warming (mean temp on
arrival to recovery 36.6°C)

Results
• control - 19% SSI (18/96)
• treatment - 6% SSI (6/104), P=0.009
Kurz A, et al. N Engl J Med. 1996.
Also: Melling AC, et al. Lancet. 2001. (preop warming)
Oklahoma Foundation for
Medical Quality

Supplemental Perioperative O2
500 colorectal surgery patients
• control - 30% FiO2 intra- and post-op*
• treatment - 80% FiO2 intra- and post-op*

Results
• control - 11.2% SSI (28/250)
• treatment - 5.2% SSI (13/250), P=0.01
*2 hours postoperatively
Greif R, et al. N Engl J Med. 2000.
Reducing Surgical Infections
Oklahoma Foundation for
Medical Quality

Summary
In addition to usual infection control:
• Appropriate antibiotic treatment
– timing, selection, duration (intra-op dosing
for long cases or excess blood loss)
• Avoid shaving and other HICPAC
recommendations
• Blood glucose control (diabetics and
non-diabetics)
• Temperature control (goal 37°C)
• Supplemental O2
Oklahoma Foundation for
Medical Quality
Website Resource
www.surgicalinfectionprevention.org
Oklahoma Foundation for
Medical Quality
Performance Improvement for the
Surgeon: SIPP and SCPP
Surgical Complication Prevention Project
 New project being piloted now
 More broad than SIPP
 Will probably become routine PPI project
Oklahoma Foundation for
Medical Quality
Performance Improvement for the
Surgeon: SIPP and SCPP
What does this mean for you?
 It will improve your patient outcomes
 It may satisfy MOC requirements
 It may become your hospital’s PPI
project
 Surgeons should remain quality
leaders