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Today’s Webinar will begin at noon
3/27/12
Welcome from Barb DeBaun, RN, MSN, CIC
Introduction
Introduction
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Heather Young, MD
Surgical Site Infection after
Hysterectomy in Colorado
WHY
WHY
WHAT
HOW
•Heather Young MD
•March 27, 2012
Objectives
• WHY
– Public reporting in CA, CO and nationwide
– Our SSI problem
• WHAT
– Pilot and statewide study
• HOW
– Transfusion and outcomes
– Transfusion and immunity
– Transfusion at our hospital
WHY
WHY
WHAT
HOW
Why we started this project
Public Reporting of HAI
Committee to Reduce Infection Deaths 2010
Public Reporting Agencies
State
CMS
>
=
<
Online hospital comparisons
Pay for performance
All orthopedic, cardiac, and GI surgeries including:
Hip prosthesis
Knee prosthesis
Open fracture fixation
Laminectomy
Spinal fusion
Spinal refusion
Coronary bypass grafting
Cardiac surgery
Pacemaker surgery
Backer 2011
Colon surgery
Rectal surgery
Small bowel surgery
Gallbladder surgery
Appendectomy
Gastric surgery
Biliary, liver, pancreatic surgeries
AUGUST 2007
Coronary artery bypass grafting
Partial & total knee replacement
Partial & total hip replacement
AUGUST 2008
Herniorrhaphy
AUGUST 2009
Vaginal hysterectomy
Abdominal hysterectomy
JANUARY 2012
Colon surgery
Breast surgery
Reese 2011
WHY
WHAT
HOW
Why we started this project
What we did and What we found
Preparation for Reporting
Jul-Dec
2006
Jan-Jun
2007
Jul-Dec
2007
Jan-Jun
2008
Jul-Dec
2008
Jan-Jun
2009
National
Rate
WHY
WHAT
HOW
Why we started this project
What we did and What we found
Pilot Data, Study Design
Single center, retrospective chart review
Inclusion:
• All patients who had total abdominal hysterectomy (TAH)
• Dec 30, 2005, to Mar 9, 2010
• Age ≥ 18 y.o.
Exclusion:
• Emergent surgery
• Surgery for known infection (tubo-ovarian abscess)
• No follow-up documented in 30 days after TAH
Young 2011
Hypotheses
• Do our surgeons adhere to evidencebased guidelines?
• Are there other published variables that
we should consider for intervention?
Inclusion/Exclusion
Study Population
N (%)
Total number of patients
229 (100%)
Excluded from analysis
37 (16.2%)
Emergent indication
No TAH performed
Surgery for TOA
No follow-up in 30 d after TAH
Young 2011
26
5
4
2
Included in analysis
192 (83.8%)
Developed SSI
21 (10.9%)
Patient & Hospital Variables
PMHx, PSHx
Indication for TAH
Length of time in OR
Estimated blood loss (EBL)
Blood transfusion
Concomitant OR procedures
Type of skin incision
Surgeon
ASA score
Wound class
SCIP measures compliance
Olsen 2009; Ahmed 2001; Taylor 1998; Shapiro 1982; Meltomaa 2000; Molina-Cabrillana 2008; Ghezi 2009; Leung
2007; Persson 1996
Adherence to SSI Bundle
120
Percentage
100
80
Green60= SSI
Blue =40 No SSI
20
0
Antibiotics within Appropriate
60 minutes of antibiotics
incision
Young 2011
No
PACU arrival
temperature ≥36
SSIdegreesSSI
Composite
Selected Variables and SSI
Variable
SSI
N, %
No SSI
N, %
P
Diabetes
4
19.1%
18
10.5%
0.247
Smoking
4
19.1%
58
33.9%
0.169
Obesity
BMI ≥ 30
14
66.7%
76
45.1%
0.061
Blood
transfusion
6
28.6%
18
10.5%
0.018
EBL ≥ 500 mL
10
47.6%
47
25.7%
0.035
Young 2011
Selected Variables and SSI
Variable
SSI
N, %
No SSI
N, %
P
Diabetes
4
19.1%
18
10.5%
0.247
Smoking
4
19.1%
58
33.9%
0.169
Obesity
BMI ≥ 30
14
66.7%
76
45.1%
0.061
Blood
transfusion
6
28.6%
18
10.5%
0.018
EBL ≥ 500 mL
10
47.6%
47
25.7%
0.035
Young 2011
Laboratory Variables
Pre-operative creatinine
Pre-operative complete blood count
Post-operative hemoglobin / hematocrit
Microbiology, if applicable
Meltomaa 2000
Lab Values and SSI
Lab Value
SSI
Mean (SD)
No SSI
Mean (SD)
P
WBC
7.75 (2.66)
7.65 (2.67)
0.869
Platelet
359 (133)
335 (137)
0.448
Hematocrit
37.94 (4.10)
39.26 (4.87)
0.234
Post-operative
hematocrit
31.81 (4.13)
31.67 (5.74)
0.913
Delta hematocrit
6.13 (4.06)
7.62 (4.94)
0.187
Young 2011
Multivariate Analysis
Young 2011
Model I
Model II
N = 192
EBL <500 mL EBL ≥500 mL
N = 138
N = 54
Blood
transfusion
3.58
1.21, 10.62
7.56
1.59, 35.98
1.14
0.25, 5.16
BMI ≥30
2.55
0.96, 6.74
---
---
Reasons for Blood Transfusion
Young 2011
Variable
Frequency
“Anemia”
72.7%
“High amount of EBL”
27.3%
“Dizziness” or
“shortness of breath”
24.2%
“Comorbid heart
disease”
18.2%
“Use of anticoagulants”
9.1%
Discussion
1.Obesity trends toward significance
2.Blood transfusion associated with
SSI after TAH, especially if EBL <500
mL
1.Most indications for blood
transfusion are subjective and
potentially modifiable
Young 2011
Strengths & Weaknesses
Excellent post-discharge
follow-up (99%)
Use of standard definitions
Single center
Relatively small number of infections and
transfusions
Young 2011
Next Steps
•
•
•
•
Expand to multicenter
State of Colorado
Survey of infection control nurses
IRB approved at 35 / 51 hospitals that perform
TAH
8 still pending at publication
8 declined participation
• Colorado Hospitals Association (CHA)
Methods
• Survey designed
• Website developed, supported by CHA
• Emails sent to all infection control nurses
at participating facilities
• Stipend offered for participation
Young 2012
Participants
•
•
•
•
6 facilities
567 subjects entered into database
20 excluded
547 subjects analyzed
• 10 (1.8%) developed SSI
• 35 (6.5%) had blood transfusion
Young 2012
Associations with SSI
Variable
SSI
No SSI
P
BMI ≥30
60.0%
40.4%
0.33
Hct <30
0.0%
5.0%
1.00
EBL ≥500 mL
20.0%
6.7%
0.15
Blood transfusion
20.0%
6.2%
0.13
Antibiotic < 60 min
before incision
100.0%
96.4%
1.00
Young 2012
Associations with SSI
Variable
SSI
No SSI
P
BMI ≥30
60.0%
40.4%
0.33
Hct <30
0.0%
5.0%
1.00
EBL ≥500 mL
20.0%
6.7%
0.15
Blood transfusion
20.0%
6.2%
0.13
Antibiotic < 60 min
before incision
100.0%
96.4%
1.00
Young 2012
Stratification Analyses
OR to develop SSI
95% Confidence Interval
Blood transfusion
Young 2012
EBL <500 mL
EBL ≥500 mL
7.20
1.37, 37.72
---
Discussion
• Blood transfusion and EBL ≥500
mL continue to be risk factors for
SSI across several diverse
institutions
• Biggest contribution of blood
transfusion to SSI was in cases
of EBL <500 mL
Young 2012
Who is more likely to have SSI?
EBL 1200
mL
EBL 300
mL
pRBC
pRBC
WHY
WHAT
HOW
How blood transfusions relate to patient outcomes
How blood transfusions relate to immune function
How we changed transfusions in hospital practice
(sort of!)
Transfusion-Related
Immunomodulation (TRIM)
↑ renal transplant
survival
↑ cancer recurrence
↓ Crohn’s disease flares
↑ post-operative bacterial
infection
↓ miscarriage rate
↑ mortality
Beneficial effects
Vamvakas 2007
Detrimental effects
TRIM and Hospital Outcomes
Blood transfusions are
associated with worse
hospital outcomes
Especially in patients
who are not severely ill or
profoundly anemic
Hebert et al 1999
ICU Mortality
– 838 patients, multicenter, Canada
– Randomized controlled trial
– Blood transfusion threshold of Hg 7-9
vs 10-12 in community ICU patients
– Outcome: 30-day death
Hebert et al
1999
Received
less blood
Received
more blood
Received
less blood
Received
more blood
Hebert et al
1999
Hebert et al
1999
Received
less blood
Received
more blood
Rao et al 2004
Acute Coronary Syndrome
– 24,112 patients, multicenter,
international
– Observational study
– Impact of blood transfusion in patients
with ACS
– Outcome: 30-day death
Rao et al 2004
OR for 30-day death (by Hct)
in patients w/ vs w/o blood transfusion
– 24,112 patients, international
Nadir Hematocrit
– Impact of blood transfusion
on 30-day death in
patients with ACS
Adjusted OR
(95% CI)
20
25
30
35
1.59
(0.952.66)
1.13
(0.701.82)
168.64
(7.49-3798)
291.64
(10.288274)
Rao et al 2004
OR for 30-day death (by Hct)
in patients w/ vs w/o blood transfusion
– 24,112 patients, international
Nadir Hematocrit
– Impact of blood transfusion
on 30-day death in
patients with ACS
Adjusted OR
(95% CI)
20
25
1.59
(0.952.66)
1.13
(0.701.82)
30
35
168.64
(7.49-3798)
291.64
(10.288274)
Blood Transfusion & Surgical Site Infection
Author Year
Surgical Procedure
Multivariate Analysis
Bernard 2009
Visceral, vascular, trauma
OR 1.3
Rogers 2009
Coronary artery bypass
OR 2.3
Poon 2009
Laparoscopic colorectal
OR 2.4
Olsen 2008
Breast
OR 3.4
Asensio 2008
Liver transplant
OR 2.0
Blumetti 2007
Colorectal
OR 2.3
Walz 2006
Small bowel, colorectal
OR 1.6
Talbot 2004
Sternotomy
OR 3.2
Olsen 2003
Saphenous vein harvest
OR 2.8
Olsen 2009
Hysterectomy
OR 2.4
Schwarzkopf 2010
Thoracic, lumbar spine
OR 8.0
Costello 2010
Cardiac, pediatric
OR 7.9
Tang 2001
Colorectal
OR 5.3
Innerhofer 2005
Hip and knee arthroplasty
OR 23.7
Koch et al 2008
Cardiac surgery
– Newer vs older blood (<14 vs ≥14 days)
– Outcomes: “serious adverse events” and
long term survival
– Older blood associated with more serious
complications and deaths
Koch et
al 2008
Death
Ventilation
Renal failure
Sepsis
Multiorgan failure
Limb ischemia
Composite
SURVIVAL
Koch et
al 2008
Offner et al 2002
Trauma surgery
– Newer vs older blood (<14 vs ≥14 days)
– Outcomes: “major infectious complications”
– Older blood associated with more infections
Offner et al 2002
>14 Days
>21 Days
Yellow = no infection
Blue = major infection
Mean # PRBC transfused
Offner et
al 2002
How does blood change the
immune system?
Theory: Soluble factors in blood
products accumulate over time and
contribute to diminished immune
function.
Muylle et al 1993
Platelet study
Two phases:
• (1) IL6, TNFα, IL1β at storage day 3, 5, 7
• (2) Correlate IL6, TNFα, IL1β with febrile
transfusion reactions
Muylle et al 1993
(1) Cytokines at storage day 3, 5, 7
• ↑IL6 in 8/12 samples at day 3
• ↑IL6 in 10/12 samples at day 5, 7
• ↑TNFα and IL1β in samples with ↑IL6
• Linear increases with storage time
• Increased cytokines about 100-1000x perstorage levels
Similar findings found by Stack & Snyder 1994
Muylle et al 1993
(2) Correlate IL6, TNFα, IL1β with febrile
transfusion reactions
• 45 platelet tx, 6 febrile reactions
• ↑IL6 and TNFα in plasma of platelets that caused
reactions (p <0.001)
Muylle 1993
Conclusion:
Perhaps some
transfusion reactions
are due to transfusion
of cytokine-rich plasma
Wadhwa et al 2000
Cytokine levels in WBC-reduced pRBC
– Does the timing of WBC-reduction
influence cytokine levels over storage
time?
– IL8, TGFβ1, RANTES
Wadhwa et al 2000
Conclusion:
– Cytokines tend to increase over time in
stored blood products
– Pre-storage plasma filtration prevents
cytokine accumulation compared to poststorage
Offner et
al 2002
How does blood change the
immune system?
Theory: Soluble factors in blood
products accumulate over time and
contribute to diminished immune
function
Muylle et al 1993
Platelet study
Two phases:
• (1) IL6, TNFα, IL1β at storage day 3, 5, 7
• (2) Correlate IL6, TNFα, IL1β with febrile
transfusion reactions
Muylle et al 1993
(1) Cytokines at storage day 3, 5, 7
• ↑IL6 in 8/12 samples at day 3
• ↑IL6 in 10/12 samples at day 5, 7
• ↑TNFα and IL1β in samples with ↑IL6
• Linear increases with storage time
• Increased cytokines about 100-1000x perstorage levels
Similar findings found by Stack & Snyder 1994
Muylle et al 1993
2) Correlate IL6, TNFα, IL1β with febrile
transfusion reactions
• 45 platelet tx, 6 febrile reactions
• ↑IL6 and TNFα in plasma of platelets that caused
reactions (p <0.001)
Muylle 1993
Conclusion:
Perhaps some
transfusion reactions
are due to transfusion
of cytokine-rich plasma
Wadhwa et al 2000
Cytokine levels in WBC-reduced pRBC
– Does the timing of WBC-reduction influence
cytokine levels over storage time?
– IL8, TGFβ1, RANTES
Wadhwa et al 2000
Conclusion:
– Cytokines tend to increase over time in
stored blood products
– Pre-storage plasma filtration prevents
cytokine accumulation compared to poststorage
Summary
• Immune mediators are present and
accumulate over time in blood products
Summary
• Immune mediators are present and
accumulate over time in blood products
• The quantity of innate immune mediators in
blood products is sufficient to cause febrile
reactions to platelets
Summary
• Immune mediators are present and
accumulate over time in blood products
• The quantity of innate immune mediators in
blood products is sufficient to cause febrile
reactions to platelets
• Levels of innate immune inhibitors in
patients after receiving blood products have
not been studied
Feedback, Follow-up
Jul-Dec
2006
Young 2011
Jan-Jun Jul-Dec Jan-Jun
2007
2007
2008
Jul-Dec
2008
Jan-Jun
2009
Jul-Dec Jan-Jun
2009
2010
Jul-Dec
2010
Thank You
Connie Price
Jim Carr
Chris Carey
Cathy Vigil
Walt Biffl
Amber Miller
Bill Burman
Morgan Silverman
Robin Bliss
Heather Gilmartin
Bryan Knepper
Elizabeth Wodrich
LARRK Foundation
Sandy Alexander
Crystal Berumen
QUESTIONS?
[email protected]
[email protected]
Notes will be on our website
Cynosure Quality Swap Meet
May 21, 2012
www.cynosurehealth.org
Thanks for joining us today