Can We Further Decrease Surgical Site Infection (SSI) after Colorectal Surgery?A Lunch Symposium held during SISNA 2007 at the Westin Harbour Castle Hotel in Downtown Toronto, Ontario, Canada on Thursday April 19th, 2007 www.sisna.org

FACULTYKamal Itani, M.D.Chief of SurgeryVA Boston Healthcare SystemAssociate Chief of Surgery for Veterans AffairsBoston Medical CenterBrigham and Womens HospitalProfessor of SurgeryHarvard University Medical SchoolBoston University Medical SchoolBoston, MADonald E. Fry, MD, FACSProfessor EmeritusUniversity of New Mexico Executive Vice-PresidentMichael Pine and AssociatesChicago, ILSamuel Eric Wilson, MD Department of SurgeryUniversity of California, IrvineIrvine, CA

Bowel Preparation or Not? Kamal Itani, MD

The Role of Oral Antibiotics Eric Sam Wilson, MD

Prophylactic Systemic AntibioticsDonald E. Fry, MD, FACSAGENDA

This symposium is made possible by an educational grant fromMerck & Co.

Surgical Site Infection (SSI)Wound ClassificationClass 1 = CleanClass 2 = Clean-contaminatedClass 3 = ContaminatedClass 4 = Dirty-infectedMangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:250-278.

SSIRisk StratificationNNIS Project (CDC)3 independent variables associated with SSI riskASA score >2Contaminated or dirty-infected wound classificationLength of operation >75th percentile of the specific operation being performedNNIS=National Nosocomial Infection Surveillance; CDC = Centers for Disease Control and Prevention; ASA = Anesthesia Society of America.NNIS. CDC. Am J Infect Control. 2001;29:404-421.

SSIWound Class vs NNIS ClassNNIS. CDC. Am J Infect Control. 2001;29:404-421.$1 billion direct cost$10 billion indirect cost

Wound ClassAllNNIS 0NNIS 1NNIS 2NNIS 3Clean2.1%1.0%2.3%5.4%NAClean-contaminated3.3%2.1%4.0%9.5%NAContaminated6.4%NA3.4%6.8%13.2%Dirty-infected7.1%NA3.1%8.1%12.8%All2.8%1.5%2.9%6.8%13.0%

Initiated in 2003 by CMS and CDC, the SCIP partnership seeks to substantially reduce surgical mortality and morbidity through collaborative efforts.CMS = Centers for Medicare & Medicaid Services.

Procedures Included in Performance MeasureCardiacColorectalHip and knee replacementAbdominal and vaginal hysterectomyVascular surgeryAneurysm repairThromboendarterectomyVein bypass

Colorectal Surgery and SSISmith et al. Ann Surg. 2004;239:599-605Incidence 26%Risk factors: Obesity, intraoperative hypotensionExpenses: $6200/patient Itani et al. N Engl J Med. 2006;355:2640-2651Incidence 24.7%Risk factors: Type of antibiotic prophylaxis, obesity, current use of tobacco, no removal of hair from the surgical site, COPD, intraoperative contaminationCOPD = chronic obstructive pulmonary disease.

Surgical site infections are categorized into four classes depending on wound type. Class 1 is a clean wound, class 2 is a clean contaminated wound, class 3 is a contaminated wound, and class 4 is a dirty infected wound.

Three independent variables have been shown to be associated with surgical skin infection risk through the National Nosocomial Infection Study. These include an ASA greater than 2, classification of the wound as contaminated or dirty, and length of operation being longer than the 75th percentile of the specific operation being performed.This chart compares the wound class for surgical site infections with the NNIS classes.Although the risk of infection increases within the wound classification, it has been shown to be also dependant within each wound class on the NNIS classification

Mike:

100% of these surgeries for all our medical centers