Surgical Site InfectionSUSPArmstrong Institute for Patient Safety and Quality

Presented by: Elizabeth C. Wick, M.D. and Deborah B. Hobson, R.N.

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• Understand pathogenesis, monitoring and prevention of SSIs

• To explore how to implement evidence-based behaviors to prevent SSIs

Learning Objectives

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0%

5%

10%

15%

20%

25%

Drug-related

Woundinfect.

Tech.comp.

Latecomp.

Diag.mishap

Therap.mishap

Nontech.comp.

Proc.related

Proportion of Adverse EventsMost Frequent Categories

Brennan. N Engl J Med. 1991;324:370-376

Non-surgical

Surgical

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• SSI is the most common nosocomial infection in the surgical patient

• SSI is the most common complication after colorectal abdominal surgery (3-30%)

• SSI is associated with increased mortality, length of stay and readmission

• An SSI costs between $6,200 - $15,000/per patient (superficial-organ space)

Background

Smith et al, Ann Surg, 2004 Wick et al, Arch Surg, 2011

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Pathogenesis of SSI

Bacteria

Procedure

Host

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• Superficial– purulent drainage from wound– positive wound culture– pain, redness swelling– diagnosis by surgeon

• Deep– purulent drainage from deep aspect of wound– dehiscence– abscess on exam or CT scan

• Organ Space– infection in surgical cavity (abdomen)

SSI Definitions

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NEW MANDATORY Monitoring: colon and hysterectomy

• Rate will be risk adjusted based on age and ASA

• Deep incisional and organ space rates for colon and hysterectomy will be reported to CMS (required for full payment)

• Data to be transmitted to CMS late 2012, 2013

• Hospital specific standardized infection ratios will be generated for colon and hysterectomy

Monitoring: NHSN(CDC-National Healthcare Safety Network)

http://www.cdc.gov/nhsn/PDFs/FINAL-ACH-SSI-Guidance.pdf

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• Data – Robust preoperative risk factors for risk adjustment– 30-day postoperative mortality and morbidity

• Program– Costs approximately $30K/year; infection only one of many

outcomes studied– Requires full time RN dedicated to data collection AND surgeon

champion– Includes annual audit by NSQIP and risk adjusted reports – Option to collect all colon and rectal procedures vs. random sample

of surgical procedures

Monitoring: NSQIP(National Surgical Quality Improvement Program)

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SCIP PROCESSES TO PREVENT SSI

SCIP Data Johns Hopkins ComparisonHospitals

Surgery patients who were given an antibiotic at the right time (within one hour before surgery) to help prevent infection

98% 97%

Surgery patients who were given the right kind of antibiotic to help prevent infection 98% 98%

Surgery patients whose preventive antibiotics were stopped at the right time (within 24 hours after surgery)

97% 96%

Surgery patients needing hair removed from the surgical area before surgery, who had hair removed using a safer method (electric clippers or hair removal cream – not a razor)

100% 100%

Patients having surgery who were actively warmed in the operating room or whose body temperature was near normal by the end of surgery.

98% 99%

Johns Hopkins Hospital. May 2010 SCIP, Hospital Compare, www.medicare.gov

Does SCIP Give Us Enough information?

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Problem : Penicillin-allergic patients undergoing colorectal surgery were not receiving proper prophylactic antibiotics (Clindamycin and Gentamycin).

Johns Hopkins CUSP Experience:Room for Improvement in SCIP Compliance

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Antibiotic Compliance ProjectJohns Hopkins

Before After0

25

50

75

100

33%

92%

Correct Dose of Gentam-icin Received

% o

f Pat

ient

s C

ompl

iant

Interventions

• Increased amount of gentamicin available in the room

• Added dose calculator in anesthesia record

• Educated surgeons, anesthesia, and nursing in

Wick et al, JACS 2012 (in press)

 Antibiotics practices All cases (n = 3002) number (%)

Nonemergency (n = 2743) number (%)

Emergency cases (n = 248) number (%)

Was an SCIP-compliant antibiotic chosen? 2,431 (81.4%) 2,293 (83.6%) 130 (52.4%)

Was antibiotic given within 1 h before incision? 2,712 (90.8%) 2,544 (92.7%) 159 (64.1%)

Antibiotics weight-adjusted (n = 972) 552 (56.8%)    

Antibiotics redosed (n = 398) 24 (6.0%)    

Total surgical site infection 269 (9.0%) 245 (8.9%) 24 (9.7%)

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Perioperative Antibiotic Compliance:Michigan Surgical Quality Collaborative

Hendren et al. Am. J Surg 2011

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Problem: Patients arrive in the recovery room with temperature < 36°C despite having a forced air warmer during surgery

Johns Hopkins CUSP Experience:Room for Improvement in SCIP Compliance

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Normothermia Project Johns Hopkins

Before After0

25

50

75

100

83%

95%

Temperature > 36 °C Post-Op

% o

f Pat

ient

s C

ompl

iant

Interventions

• Confirmed that temperature probes were accurate (trial comparing foley and esophageal sensors)

• Initiated forced air warming in the pre-operative area

• Heightened awareness

Wick et al, JACS 2012 (in press)

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EMERGING EVIDENCE FOR SSI PREVENTION

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1. Antibiotic Usage– Redosing– Weight based dosing of cephalosporins

2. Maintenance of normogylcemia3. Utilization of mechanical bowel preparation

with oral antibiotics4. Standardization of skin preparation

Emerging Evidence for SSI Prevention

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• Antibiotic Redosing

– Maintain therapeutic antibiotic serum levels during entire procedure

Additional Interventions to Improve Antibiotic Efficacy

Consensus Guidelines, in pressIDSA/SIS/SHEA/AHPS

Medication Dosing Interval

Cefazolin q3hrs

Cefotetan q6hrs

Cefoxitin q2h

Clindamycin q6h

Vancomycin q12h

BACKGROUND:• Hyperglycemia is common in

hospitalized patients

• 38% of medical and surgical patients had hyperglycemia (26% diabetic and 12% non-diabetic

• In cardiac surgery, degree of post-operative hyperglycemia correlates with SSI; adopted as SCIP measures

GOAL: Glucose <180mg/dl in all hospitalized patients

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Hyperglycemia and Infection

Ramos. Ann Surg 2008

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BACKGROUND• 1012 Bacteria reside on the skin• Staphlococcus and Streptococcus species among others

GOAL OF SKIN PREPARATION• Reduce bacterial burden on skin prior to incision

BEST PRACTICE• Dual-agent skin preparation (chlorhexidine + alcohol, providone-iodine

+alcohol)• Skin prep should include alcohol to increase durability of sterilization• Prep should be applied to specification (duration and amount)• Prep must dry before incision

Preparation of the Surgical Site

Darouiche RO et al. N Engl J Med. 2010 Swenson BR et al. Infect Control Hosp Epidemiol. 2009

• Oral antibiotics for prevention of SSI was first described in the 1940’s

• 1973 Nichols and Condon FAVORABLE

• 1974 Washington et al randomized trial FAVORABLE

• 1990’s-2000’s oral antibiotics fell out of favor in US– Patients not tolerant of preparation (nausea, dehydration)

• 2002 Lewis et al – Randomized controlled trial– Oral neomycin and metronidazole plus systemic antibiotics vs

systemic antibiotics alone (5% neomycin and metronidazole vs 17% placebo)

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Bowel Preparation:A Brief History

Reviewed in Fry, 2011.

Bowel Preparation:A Brief History

• Rigorous studies of IV antibiotics did not include oral antibiotics

• 1990’s-2000’s oral antibiotics fell out of favor in US– Patients not tolerant of preparation (nausea, dehydration)– Patients no longer admitted to hospital pre-operatively

• Lewis et al (2002)– Randomized controlled trial– Oral neomycin and metronidazole plus systemic antibiotics vs systemic

antibiotics alone (5% neomycin and metronidazole vs 17% placebo)

• 2012– AHPSA guidelines on antimicrobial prophylaxis endorse use of oral

antibiotics with mechanical bowel preparation plus IV antibiotics to prevent SSIs

25Reviewed in Fry, 2011.

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Cochrane Review:Oral Antibiotics + Bowel Preparation is Associated with Lowest SSI Rate

1Guenega, Cochrane Database Syst Rev,20092Nelson, Cochrane Database Syst Rev,2009

Slide adapted fromPatch Dellinger, MD University of Washington

SS

I Rat

e

Nelson Study1 Guenaga Study2

SS

I Rat

eMBP + oral +

parenteral

MBP - no oral +

parenteral

MBP + + parenteral

No MBP + + parenteral

MBP = Mechanical Bowel Preparation

• Appropriate prophylactic antibiotics– Selection*– Weight-based dosing of cephalosporins– Timing*– Redosing– Discontinuation*

• Appropriate hair removal as close to time of surgery as possible*

• Temperature management*• Appropriate glycemic control• Dual agent (with alcohol) surgical skin prep • Mechanical bowel prep and oral antibiotics

Summary of SCIP and Emerging Evidence to Prevent Colorectal SSIs

*SCIP measures 28

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• Review current colorectal SSI bundles at your hospital (policy and practice)

• Review hospital process measure data

• With assembled CUSP team, plan for administration of staff safety assessment

Next Steps

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Who’s on the call?

Poll

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Does your hospital have a colorectal SSI bundle in place?

Poll

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If your hospital has a colorectal SSI bundle in place, what’s in it?

Poll

On-boarding Call Evaluation

We want to ensure that the on-boarding callsprovide useful and pertinent information for theSUSP teams. For this reason we request thatyou complete a brief evaluation following eachcall. The evaluation may be found at thefollowing link:

https://www.research.net/s/Onboarding_Evaluation