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CDS PROJECTASSURING APPROPRIATE ADHERENCE AND REPORTING OF ANTIBIOTIC SURGICAL SCIP
MEASURE
Dave Robbins
Lisa Heavilon
Wendelyn Bradley
Bonnie Livingston
Hospital Acquired Infections
HAIs in American hospitals:
•1.7 million infections and 99,000 deaths each year •Of these infections, 22 percent are surgery-related
Post-operative infections:
•Prior to the mid 19th century “irritative fever” common – purulent incisional drainage, sepsis, and often death
•1860s - Joseph Lister’s work radically changed surgery from an activity associated with infection and death to a discipline that could eliminate suffering and prolong life
GENERAL BACKGROUND
Surgical site infection prevention
• Surgical site infections account for 15% of all hospital-acquired infections
• Patients who develop surgical site infections are twice as likely to die as other surgical patients
• Preoperative antibiotics given within 1 hour of incision optimize drug levels in the tissues and are more effective than prophylactic antibiotics administered during or after the operation
• Appropriately chosen antibiotics provide effective protection against bacteria common at surgical sites without giving excessively broad coverage.
Negative Outcome Poorer patient outcomes
• Increased length of stay• Need for additional health care (MD visits, home
care, medications)• Development of organism resistance
Costs • HAIs cost up to $45 billion per year• Infection control interventions could save approx
$31 billion per year• CMS refusing reimbursement for post-operative
infections
Public Perception• Published results i.e. Hospital Compare• Word-of-mouth
PROBLEM DEFINITION
• Hospital 80% compliant with SCIP Core Measure for antibiotic administration prior to surgical procedures
• CMS diminished payment due to current compliance number
• Tedious and time consuming chart review for report generation and submission to CMS
• Physician frustration
• IC concern over potential increase of post operative infection rate
Goal DEFINITION
• Improve compliance with antibiotic surgical SCIP measures from 80% to 100% within one year of CDS implementation
• Reduce CMS non-reimbursable HAI’s • Automated data, analysis, and
presentation reporting• Stay current with relevant regulations,
standards and benchmarks. – Facilitate HAI mandatory reporting to NHSN– Achieve TJC 2009 National Patient Safety Goals
MODEL UTILIZED
• Alert System [at two clinical junctures]– Use of data elements to include
• Transactional• Temporal• Text
• Data repository for reporting to include– Data Management– Model Management– Knowledge Engine– User Dashboard
MODEL KNOWLEDGE
Transactional Data Elements
• Antibiotic Algorithm for Surgical Type
• Over-ride transaction message
• CPT/ICD-9=Surgical Type• MR #• Account #• Surgery/Admit Date • NDC• Antibiotic Administration
Date• Discharges with an ICD-9-CM
Principal Procedure Code or ICD-9-CM Other
Temporal Data Elements
• Antibiotic Administration Time
• Surgical Incision Time
Database Elements• Data Base Management• Model Management• Knowledge engine• User Dashboard
MODEL KNOWLEDGE
Included Populations:• ICD-9-CM Principal Procedure
Code or ICD-9-CM Other Procedure Code for selected surgical types.
• Discharges with an ICD-9-CM Principal Procedure Code or ICD-9-CM Other
Excluded Populations:• Admission DX suggestive of
preoperative infectious diseases
• Antibiotics within 24 hours prior to arrival (except colon surgery patients taking oral prophylactic antibiotics).
• Readmissions of patients with MDRO history
• Post-surgical re-admits• Micro lab confirmation of
reportable diseases
Denominator Statement: All selected surgical patients with no prior evidence of infection
MODEL-SX-ABX Algorithm
HIP/KNEE ARTHROPLASTY
• Preferred: – Cefazolin (AncefÆ)
• High-risk for MRS (documented)– Vancomycin
• If Beta-lactam-allergy:– Vancomycin– Clindamycin
CV-VASCULAR SURGERY
• Preferred: – Cefazolin (AncefÆ)
• High-risk for MRS (documented)– Vancomycin
• If Beta-lactam-allergy:– Vancomycin– Clindamycin
Use of Vancomycin for surgical prophylaxis, in the absence of a documented beta-lactam allergy, requires physician documented rationale in the medical record.
MODEL-SX-ABX Algorithm
• COLORECTAL SURGERY-GENERAL SURGERY• Cefotetan (CefotanÆ) or Cefazolin (AncefÆ) and
Metronidazole (FlagylÆ)• Or Ampicillin-sublactam (UnasynÆ)• Or Ertapenem (InvanzÆ) as a single dose• If Beta-lactam allergy:
– Clindamycin combined with Gentamicin or parenteral Fluroquinolone
– or AztreonamorMetronidazole (FlagylÆ) with Gentamicin or parenteral Fluroquinolone (LevaquinÆ)
MODEL FRAMEWORK
System Description
• Key components
• HIS• AIS/OR • CPOE (with predefined order templates)• PIS • ADC (with antibiotic compliance alerts)• LIS• HAI Monitoring • Data Warehouse
• Integration made possible via HL7• Standard codes CPT, NDC
Functional Overview
Specialized Antibiotic Alert
• At the time of dispense the ADC presents an alert if the prescribed antibiotic (based in NDC) does not match the surgical procedure (based on CPT)
• Anesthesiologist or Nurse may override the alert to dispense the ordered or alternate antibiotic
• System log is maintained with date/time, user id, NDC and reason for override whenever the alert is triggered
Specialized Antibiotic Alert
• All overrides must be accompanied by a justification
• Non-conforming antibiotics must be chosen from a predefined list
• AIS/OR system records date and time of medication administration for comparison against cut time
Non-conforming Antibiotic Alert
Alert Override Justification
Evaluation Overview
• Core Evaluation Goals– Goal 1: Functional Integrity
• Assess the CDS to make sure it is functioning as intended.
– Goal 2: Intervention Performance• Evaluate the performance of the intervention
against organizational objectives and industry benchmarks.
– Goal 3: Continuous Product Improvement• Refine the intervention, keep it up to date,
evaluate it in context.
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Goal 1: Functional Integrity
• Verification: Was the Intervention Built Correctly?– Confirm PFO is displayed under right
conditions.– Alerts are fired 100% at correct time, 0% at
incorrect time.
• Validation: Was the Right Intervention Built?– Staff interviews, workshops and surveys.– Observation.
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Example Industry Benchmarks
Goal 2: Intervention Performance
• Direct Objectives: Increase Compliance with SCIP Guidelines– Appropriate Antibiotic Selection
• Automated data collection, monthly reporting• Compare to monthly trend and industry benchmarks
– Timeliness of Antibiotic Administration• Automated data collection, monthly reporting• Compare to monthly trend and industry benchmarks
• Indirect Objectives: Decrease Surgical Site Infections– Trend surgical site infections over time– Differentiate from overlapping interventions
Goal 3: Continuous Improvement
• Currency: Keep knowledge up to date• Annual knowledge expiration date• SCIP Program listserv• Receive updates from vendor
• Refinement: Improve and extend• Assess ways to improve efficiency and efficacy with
workshops and surveys• Evaluate ways to extend the system capabilities to
deliver additional value
• Portfolio Management: Evaluate in Context
• Evaluate high level goals across specific interventions• Plan for future interventions in coordinated fashion
CONCLUSION
We’ve presented • An overview• The Model• System Description
• Evaluation
Are there any questions?
Thanks!
Thanks to Gary Larson
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