Felix W Tsai MD 1 Kathy Masters RD 2 Douglas Maposa MD 3 Lillian S Kao MD 4 Charles Monney MS 5 and Galit HolzmannPazgal MD 6 1 Department of Pediatric Surgery 3 Department of Anesthesia 4 Department of Surgery 6 Department of Pediatrics UTHSC 2 D ID: 678566
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Slide1
Developing a surgical site infection bundle to improve patient outcomes
Felix W. Tsai MD
1
, Kathy Masters RD
2
, Douglas
Maposa
MD
3
, Lillian S. Kao MD
4
, Charles
Monney
MS
5
, and
Galit
Holzmann-Pazgal
MD
6
1. Department of Pediatric Surgery, 3. Department of Anesthesia, 4. Department of Surgery, 6. Department of Pediatrics, UTHSC; 2. Department of Healthcare Improvement, 5. Department of Infection Control, Memorial Hermann HospitalSlide2
Background- 44,000-98,000 preventable deaths a year- World Health Organization (WHO) Surgical Safety Checklist demonstrated to decrease mortality and morbidity world-wide- National Health Service has since advocated universal usage of the checklist
N
Engl
J Med 2009;360:491Slide3
BackgroundSurgical Site Infections Range between 2-5% for all surgical patients- Can add up to $30,000 additional hospital costs- Patient specific risk factors- Modifiable risk factors- Our infection rate- Between July 2007-December 2008, 7%- Between January 2009-September 2009, 4.8%Slide4
Goals- Decrease overall infection rates to less than 3% within 12 months- To develop a Surgical Site Infection (SSI) bundle, facilitated by an operative checklist, to decrease morbiditySlide5
Methods- SSI bundle creationPreoperative chlorhexidine baths – September 2008Routine antibiotic discontinuation within 48 hours – April 2009- Standardized prophylactic
Vancomycin
(targeted antibiotics) –
January 2010
- Antibiotics given 30-120 minutes before skin incision –
March 2010Slide6Slide7
Methods- SSI bundle creation- Preoperative chlorhexidine baths- Standardized prophylactic Vancomycin (targeted antibiotics) - Antibiotics given 30-120 minutes before skin incision- Routine antibiotic discontinuation within 48 hoursSlide8
Methods- SSI bundle creationPreoperative chlorhexidine baths- Routine antibiotic discontinuation within 48 hours- Standardized prophylactic Vancomycin (targeted antibiotics)
- Antibiotics given 30-120 minutes before skin incision
1
1
J
Antimicrob
Chemother
2006;58(3):645Slide9
Methods- SSI bundle creationPreoperative chlorhexidine baths- Routine antibiotic discontinuation within 48 hours- Standardized prophylactic Vancomycin (targeted antibiotics)
- Antibiotics given 30-120 minutes before skin incision
1
1
J
Antimicrob
Chemother
2006;58(3):645Slide10
Methods- SSI bundle creationPreoperative chlorhexidine baths- Routine antibiotic discontinuation within 48 hours- Standardized prophylactic Vancomycin
(targeted antibiotics)
- Antibiotics given 30-120 minutes before skin incision
1
1
J
Antimicrob
Chemother
2006;58(3):645Slide11
Methods- SSI bundle creationPreoperative chlorhexidine baths- Routine antibiotic discontinuation within 48 hours- Standardized prophylactic Vancomycin (targeted antibiotics) -
Antibiotics given 30-120 minutes before skin incision
1
1
J
Antimicrob
Chemother
2006;58(3):645Slide12
Methods- Risk stratification by Risk Adjusted Congenital Heart Surgery (RACHS) score- Low risk (RACHS 1, 2)- Medium risk (RACHS 3, 4)- High risk (RACHS 5, 6)Slide13
MethodsRetrospective and prospective data collection between August 2007 to August 2010Continuous ongoing data collectionPreoperative baths – September 2008
Routine antibiotic discontinuation within 48 hours – April
2009
- Standardized antibiotic usage in January 2010
Implementation
of operative checklist began on March 24,
2010
- First cohort (August 2007-March 2010): 349 patients
- Second cohort (March 2010-September 2010): 73 patientsSlide14
Methods- Outcomes measured- Time between antibiotic administration and skin incision- SSI ratesSlide15
ResultsRandom audits of preoperative baths: 100% complianceRoutine discontinuation of antibiotics on order form: 100%Standardized usage of Vancomycin: >95%- Before the checklist, appropriate timing and dosing was only found in 21.4 - 40% of patientsAfter the checklist, actual compliance was 97.2% in all cases requiring cardiopulmonary bypassSlide16
Results
Pre-intervention Antibiotic to Skin Incision Time
Post-intervention Antibiotic to Skin Incision Time
p value
Low Risk
(RACHS 1,2)
26
±
34
Median = 24
minutes
60
±
29
Median = 59
minutes
0.003
Medium Risk
(RACHS 3,4)
32
±
27
Median = 22.5
minutes
55
±
28
Median = 62.5
minutes
0.000
High Risk
(RACHS 5,6)
26 ± 13 Median = 21 minutes59 ± 23 Median = 57 minutes0.036
Surgical operations stratified as low risk, medium risk and high risk
Pre- and post-bundle antibiotic dosage timing was analyzed by Student’s t-testSlide17
Antibiotic Dosing IntervalSlide18
ResultsSlide19
ResultsSlide20
ResultsSlide21
Conclusions- A SSI bundle appears to improve antibiotic delivery to biologically plausible timesThis may help decrease the overall risk of developing a SSIQuality process improvement requires a baseline commitment and environmentSlide22
ConclusionsChecklists are flexible tools that may be effective in a variety of situations- Checklist utilization serve as reminders and may improve teamwork and intraoperative safety cultureSlide23
Future DirectionsContinue SSI surveillanceGeneral pediatric surgery: process compliancePediatric neurosurgery & plastic surgery: near-misses (implants)Laparoscopic surgery: OR efficiencyFurther studies are needed to determine factors that help and hinder checklist utilizationSlide24
AcknowledgementsJannette GutierrezJose DelgadoRaul GuardiolaBetsabe QuezadaSarah Eshelman
Heather Dunne
Bill Douglas
Mohammed
Rafique
Kevin
Lally
Kathy Masters
Eric Thomas
This work was supported in part by a training fellowship from the AHRQ Training Program of the W.M. Keck Center for Interdisciplinary Bioscience Training of the Gulf Coast Consortia (AHRQ Grant No. T32 HS017586)