Developing a surgical site infection bundle to improve patient outcomes - PowerPoint Presentation

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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 2010Slide6
Slide7

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)