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Perioperative Antibiotic Prophylaxis: What Anesthesia Needs to Know

Neil Roy Connelly, MD Professor of Anesthesiology Tufts University School of Medicine

Outline
Science/History Consensus Oversight Results Process

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Antibiotic Prophylaxis in Gastric, Biliary and Colonic Surgery, 1976

400 patients 4 groups:

Early (12 hrs before incision) Preoperative (1 hr before incision) Postoperative (1 hr after closure) None

Antibiotic Prophylaxis in Gastric, Biliary and Colonic Surgery

Early = Preoperative Early/Preoperative better than None Postoperative = None

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Timing of Antibiotic Prophylaxis GI Operations

20% 15% 10% 5% 0% 12 hr Preop 1 hr Preop Postop Placebo

Stone HH et al. Ann Surg. 1976;184:443-452.

2847 patients 4 groups:

Early (2-24 hrs before incision) Preoperative (2 hrs before incision) Perioperative (3 hrs after incision) Postoperative (3-24 hrs after incision)

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Infection Rates
Early 3.8% Preoperative 0.6% Perioperative 1.4% Postoperative 3.3%

Perioperative Prophylactic Antibiotics

Timing of Administration
4

14/369

15/441 1/41

Infections (%)

1/47 1/81 5/699 5/1009 2/180

-3

-2

-1

Hours From Incision

Classen. NEJM. 1992;328:281.

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Bratzler, et alAdvisory Statement

3 Measures:
Tiiming Correct Choice Duration of therapy

Bratzler, et alAdvisory Statement

Timing: within 1 hr
vs 30 minvs 120 min consensus opinion not scientific proof Quality projects

Correct Choice Duration of therapy

No evidence >24 hrs offers benefit >24 hrs does inc resistance/ c diff

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Bratzler, et al.: Results

Tiiming: 55.7% Correct Choice: 92.6% Duration of therapy: 40.7%

Antibiotic Timing Related to Incision

60 50
56

Percent

40 30 20 10 0
0 12 061 60 -0 24 018 1 18 012 1 060 0 12 118 0 24 61 -1 2 >
2.7 1.2 4.3 20.3

Incision

9.6 2.8 1.4 0.9 0.9

18 124 0

Minutes Before or After Incision

Bratzler DW, Houck PM, et al. Arch Surg. 2005;140:174-182.0

>

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www.medqic.org/sip

Surgical Care Improvement Project

Formerly SIP National Quality Partnership

CMS,CDC

Reduce nationally the incidence of surgical complications by 25% by 2010 (13,027 deaths, 271,055 complications)/yr Focus on

Surgical infection prevention Adverse cardiac events Prevention of DVT Post operative pneumonia

Using evidence based medicine

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Surgical Infection (SI): Epidemiology & Impact

SSI = Surgical Site Infection Account for 14-16 % of all Hospital Acquired Infections (HAI) 2-5% of operative patients will develop SI

0.8-2 million infections a year Average 7.5 additional days $130-$845 million per year Adds $2,734 - $26,019 per pt (average $3,000)

SI increase LOS

Excess costs

Pain and suffering

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SI: Patients who develop infection

60%

more likely to spend time in an ICU 5 times as likely to be readmitted Have a mortality rate twice that of noninfected patients
An

estimated 40-60% of these infections are preventable

IPPS Inpatient Prospective Payment System APU Annual Payment Update

U AP

re inc

as

t ed

% o2

Financial Incentive for SCIP

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Baystate Medical Center

700 bed tertiary care referral center (population of ~1M) 41 k admissions/year Annual surgical volume: 29,043 Member CoTH, 9 residency programs, 244 residents---Council of Teaching Hospitals 1200 member medical staff, 206 faculty MDs Level 1 Trauma Center IHI Mentor Hospital Surgical Infection Prevention institute for health care improvement

SIP Baseline 2002

100 80

BMC Baseline 02 National Baseline 02

% Patients

60 40 20 0 SCIP 1 SCIP 2 SCIP 3

Use of antimicrobial prophylaxis for major surgery: baseline results from the National Surgical Infection Prevention Project Arch Surg. 2005 Feb;140(2):174-82.

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Quality Improvement Process

Benchmarking, measurement, and feedback Work with key physician champions Disseminate recommendations to educate Use physician order entry Enlist help of case managers as quality safety net Use PDSA cycles to test and improve

HAVE BUY INADMINISTRATION

Prophylactic Antibiotics
Antibiotics given for the purpose of preventing infection when infection is not present but the risk of post-operative infection is present

11

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Prophylactic Antibiotics
Questions

Which cases benefit? When should you start? Which drug should you use? How much should you give? How long should antibiotics be continued?

Recently Updated Antibiotic Recommendations

Surgery Type Hip or knee arthroplasty Antimicrobial recommendations Preferred: Cefazolin or cefuroxime If patient high risk for MRSA: Vancomycin* Beta-lactam allergy: Vancomycin or clindamycin Cardiac or vascular Preferred: Cefazolin or cefuroxime If patient high risk for MRSA: Vancomycin* Beta-lactam allergy: Vancomycin or clindamycin

* For the purposes of national performance measurement a case will pass the antibiotic selection performance measure if vancomycin is used for prophylaxis (in the absence of a documented beta-lactam allergy) if there is physician documentation of the rationale for vancomycin use (effective for July 2006 discharges).

Recently Updated Antibiotic Recommendations (continued)

Surgery Type Hysterectomy Antimicrobial recommendations Cefotetan, cefazolin, cefoxitin, cefuroxime, or ampicillin-sulbactam Beta-lactam allergy: Clindamycin + gentamicin or fluoroquinolone* or aztreonam Metronidazole + gentamicin or fluoroquinolone* Clindamycin monotherapy Colorectal Neomycin + erythromycin base; neomycin + metronidazole Cefotetan, cefoxitin, cefazolin + metronidazole, or ampicillinsulbactam Beta-lactam allergy: Clindamycin + gentamicin or fluoroquinolone* or aztreonam Metronidazole + gentamicin or fluoroquinolone*
* Ciprofloxacin, levofloxacin, gatifloxacin, or moxifloxacin (effective for July 2006 discharges). For the purposes of national performance measurement, a case will pass the antibiotic selection indicator if the patient receives oral prophylaxis alone, parenteral prophylaxis alone, or oral prophylaxis combined with parenteral prophylaxis.

12

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Prophylactic Antibiotics
Questions

Which cases benefit? When should you start? Which drug should you use? How much should you give? How long should antibiotics be continued?

Visual Prompt and data collection

BMC AB Timing by Anesthesiologist BMC AB Timing by Anesthesiologist

100 90 80 70
% Patients

2004 2005 Jan-June 2006 July-Dec 2006

60 50 40 30 20 10 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

Never Underestimate the Power of Competition

13

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Memorandum
DIVISION OF HEALT HCARE QUALITY TO: FROM: Associate Medical Director DATE: , 2006 , MD

SUBJECT: SCIP (Surgical Care Improvement Program) As part of the SCIP process, the medical record of PATIENT was reviewed. As eviden ced by the attached documentation , it appearsthat thepatient s prophylactic pre -operativeantibiotic w as: _____given greater than 1 hour prior to th e initial incisiontime, _____not re-dosed. _____given after the initial surgical incision. _X__not g iven at all ( no time of administration was documented) Pleaserememberthat current standard of practice is prophylactic pre -operative an tibiotic administration within 60 minutes p rior to the incision (Levaq uin and Vancomycin are within 120 minutes prior to theincision ). Re-dosing of antibiotics if the case extends beyond 3 hours when cefazolins are used Please contact me at 4 4326 if you have any questions. Thank you.

SIP: Prophylactic AB given < 60 M Prior to Incision Baystate Medical Center Springfield MA USA 100 Improved documentation

National Top Decile BMC Rate

80
Ongoing 1:1 review of outliers
% Patients

60
Anesthesiologists to give Abs rates posted in OR

Pre printed prompt on Anesthesia record

Ongoing Review

40 20

Pre op gives AB Initial education all staff, Rates adoped for monthly report to PI teams SIP starts

Anesthesiologist specific score card adopted for posting; Ongoing 1:1 review of outliers

0
Ap r-0 2 Ju n-0 Au 2 g -0 2 Oc t-0 De 2 c -0 Fe 2 b-0 Ap 3 r-0 3 Ju n-0 Au 3 g -0 3 Oc t-0 De 3 c -0 Fe 3 b-0 Ap 4 r-0 4 Ju n-0 Au 4 g -0 4 Oc t-0 De 4 c -0 Fe 4 b-0 Ap 5 r-0 5 Ju n-0 Au 5 g -0 5 Oc t-0 De 5 c -0 Fe 5 b-0 Ap 6 r-0 6 Ju n-0 Au 6 g -0 6
BMC Prophylaxis AB Timing (within 60 M of incision)
100

National Top Decile BMC Rate

80

% Patients

60

40 20

0
Apr02 Jun- Aug- Oct- Dec- Feb- Apr02 02 02 02 03 03 Jun- Aug- Oct- Dec- Feb- Apr03 03 03 03 04 04 Jun- Aug- Oct- Dec- Feb- Apr04 04 04 04 05 05 Jun- Aug- Oct- Dec- Feb- Apr05 05 05 05 06 06 Jun- Aug- Oct- Dec- Feb06 06 06 06 07

BMC Prophylaxis AB Duration (DC within 24 H surgery end time )

100 80
% Patients

National Top Decile BMC Rate

60 40 20 0
Apr- Jun- Aug- Oct- Dec- Feb- Apr- Jun- Aug- Oct- Dec- Feb- Apr- Jun- Aug- Oct- Dec- Feb- Apr- Jun- Aug- Oct- Dec- Feb- Apr- Jun- Aug- Oct- Dec- Feb02 02 02 02 02 03 03 03 03 03 03 04 04 04 04 04 04 05 05 05 05 05 05 06 06 06 06 06 06 07

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How to do it

Electronic promptreference

Prophylactic Antibiotics
Questions

Which cases benefit? When should you start? Which drug should you use? How much should you give? How long should antibiotics be continued?

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Quality Indicator #2:

Proportion of patients who receive prophylactic antibiotics consistent with current recommendations

Antibiotic Recommendation Sources

American Society of Health System Pharmacists Infectious Diseases Society of America The Hospital Infection Control Practices Advisory Committee Medical Letter Surgical Infection Society Sanford Guide to Antimicrobial Therapy 2003

Antibiotic Selection Successful Interventions

Distribution of guidelines to perioperative staff (standardize practice) Antibiotic selection and ordering (standardize process) Decision aids in the system (active prompt ) Use of cephalosporins and vancomycin/ gentamicin in penicillin allergic patients Reviewed and revised AB selections in computer order sets (opt out, forcing function)

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ADMISSION ORDER FORM FOR SURGICAL OR DIAGNOSTIC PROCEDURES

**SURGERY
Last name: ____________________________ First name: ________________ MI: _______ Date of birth:______________ Physician: __________________ PCP:____________________ Surgery/procedure date:____/____/___ Time:__________ Hospital based PAE booked? YES: NO: If yes specify reason: ______________________________________________

PROCEDURE: __________________________________________________________________________________________

_________________________________________________________________________________ _________________________________________________________________________________
________________________________________________________________________________________________________ CONSENT: _____________________________________________________________________________________________

_________________________________________________________________________________ _________________________________________________________________________________ ALLERGIES: _______________________________________________________________________ _________________________________________________________________________________ ___________________________________________________________________ Patient states none

PRE OPERATIVE ORDERS include IV fluids, selected medications and laboratory tests including Type and Screen will be ordered according to Baystate Medical Center Preadmission Evaluation Guidelines. No additional laboratory requests are necessary. SPECIAL LABORATORY TESTS PER MD REQUEST:_________________________________________________________________

Type of Surgery

If No Penicillin Allergy
1 gm (<70Kg) 2 gm (>70 Kg) IV cefazolin or cefoxitin

(Pts weight in _____ KG)

Colectomy/rectal resection Appendectomy Non-perforated Biliary Tract and Pancreas/ Gastroduodenal/small intestine Breast; Hernia Orthopedic Head/neck procedures Neurosurgery; Kidney transplant Hysterectomy Urologic

If anaphylaxis to penicillin or Cephalosporin or documented high risk for resistant organism clindamycin IV 600 mg PLUS gentamicin IV 80 mg if pt wt < 70 K or 120 mg > 70 K vancomycin IV 1 gm IVPB PLUS gentamicin IV 80 mg if pt wt < 70 K or 120 mg > 70 K vancomycin IV 1 gm OR clindamycin IV 600 mg vancomycin IV 1 gm OR clindamycin IV 600 mg vancomycin IV 1 gm

Alternative

cefoxitin IV give 1 gm if wt < 70 Kg or 2 gm if wt > 70 kg cefazolin IV give 1 gm if wt < 70 Kg or 2 gm if wt > 70 kg cefazolin IV give 1 gm if wt < 70 Kg or 2 gm if wt > 70 kg cefazolin IV give 1 gm if wt < 70 Kg or 2 gm if wt > 70 kg cefazolin IV give 1 gm if wt < 70 Kg or 2 gm if wt > 70 kg cefazolin IV give 1 gm if wt < 70 Kg or 2 gm if wt > 70 kg levofloxacin 500 mg PO OR IV cefazolin IV give 1 gm if wt < 70 Kg or 2 gm if wt > 70 kg

Urologic Robotic Procedure (radical prostatectomy)

clindamycin IV 600 mg PLUS gentamicin IV 80 mg if pt wt < 70 K or 120 mg > 70 K vancomycin IV 1 gm IVPB PLUS gentamicin IV 80 mg if pt wt < 70 K or 120 mg > 70 K vancomycin IV 1 gm IVPB PLUS gentamicin IV 80 mg if pt wt < 70 K or 120 mg > 70 K

DVT PROPHYLAXIS: (select chemical prophylaxis based on patient existing co-morbidities) Enoxaparin 40 mg subcutaneous x1 in Pre op Holding Unit. Hold for patients receiving epidural catheter Unfractionated Heparin 5000 units subcutaneous x1 in Pre op Holding Unit. Pneumatic compression device (if not lower extremity vascular procedure) in cases >30 minutes of general anesthesia HAIR REMOVAL Clip or None OTHER: Confirm Advanced Directives

PRE OPERATIVE MEDICATIONS: ________________________________________________________________________ _________________________________________________________________________________________________________ ________________________________________________________________________________________________________ Physician signature: ____________________________________________________________ Date: _____________________ H&P Dictated by________________ Date: ______ Where sent: ___________________ FAX COMPLETED AND SIGNED FORM TO PAE (413) 794 1856 OR (413) 794 4875

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Division of Healthcare Quality

June , 2006 Dear Doctor ____________: Healthcare Quality at Baystate Health System is a top priority for our patients and for our organization. Since May 2002, we have been participating in a number of national projects to improve the quality of care provided to patients admitted to BMC for surgical procedures. Two of the quality measures we monitor are prophylactic antibiotic selection and duration. Our goal is to achieve 100% compliance with appropriate selection (based on the latest recommendation to prevent surgical infections from national organizations and local experts) and short duration (stopping antibiotic within 24 hours of end time). It has been shown that prophylactic antibiotic use greater than 24 hours conveys no advantage than short term antibiotic (<24 hours) to decrease the rate of post operative surgical infections, and in some case will contribute to increases in development of resistant organisms. Since 2002, BMC has been working on correct selection and stopping antibiotic dosing within 24 hours of surgery end time. Currently, our rate is at the state average for selection and less than the state average for duration for Massachusetts teaching hospitals. Recently, you and your colleagues cared for _________________ at BMC (__/__/200_), whose chart was flagged as having the: ____ incorrect antibiotic selection based on document in the medical record ____ duration of prophylactic antibiotics > 24 hours of surgery end time We want to call your attention to this recent hospitalization to emphasize the current quality improvement measures we are tracking for some of your patients. If you believe there was an error in this determination, please contact Jan Fitzgerald, MS, RN at 794-2531 or Gina Trelease, MEd, RN at 794-2432. Attached to this letter is a list of quality measures we are tracking that may involve your patients. Thank you for participating in the quality improvement process. Please let us know how we can help you to provide the highest quality care to your patients admitted to BMC.

SIP: Appropriate Antibiotic Selection - All Patients

100 80
% Patients

BMC Rate Target

60 40 20 0
Jul-04 Mar-04 Mar-05 Jul-05 May-04 May-05 Mar-06 May-06 Jan-04 Jan-05 Nov-04 Nov-05 Sep-04 Sep-05 Jan-06

Expanded pt populations

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Prophylactic Antibiotics
Questions

Which cases benefit? When should you start? Which drug should you use? How much should you give? How long should antibiotics be continued?

Quality Indicator #3
Proportion of patients whose prophylactic antibiotics were discontinued within 24 hours of surgery end time

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Discontinuation of Antibiotics
100
85.8 79.5 88 90.7

100

80

73.3

80
Cumulative Percent

Percent

60
40.7

50.7

60

40
26.2 22.6

40

20

14.5 10 6.2 6.3 9.3 2.2 2.7

20

0
-2 4 -3 6 -4 8 -6 0 -7 2 -8 4 le -9 6 >1 2 >2 4 >3 6 >4 8 >6 0 >7 2 >8 4 > 96 ss

12

or

Hours After Surgery End Time

Patients were excluded from the denominator of this performance measure if there was any documentation of an infection during surgery or in the first 48 hours after surgery.
Bratzler DW, Houck PM, et al. Arch Surg. 2005;140:174-182.

Antibiotic Prophylaxis Duration

Most studies have confirmed efficacy of

12 hours

Many studies have shown efficacy of a

single dose
Whenever compared, the shorter course

has been as effective as the longer course

Papers Comparing Duration of Peri-op Antibiotic Prophylaxis

Colorectal Mixed GI Hysterectomy Gyn & GI Head & Neck Orthopedic Vascular Cardiac Total

3 4 3 1 3 4 3 __7__ 28

Papers supporting longer duration 1

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Duration should not exceed 24-hour Prophylactic antibiotics should be discontinued within 24 hours of the end of surgery Medical literature does not support the continuation of antibiotics until all drains or catheters are removed and provides no evidence of benefit past 24 hours

http://www.aaos.org/wordhtml/papers/advistmt/1027.htm

Consequences of Prolonged AB Use

Increased antibiotic and drug administration costs Increased antibiotic-associated complications Increased patterns of antibiotic resistance Clostridium difficile Enterocolitis Colonization with MRSA

Division of Healthcare Quality

July, 2006 Dear Doctor ___________: Healthcare Quality at Baystate Health System is a top priority for our patients and for our organization. Since May 2002, we have been participating in a number of national projects to improve the quality of care provided to patients admitted to BMC for surgical procedures. Two of the quality measures we monitor are prophylactic antibiotic selection and duration. Our goal is to achieve 100% compliance with appropriate selection (based on the latest recommendation to prevent surgical infections from national organizations and local experts) and short duration (stopping antibiotic within 24 hours of end time). It has been shown that prophylactic antibiotic use greater than 24 hours conveys no advantage than short term antibiotic (<24 hours) to decrease the rate of post operative surgical infections, and in some case will contribute to increases in development of resistant organisms. Since 2002, BMC has been working on correct selection and stopping antibiotic dosing within 24 hours of surgery end time. Currently, our rate is at the state average for selection and less than the state average for duration for Massachusetts teaching hospitals. Recently, you and your colleagues cared for __________ at BMC (____/06), whose chart was flagged as having the: ____ incorrect antibiotic selection based on document in the medical record __X duration of prophylactic antibiotics > 24 hours of surgery end time We want to call your attention to this recent hospitalization to emphasize the current quality improvement measures we are tracking for some of your patients. If you believe there was an error in this determination, please contact Jan Fitzgerald, MS, RN at 7942531 or Gina Trelease, MEd, RN at 794-2432. Attached to this letter is a list of quality measures we are tracking that may involve your patients. Thank you for participating in the quality improvement process. Please let us know how we can help you to provide the highest quality care to your patients admitted to BMC. Sincerely,

confidential
Gary Kanter, M.D. Associate Medical Director, Healthcare Quality Neal Seymour M.D. Vice Chairman Department of Surgery

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BMC SCIP Progress

BMC Baseline 02 National Baseline 02 BMC 06 National Benchmark 06

100

80

% Patients

60

40

20

0 SCIP 1 SCIP 2 SCIP 3

Barriers Antibiotic Use

Timing Consistency Sustainability (constant monitor) Selection Resistance (surgeons and organism) Availability; national consensus issues Duration Knowledge gap If it s not broke, don't change it

Outcome

What s important? Meeting national criteria?

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SurgicalGRAPH Infection Rate 21B

Control Chart - All Surgery (1 qtr periods)

3.5% 3.0% 2.5% 2.0% 1.5% 1.0% 0.5% 0.0%
Mar-96 Mar-99 Mar-02 Sep-94 Sep-97 Sep-00 Sep-03 Mar-05 Dec-93 Dec-96 Dec-99 Dec-02 Dec-05 Sep-06 Jun-95 Jun-98 Jun-01 Jun-04

st.dev. 0.39% 3.16% 2.77% 2.39% avg 2.00% 1.61% 1.23% 0.84% inhse 0.86%

1.13 %

rate a+3s a+2s a+1s avg a-1s a-2s a-3s inhse

NNISS Benchmark = 2-11 %

Duration of Antibiotic Prophylaxis: What is Best for Our Patients?

Antibiotic prophylaxis is one (of many) methods for reducing SSI No evidence that antibiotics given after the operation prevent SSI There is evidence that increased use of antibiotics promotes antibiotic resistance

Hair Removal Pre-operative Shaving

Shaving the surgical site with a razor induces small skin lacerations:

Potential sites for infection Disturbs hair follicles which are often colonized with S. aureus Risk greatest when done the night before Patient education
be sure patients know that they should not do you a favor and shave before they come to the hospital!

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Shaving, Clipping & SI

12 Clean Clean-Contam

Infections (%)

0 PM Razor AM Razor PM Clipper AM Clipper

Alexander. Arch Surg 1983; 118:347

Hair Removal
" Shaving the night before an operation -- a

significantly higher SI risk than either the use of depilatory agents or no hair removal " Do not remove hair unless it will interfere with the operation (Category IA) " If hair is removed, remove immediately before, with electric clippers (Category IA)

Cochrane Database Syst Rev. 2006 Apr 19;(2)

Three trials involving 3193 patients Shaving vs clipping More SSIs when people were shaved (Rate Ratio 2.02, 95%CI 1.21 to 3.36)

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Interventions
Razors removed from OR s Razors removed from most clinical areas Patients may use razors for personal hygiene Clippers in every OR

ADMISSION ORDER FORM FOR SURGICAL OR DIAGNOSTIC PROCEDURES

**SURGERY
Last name: ____________________________ First name: ________________ MI: _______ Date of birth:______________ Physician: __________________ PCP:____________________ Surgery/procedure date:____/____/___ Time:__________ Hospital based PAE booked? YES: NO: If yes specify reason: ______________________________________________

PROCEDURE: __________________________________________________________________________________________

_________________________________________________________________________________ ________________________________________________________________________ _________

________________________________________________________________________________________________________ CONSENT: _____________________________________________________________________________________________

________________________________________________________________________ _________ _________________________________________________________________________________ ALLERGIES: _______________________________________________________________________ ________________________________________________________________________ _________ ___________________________________________________________________ Patient states none
PRE OPERATIVE ORDERS include IV fluids, selected medications and laboratory tests including Type and Screen will be ordered according to Baystate Medical Center Preadmission Evaluation Guidelines. No additional laboratory requests are necessary. SPECIAL LABORATORY TESTS PER MD REQUEST:_________________________________________________________________

Type of Surgery

If No Penicillin Allergy
cefazolin or cefoxitin 1 gm (<70Kg) 2 gm (>70 Kg)

(Pts weight in _____ KG)

Colectomy/rectal resection Appendectomy Non-perforated Biliary Tract and Pancreas/ Gastroduodenal/small intestine Breast; Hernia Orthopedic Head/neck procedures Neurosurgery; Kidney transplant Hysterectomy Urologic

IV

If anaphylaxis to penicillin or Cephalosporin or documented high risk for resistant organism clindamycin IV 600 mg PLUS gentamicin IV 80 mg if pt wt < 70 K or 120 mg > 70 K vancomycin IV 1 gm IVPB PLUS gentamicin IV 80 mg if pt wt < 70 K or 120 mg > 70 K vancomycin IV 1 gm OR clindamycin IV 600 mg vancomycin IV 1 gm OR clindamycin IV 600 mg vancomycin IV 1 gm

Alternative

cefoxitin IV give 1 gm if wt < 70 Kg or 2 gm if wt > 70 kg cefazolin IV give 1 gm if wt < 70 Kg or 2 gm if wt > 70 kg cefazolin IV give 1 gm if wt < 70 Kg or 2 gm if wt > 70 kg cefazolin IV give 1 gm if wt < 70 Kg or 2 gm if wt > 70 kg cefazolin IV give 1 gm if wt < 70 Kg or 2 gm if wt > 70 kg cefazolin IV give 1 gm if wt < 70 Kg or 2 gm if wt > 70 kg levofloxacin 500 mg PO OR IV cefazolin IV give 1 gm if wt < 70 Kg or 2 gm if wt > 70 kg

Urologic Robotic Procedure (radical prostatectomy)

clindamycin IV 600 mg PLUS gentamicin IV 80 mg if pt wt < 70 K or 120 mg > 70 K vancomycin IV 1 gm IVPB PLUS gentamicin IV 80 mg if pt wt < 70 K or 120 mg > 70 K vancomycin IV 1 gm IVPB PLUS gentamicin IV 80 mg if pt wt < 70 K or 120 mg > 70 K

DVT PROPHYLAXIS: (select chemical prophylaxis based on patient existing co-morbidities) Enoxaparin 40 mg subcutaneous x1 in Pre op Holding Unit. Hold for patients receiving epidural catheter Unfractionated Heparin 5000 units subcutaneous x1 in Pre op Holding Unit. Pneumatic compression device (if not lower extremity vascular procedure) in cases >30 minutes of general anesthesia

HAIR REMOVAL

Clip or

None

OTHER:

Confirm Advanced Directives

PRE OPERATIVE MEDICATIONS: ________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ _

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SSI Surveilance

How do we do it? What is investigated? Administrative Quality Support

Surveillance
" List of patients sent to each surgeon, 30 days

post procedure 97% return rate (SASE, interoffice mailing) Self report: any post operative infection/ comments " Daily admissions with wound infection Review for surgical date and s/s infection " Daily microbiology reports of all + cultures reviewed for wound, fluid cultures, e.g joint aspirates Charts reviewed for NNIS criteria, surgical date and s/s infection

Investigation
NNIS criteria: ASA, Wound Class, Length of Procedure Presence of interventions

Antibiotic use Surgical prep and skin condition Implants Specific conditions of the patient Surgical environment Organism Surgical team

Cluster evaluation

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Potentially Preventable Review

All infections reviewed for potential preventability using SCIP guidelines Reviewed using other criteria as well Review done by IC dept and fed back to multiple cmts (COI, SCIP, SPIT, SAQI) System level changes made when applicable Consistently, 50% of infections have a SCIP miss!!

Where Do Things Fall Through the Cracks?

System

information, tests, diagnoses Communication Hand offs Failure to recognize Failure to activate Failure to rescue

Improvement Tools
Systems Populations Cycles

of Change
Six Sigma, LEAN

PDSA,

Process

Analysis Failure Mode Identification BH PI Tool Kit

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Keys to Success
Persistence and reinforcement/high visibility Senior leader support Multidisciplinary cooperation & collaboration Willing to try changes and take a risk Develop reliable systems

Make changes easy and transparent

Stress importance of impact on patient and practitioner Make the Right thing the easy thing

Surveillance

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Background
>46,000

operations/year 2007 three successive quarters of elevated SSI Cluster Investigation

Cluster Investigation
Chart

review processing OR traffic Microbiology OR observations Link to specific OR? Link to specific practitioner? Link to Surgical Processing? Correct/timing of antibiotics?
Surgical

Standard
Soap Nail

Two hand Sterilization Techniques

Chlorhexidine/Alcohol

water pre-wash pick Sufficient solution

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Solution Chosen
Education Removal

of Product

Conclusion
There

is no right solution worked along with education Continued surveillance imperative

Removal

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Lessons Learned

Involve all stakeholders Leave your stripes at the door Must have physician champions- credible Be humble BROAD shoulders Must work as team Small tests of change with frequent tempo Small pilot population Work within your culture Make the right thing the easy thing

Future

Won t be antibiotics Will have equal or greater impact

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Check List Items

Wash Hands Prep Skin Gown/glove/mask/full drape Avoid Groin Remove ASAP

Real Value
Provide Framework for success/quality Empower all providers Standardize Care Don t worry about credit

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If 99.9% were good enough.

The IRS would lose over 2 million documents this year 16,000 items would be lost in the mail every hour There would be 37,000 ATM errors every hour There would be a major plane crash every 3 days 12 babies would be given the wrong parents each day 107 erroneous medical procedures would be performed each day 291 pacemakers would be incorrectly installed this year

Medicine used to be simple, ineffective, and relatively safe. Now

it is complex, effective, and potentially dangerous.

Sir Cyril Chantler

1999 Hollister Lecture at Northwestern University, Illinois

James, B. 16th IHI Conference

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