The Joint Commission Center for Transforming Healthcare (CTH)
Surgical Site Infections in Colorectal Surgeries Project: 2012
Sasha Madison, MPH, CIC
Director Infection Prevention & Control Dept.
May 14, 2014
PROJECT #4:
SURGICAL SITE INFECTION
• Collaborate with American College of
Surgeons & NSQIP measurement system
leveraged.
• Seven participating hospitals:
1. Mayo Clinic, MN
2. Cleveland Clinic, OH
3. Stanford Hospital & Clinics, CA
4. OSF Saint Francis, IL
5. Northwestern Memorial Hospital, IL
6. North Shore LIJ, NY
7. Cedars-Sinai Medical Center, CA
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Systematic Approach to Problem Solving –
Surgical Site Infections (1)
The Center worked with the American College of Surgeons to determine the
scope of the SSI project, since there is a wide range of surgeries and procedures
that can develop SSIs – each with its own unique set of complications and
challenges.
To help narrow the scope of the project, the following criteria were used to
identify a specific procedure that:
Is common across different types of hospitals
Has significant complications with an adverse clinical impact
Hospitals have significant opportunities to improve performance
Has high variability in performance across hospitals
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Collaborative Project Definition
DMAIC
Problem Statement:
 The incidence of Surgical Site Infections in colorectal surgery is high, variable, and
represents opportunity for improvement.
Goal:
 Reduce colorectal surgical site infections by 50% (Observed and Observed/Expected)
Scope:
 Process Begins: Pre-Operative Processes (Pre-Op Clinic with Surgeon)
 Process Ends: 30 Days Post-Surgery
 Includes: All emergent & elective surgical procedures
 Excludes: Trauma and Transplant patients & Patients under 18 years of age
Timeline:
August 2010 – March 2012
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2009 Metrics:
Observed & O/E Baseline Performance DMAIC
Metric 1- Observed Colorectal SSIs
Baseline: 18.5%
Target: 9.3%
(50% reduction)
Metric 2- O/E* Ratio for Colorectal SSIs
Baseline: 1.49
Target: 0.74
(50% reduction)
Average SSI Cases / Month = 3
Note: Observed/Expected / Index Value
Expected Value is Dependent on “Expected” influence/calculation
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SHC SSI Project Phases & Elements
DMAIC
Milestone
Key Elements
Define
Incidence of Surgical Site Infections in colorectal surgery is high, variable, and represents
opportunity for improvement.
Measure
Reduce colorectal surgical site infections by 50% (Observed and Observed/Expected)
Analyze
(Based on
statistical
analysis of
SHC data)
Statistically Significant Variables
(Potential Risk Factors for SSI)





Wound Disruption (0.003)
OR Duration (0.066)
ASA Class > 2 (0.015)
Open/Laparoscopic Procedure (0.054)
Total Hospital LOS (0.036)
Note: Above variables found to be statistically
significant, however not entirely modifiable.
- No Interventions Made
Potential Identified Variables /Opportunities
 Lowest Patient Intra-Operative Temperature
 Post-Operative Wound Care
 Hand Hygiene
 Dressing Removal at 48hrs
 Post-Operative Bathing
 Surgical Closure
 Glove Change Prior to Closing Fascia
 Separate Colorectal Closure Tray
 Tissue Irrigation
- Irrigation Solution Type
 Note: Actual Interventions in blue & Monitoring in green
Improve
Focus on identified causes, target solutions, patient outcomes
Control
Correlate interventions with SSI outcomes and create sustainability plans for any intervention
that successfully decreased SSIs
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Project Interventions & Monitoring
Improvement
Baseline
DMAIC
Target &
Measurement Tools
Implementation
Month-Year
Glove Changes
 Standardize closing process
59% of clinicians
responded “No” to
changing gloves before
closure

Colorectal Closure Tray
 Standardize major set closing tray
No separate closing tray
 100% separate and clean
closing instruments
 MIDAS Focus Audit
Patient and Room Temperature Guidelines
Given to OR & ASC
No baseline measurement
Per SCIP & AORN
Guidelines:
 Patient temperature should
be equal to or greater than
36 Degrees Celcius
 Ambient OR room
temperature should be
68-72 Degrees Fahrenheit
 MIDAS Focus Audit
August 2011
Post Op Wound Care Protocol (Collaborative
best practice)
 Dressing marked by surgical team
 Dressing Removal Goal = 48 hours
No baseline measurement
 100% Dressing marked by
surgical team
 100% Dressing Removal:
Goal = 48 hours
 MIDAS Focus Audit
August 2011

100% glove changes
before closing fascia
MIDAS Focus Audit
February 2011
April 2011
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DMAIC
NHSN Publicly Reported Cases- MIDAS Focus Study
MIDAS Focus Objectives:
• Detailed abstraction of elements with
identified areas of opportunity
• Data will be analyzed for any potential
trends and to serve as a guide for further
interventions
• Surgeon specific SSI rates
• Surgical Quality Council Dashboard will
include SSI outcomes
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Antibiotic Stewardship Program
DMAIC
• Dosing of Ertapenem for patients with BMI greater than 30
• Assessment of empiric therapy recommendations for contaminated and dirty
cases
• Measuring timing of prophylactic antibiotics prior to incision:
 0-15 minutes
 16-30 “ ”
 31-45 “ ”
 46-60 “ ”
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DMAIC
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Improvement ‘Bundle’
•
Interventions across the
episode of care
•
Multi-disciplinary
•
Engage staff, patient, and
families
•
Standardize as many
processes as possible
•
Ensure high compliance
with elements
o Quick audits
•
Build the elements into the
system
•
Frequent feedback and
communication
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Pre-operative Interventions
 Pre-operative Chlorhexidine packets
o
Provided to all patients preoperatively with instructions
o
Use monitored morning of admission
o
If not reported as not being used, SAGE wipes used on the entire body
 Patients with BMI > 30 (Mayo)
o
SAGE wipes applied even if preoperative bath performed
o
Procedure listing software automatically identifies patients with BMI >
30
 Pre-op antibiotic ordering (Mayo)
Procedure scheduling software automatically provides SCIP appropriate
choices
Weight-based dosing
Software automatically orders intra-operative re-dosing dose if historical
data for the specific procedure and surgeon demonstrated an average case
duration >3 hours
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Pre-Operative Interventions (cont’d)
 Hair removal by electric clipper
− Outside of the operating room
 Standardized to Chlorhexidine-Alcohol
(Chloraprep™) skin preparation for all
abdominal cases
− Surgical assistant applies skin preparation
 All in-serviced on appropriate application
− Must dry for 3 minutes before drapes applied
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Intra-Operative Interventions
 Pre-procedural pause includes confirming appropriate
antibiotics administered and documented
 Re-dosing of cefazolin for cases longer than 3 hours.
(Mayo)
− Circulating nurse has the preop order and pulls
medication at the beginning of the case
− Reminder window on anesthesia provider’s computer
screen
Triggered off time of first dose administration
−Appropriate weight-based dosing
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Intra-Operative Interventions (cont’d)
 “Closing” Process
− At the time of fascia closure
 All staff change gloves
 Gowns if soiled
 Field re-blocked with sterile towels
 Instruments used during case removed and “closing
tray” brought onto the field
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Post-Operative Interventions
 All order-sets discontinue SCIP compliant antibiotics after two postop
doses or single dose when appropriate (Mayo)
o Pharmacist part of team and queries service
 Hand hygiene essential on floor
o Physician/Nursing initiative
o Patient and Family initiative
 Sterile dressing on until morning of POD 2
o Document removal
 Chlorhexidine shower/wipes daily after dressing removal (Mayo)
 Standard postop order-sets orders urinary catheter removal at 8am the
morning after surgery (Mayo)
 Dismiss with chlorhexidine soap bottle for use at home (Mayo)
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Important Lessons:
 Multidisciplinary approach is essential
o Physicians, nursing (pre, intrao-p, floor), pharmacy, CST, SA, administration,
supply chain, quality, S&P, IT, Patient Education, Infection Control, WOCN,
NSQIP team
 Address the entire surgical episode of care
o
Pre, intra, and postoperative elements may influence SSI rates
o
Interventions designed for each phase
 Introduce elements of change and audit compliance
 Build ‘clues’ into the process to ensure better compliance: convenient hand
hygiene supplies (Purell wipes, Hibiclens bottles), signage, Hibiclens packets,
etc.
 Build process improvements into the system to ensure task completion
 No evidence for which of element(s) makes a difference in the “bundle”: the
outcome is all that matters
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Challenges Encountered
DMAIC
Learnings:
 Reduction of our SSI rates continue to be challenging.
Questions 2012:
 Could we learn more by studying the elements of the National Healthcare Safety Network(NHSN) colorectal
SSI cases?
 Could we focus our efforts on the ‘bulk’ of our infections; Organ Space (asked in 2012)
 Focused our efforts on organ space infections beginning after this collaborative – later part of 2102
 Decrease seen in 2013 (decrease seen in colo-rectal SIR)
 Found part of the issue was appropriate classification of cases: major educational focus later part 2012/2013
Experienced & Foreseeable Challenges:
 Strategies for preventing infections are different based on culture, environment, surgeon practice, patient preexisting conditions
 Lag time in collection and receipt of data to assess improvements
 Nursing time for documentation of audits takes away from patient care
 Insufficient and incomplete audits
 Resources needed for this improvement project
Best Practice:
 Standardization of approach was sequential and we may not see full term change yet (glove changing, closing
trays, etc. occurred in sequence not parallel)
 Best practices identified elsewhere may not have same level of impact in our organization
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Next Steps & Opportunities
DMAIC
 Based on best practice learnings through collaborative, continue glove
changes & separate/clean closing instruments
 MIDAS Focus Study on Publicly Reported Cases
−
−
−
−
Infection Control SSI surveillance in July/Aug 2011 identified an opportunity in colorectal surgery
Data collection focused on elements which are not captured elsewhere
Need for individual physician communication of infections identified
Opportunity for Physician review of case with abstracted data elements
 Antibiotic Stewardship
− Instituted February 2012
− Review of current prophylaxis guidelines and empiric therapy
 SSI Deep/Organ Space and Sepsis commonalities
−
−
−
−
Drill down on each Organ/Space and Deep SSI
Leaks (i.e. CT scans, physician documentation, abscessogram results)
Antibiotic prophylaxis dosing for patients with BMI greater than 30
Empiric therapy and treatment protocols
 Pursue Pre-Operative Warming Improvements
− Preoperative strategies for surgery admission unit
− Potential partnership with vendors to pilot new interventions
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