The Surgical Infection Prevention
and Surgical Care Improvement Projects
Where we started and where we’re going…
Dale W. Bratzler, DO, MPH
QIOSC Medical Director
Oklahoma Foundation for Medical Quality
Why focus on surgical quality?
•
~30 million major operations each
year in the US
•
Despite advances in surgical and
anesthesia technique and
improvements in perioperative care,
variations in outcomes for patients
having surgery are well known
Why focus on surgical quality
•
Patients who experience a
postoperative complication have
dramatically increased hospital
length of stay, hospital costs, and
mortality
•
On average, the length of stay for
patients who have a postoperative
complication is 3 to 11 days longer
Consequences of Surgical
Complications
•
Dimick and colleagues
demonstrated increased costs:
•
•
•
•
infectious complications was $1,398
cardiovascular complications $7,789
respiratory complications $52,466
thromboembolic complications
$18,310.
Dimick JB, et al. J Am Coll Surg 2004;199:531-7.
Impact of Complications on Survival
Khuri and colleagues demonstrated that, independent of preoperative
patient risk, the occurrence of a 30-day complication reduced median patient
survival by 69%.
Khuri SF, et al. Ann Surg 2005;242:326-41.
Who Pays for Surgical Complications?
Hospital
Reimbursement Costs of care
$
$
Profit
$
Profit margin
%
14266
(uncomplicated)
10978
3288
23.0
21911
(complicated)
21156
755
3.4
Complications were always associated with an increase
in costs to healthcare payors: complications were
associated with an average increase in payment of
$7645 (54%) per patient.
Dimick JB, et al. Who pays for poor surgical quality? Building a business
case for quality improvement. J Am Coll Surg. 2006;202:933-7.
Medicare Surgical Infection
Prevention (SIP) Project Objective
To decrease the morbidity and
mortality associated with
postoperative infection in the
Medicare patient population
Quality Indicators
National Surgical Infection Prevention Project
•
Proportion of patients with antibiotic
initiated within 1 hour before surgical
incision
•
Proportion of patients who receive
prophylactic antibiotics consistent with
current recommendations
•
Proportion of patients whose prophylactic
antibiotics were discontinued within 24
hours of surgery end time
Efficacy Of Prophylaxis Is Independent Of The
Specific Antibiotic
Penicillin, 40,000 U
Lesion Size, mm (24 Hours)
10
Erythromycin, 0.1 mg/Kg
10
Control
5
Staph + Penicillin
0
5
Staph + Erythromycin
0
Chloramphenicol, 0.1 mg/Kg
10
5
Control
Tetracycline, 0.1 mg/Kg
10
Control
Staph + Chloramphenicol 5
0
Control
Staph + Tetracycline
0
-2
0
2
4
6
-2
0
2
Age of Lesion at Antibiotic Injection (Hours)
Burke JF. Surgery. 1961;50:161.
4
6
Clin Infect Dis. 2007; 44:921–7.
Clin Infect Dis. 2007; 44:921–7.
Discontinuation of Prophylaxis
•
Numerous clinical trials have
compared short-term to long-term
antimicrobial prophylaxis
•
Many compared single-dose prophylaxis to
multiple dose prophylaxis
• Wide variety of operations using a wide variety
of antimicrobial agents
• Infection rates are the same regardless of
duration of prophylaxis
•
Prolonged prophylaxis has been associated with higher
rates of infections with resistant organisms (when
infection occurs). Prolonged prophylaxis only changes
the flora – it does not lower infection rates.
Prolonged prophylaxis is a patient safety issue.
Conclusions: One-dose antibiotic prophylaxis did not lead to an
increase in rates of surgical site infection and brought a monthly
savings of $1980 considering cephazolin alone. High
compliance to 1-dose prophylaxis was achieved through an
educational intervention encouraged by the hospital director and
administrative measures that reduced access to extra doses.
Arch Surg. 2006;141:1109-1113.
“Although it did not reach
statistical significance, the timing
of the administration of the first
dose of an antibiotic after
incision seems to be the most
important prophylaxis
parameter. Multiple
postoperative dosing did not
contribute to reduction of the
incidence of SSI. We strongly
recommend that intervention
programs on surgical
prophylaxis focus on timely
administration of the
prophylactic antibiotic.”
Clin Infect Dis. 2007; 44:921–7.
http://www.aaos.org/about/papers/advistmt/1027.asp
Recommendation 3 Duration of prophylactic antibiotic administration
should not exceed the 24-hour post-operative period.
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 when they are continued past 24 hours.
http://www.sts.org/sections/aboutthesociety/practiceguidelines/antibioticguideline/
Conclusions: The duration of antibiotic prophylaxis should not be dependent on indwelling
catheters of any type.
There is evidence indicating that antibiotic prophylaxis of 48 hours duration is effective.
There is some evidence that single-dose prophylaxis or 24-hour prophylaxis may be as
effective as 48-hour prophylaxis, but additional studies are necessary before confirming the
effectiveness of prophylaxis lasting less than 48 hours. There is no evidence that prophylaxis
administered for longer than 48 hours is more effective than a 48-hour regimen.
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
•
The Johns Hopkins Guide
•
Society of Thoracic Surgeons
Recent Guidelines
Recent Guidelines
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).
Bratzler DW, Hunt DR. The Surgical Infection Prevention and Surgical Care Improvement Projects: national initiatives to improve
outcomes for patients having surgery. Clin Infect Dis. 2006;43:322-30.
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 ampicillin-sulbactam
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.
Bratzler DW, Hunt DR. The Surgical Infection Prevention and Surgical Care Improvement Projects: national initiatives to improve
outcomes for patients having surgery. Clin Infect Dis. 2006;43:322-30.
Antibiotics for Colorectal Surgery
•
Ertapenem will be added to the acceptable
antibiotics for October discharges
• Oral antibiotic prophylaxis alone will no
longer pass the performance measure
National Surveillance
Antimicrobial Prophylaxis
Antibiotic Timing Related to Incision
Where we started in 2001
60
56
40
Incision
Percent
50
30
20.3
20
9.6
10
2.7
1.2
4.3
2.8
1.4
0.9
0.9
Minutes Before or After Incision
Bratzler DW, Houck PM, et al. Arch Surg. 2005;140:174-182.
0
24
>
18
124
0
12
118
0
0
61
-1
2
060
60
-0
12
061
18
012
1
24
018
1
>
24
0
0
Discontinuation of Antibiotics
100
88
85.8
100
90.7
79.5
80
73.3
60
60
50.7
40.7
40
40
26.2
22.6
14.5
20
20
10
6.2
9.3
6.3
2.7
2.2
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.
96
>
-9
6
>8
4
-8
4
>7
2
-7
2
>6
0
-6
0
>4
8
-4
8
>3
6
-3
6
>2
4
>1
2
le
12
or
-2
4
0
ss
0
Cumulative Percent
Percent
80
Reporting Hospitals (Voluntary)
Surgical Infection Prevention Project
3500
3247
3000
# Hospitals
2500
2000
1623
1718
1492
1500
1297
1000
808
470
500
237
30
265
271
337
894
450
42
0
02
0
2
3
Q
02
0
2
4
Q
03
0
2
1
Q
2
Q
03 003
0
2
2
3
Q
03
0
2
4
Q
04
0
2
1
Q
04
0
2
2
Q
04
0
2
3
Q
04
0
2
4
Q
1
Q
05 005
0
2
2
2
Q
05
0
2
3
Q
05
0
2
4
Q
06
0
2
1
Q
Surgical Infection Prevention
Hospital Voluntary Self-Reporting, Qtr. 1, 2006
Texas
National Average*
82.3
80
99.1
97.2
100
Benchmark
86
95.7
90.5
75.3
74
Percent
66
60
40
20
0
Antibiotics w/in 1 hour
Correct Antibiotic
Antibiotic DCed w/in 24
hours
Based on medical record abstraction from the charts of patients discharged in the 1 st quarter of 2006. Benchmark rates were calculated for
all HQA reporting hospitals in the US (N=3247) based on discharges during the 1 st quarter of 2006 using the Achievable Benchmarks of
CareTM methodology (http://main.uab.edu/show.asp?durki=14527).
243 Texas hospitals voluntarily reporting (Qtr 1, 2006).
Antibiotic practices that have been
shown to reduce the risk of SSI.
•
•
•
•
Administration of the antibiotic dose
just before incision
Antibiotic selection for the common
organisms to be encountered
Appropriate dose adjustment based on
patient weight
Redosing the patient in the operating
room for long cases
Surgical Care Improvement Project
National Goal
To reduce preventable
surgical morbidity and
mortality by 25% by 2010
SCIP Steering Committee
•
American College of
Surgeons
• American Hospital
Association
• American Society of
Anesthesiologists
• Association of periOperative Registered
Nurses
• Agency for Healthcare
Research and Quality
•
•
•
•
•
Centers for Medicare &
Medicaid Services
Centers for Disease
Control and Prevention
Department of Veteran’s
Affairs
Institute for Healthcare
Improvement
Joint Commission on
Accreditation of
Healthcare
Organizations
Surgical Care Improvement Project
(SCIP)
•
Preventable Complication
Modules
•
•
•
Surgical infection prevention
Cardiovascular complication
prevention
Venous thromboembolism
prevention
Surgical Care Improvement Project
Performance measures - Process
•
Surgical infection prevention
•
Antibiotics
•
Administration within one hour before incision
• Use of antimicrobial recommended in
guideline
• Discontinuation within 24 hours of surgery end
•
Glucose control in cardiac surgery
patients
• Proper hair removal
• Normothermia in colorectal surgery
patients
Furnary et al. Ann Thorac Surg 1999:67:352
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!
Temperature Control
•
200 colorectal surgery patients
•
•
•
control - routine intraoperative
thermal care (mean temp 34.7°C)
treatment - active warming (mean
temp on arrival to recovery 36.6°C)
Results
•
•
control - 19% SSI (18/96)
treatment - 6% SSI (6/104), P=0.009
Kurz A, et al. N Engl J Med. 1996.
Also: Melling AC, et al. Lancet. 2001. (preop warming)
Cardiovascular Complication Prevention
Prevention of Cardiac Events
Introduction
•
As many as 7 to 8 million Americans that
undergo major noncardiac surgery have
multiple cardiac risk factors or established
coronary artery disease
• More than 1 million cardiac events annually
•
Myocardial ischemia either clinically occult or
overt confers a 9 - fold increase in risk of
unstable angina, nonfatal myocardial
infarction, and cardiac death
Schmidt M, et al. Arch Intern Med. 2002;162:63-69.
Mangano DT, et al. N Engl J Med. 1996;335:1713-1720.
Selzman CH, et al. Arch Surg. 2001;136:286-290.
Surgical Care Improvement Project
Performance measure - Process
•
Perioperative cardiac events
•
Perioperative beta blockers in patients
who are on beta blockers prior to
admission
http://www.acc.org/clinical/guidelines/perio/periobetablocker.pdf
Venous Thromboembolism Prevention
Prevention of Venous Thromboembolism
•
Recent estimates show that
•
more than 900,000 Americans suffer
VTE each year
•
•
•
about 400,000 of these being DVT
About 500,000 being manifest as PE
In about 300,000 cases, PE proves
fatal; it is the third most common
cause of hospital-related deaths in
the United States.
Heit JA, Cohen AT, Anderson FA on behalf of the VTE Impact Assessment
Group. [Abstract] American Society of Hematology Annual Meeting, 2005.
National Body Position Statements
• Leapfrog1:
PE is “the most common preventable cause of hospital
death in the United States”
• Agency for Healthcare Research and Quality (AHRQ)2:
Thromboprophylaxis is the number 1 patient safety practice
• American Public Health Association (APHA)3:
“The disconnect between evidence and execution as it
relates to DVT prevention amounts to a public health crisis.”
1.
2.
3.
The Leapfrog Group Hospital Quality and Safety Survey. Available at:
www.leapfrog.medstat.com/pdf/Final/doc
Shojania KG, et al. Making Healthcare Safer: A Critical Analysis of Patient Safety Practices. AHRQ,
2001. Available at: www.ahrq.gov/clinic/ptsafety/
White Paper. Deep-vein thrombosis: Advancing awareness to protect patient lives. 2003. Available at:
www.alpha.org/ppp/DVT_White_Paper.pdf
Acquired Risk Factors
Risk Factor
Attributable Risk
Hospitalization/Nursing home
61.2
Active malignant neoplasm
19.8
Trauma
12.5
CHF
11.8
CV catheter
10.5
Neurologic disease with paresis
8.2
Superficial vein thrombosis
4.3
Varicose veins/stripping
Many others….
6
Thromboprophylaxis Use in Practice
1992-2002
Patient Group
Studies
Patients
Prophylaxis
Use (any)
Orthopedic surgery
4
20,216
90 % (57-98)
General surgery
7
2,473
73 % (38-98)
Critical care
14
3,654
69 % (33-100)
Gynecology
1
456
Medical patients
5
1,010
66 %
23 % (14-62)
Surgical Care Improvement Project
Performance measures - Process
•
Prevention of venous
thromboembolism
•
Proportion who have recommended
VTE prophylaxis ordered
• Proportion who receive appropriate
form of VTE prophylaxis (based on
ACCP Consensus Recommendations)
within 24 hours before or after
surgery
ACCP Guidelines for VTE
Prevention
Geerts WH, et al. CHEST. 2004;126:338S-400S.
Public Accountability and
SCIP
Hospital Public Reporting – “P4R”
4043
4192
0.4% Incentive
1952
1407
434
August, 2003
February,
2004
May, 2004
October, 2004
March, 2005
Number of Reporting Hospitals
98.3% of PPS hospitals now reporting
Deficit Reduction Act of 2005
For purposes of clause (i) for fiscal year 2007 and each subsequent fiscal year,
in the case of a subsection (d) hospital that does not submit, to the Secretary in
accordance with this clause, data required to be submitted on measures
selected under this clause with respect to such a fiscal year, the applicable
percentage increase under clause (i) for such fiscal year shall be reduced by
2.0 percentage points.
The Secretary shall expand, beyond the measures specified under clause
(vii)(II) and consistent with the succeeding subclauses, the set of measures
that the Secretary determines to be appropriate for the measurement of the
quality of care furnished by hospitals in inpatient settings.
The Secretary shall report quality measures of process, structure, outcome,
patients' perspectives on care, efficiency, and costs of care that relate to
services furnished in inpatient settings in hospitals on the Internet website of
the Centers for Medicare & Medicaid Services.
Deficit Reduction Act – 2005
Final Inpatient Prospective Payment System Rule
•
Rules increase requirements:
•
21 measures (8-AMI, 7-Pneumonia, 4Heart failure, 2-Surgical Infection)
•
Though reporting is voluntary, failure to
report results in loss of 2% of the Medicare
Annual Payment Update
Federal Register. August 18, 2006.
OPPS Rule
Final Rule Posted on November 1, 2006
•
Expands required measures for hospital
public reporting:
•
21 current measures
• Adds
•
•
•
SCIP Infect 2 (antibiotic selection)
SCIP VTE 1 and 2
HCAHPS (consumer satisfaction)
• Three new CMS 30-day mortality measures
for AMI, HF, and Pneumonia (based on
CMS analysis of Medicare fee-for-service
claims data)
Hospital Acquired Infections (provisions of the Deficit
Reduction Act)
In order to manage the costs associated with Hospital Acquired
Infections, the DRA requires the Secretary to identify, by October
1, 2007, at least two conditions that are:
o High cost or high volume or both
o Result in a DRG that has a higher payment when present
as a secondary diagnosis
o Could have been reasonably prevented through the
application of evidence based guidelines
The IPPS proposed that for discharges on or after October 1,
2008, that have one of the two selected conditions as a secondary
diagnosis that was not present at admission will be paid as if the
secondary diagnosis was not present. Therefore any charges
associated with the infection would not be paid.
Deficit Reduction Act - 2005
… the Secretary is directed to
begin phasing out payment
increases associated with
complications of care
Remember who pays for surgical
complications…
Deficit Reduction Act – 2005
Pay for performance
…. the Secretary is directed to develop
a plan to implement a value-based
purchasing program based on the
expanded measure set for which
hospitals will submit data starting in FY
2007. The program will begin
implementation in FY 2009 (2008).
Surgical Care Improvement
Project: Why?
Medicare could prevent* up to:
13,027 perioperative deaths
271,055 surgical
complications
* Major surgical cases
Preliminary SCIP Data
Qtr. 1, 2005
Texas
National Average
100
90
85.4
83.5
81.4
78
80
59.9
Percent
72.5 71.9
69
67.4
70
89.2
69 69.7
66.2 67
57.6
60
49.5
50
40
30
20
10
en
gi
v
VT
E
rm
ia
or
de
re
d
VT
E
ai
r
G
lu
or
m
ot
he
N
Re
m
ov
al
nt
ro
l
H
bx
A
co
hr
24
ed
DC
bx
A
A
bx
Se
l
1
ec
t
hr
0
National sample of 19, 497 Medicare patients. The charts were independently abstracted by the CMS CDAC.
SCIP Baseline – Antibiotics
Preliminary National Data
Abx 1 hour
Guideline Abx
Abx stopped <
24 hours
All operations
67.8
88.0
55.2
Cardiac
67.1
89.8
50.6
Vascular
63.1
85.8
58.1
Hip and knee
70.3
94.7
55.2
General colon
56.7
61.5
47.0
Hysterectomy
72.6
71.7
79.4
SCIP Baseline – VTE Prophylaxis
Preliminary National Data
Appropriate
Prophylaxis Ordered
Appropriate
Prophylaxis Received
All operations
78.3
76.1
Neurosurgery
93.9
92.8
Spinal surgery
96.6
96.5
General surgery
53.7
51.0
Gyn surgery
72.2
70.9
Urologic surgery
84.1
83.5
Hip replacement
91.0
89.4
Knee replacement
93.7
90.9
Summary
•
As the SIP project is expanded into the
new Surgical Care Improvement Project
we need to find ways to make evidencebased processes of care routine
•
•
We have to quit relying on memory to
ensure high quality care
Recognize that there is now a national
commitment to improving outcomes for
surgical patients
www.medqic.org/scip