Surgical Site Infection
Tools for Improvement
SUSP
© The Johns Hopkins University and The Johns
Hopkins Health System Corporation, 2011
Learning Objectives
• Review approach to SSI reduction as part
of SUSP project.
• Review auditing tools to help identify local
defects contributing to SSIs.
• Next steps
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Armstrong Institute for Patient Safety and Quality
Surgical Care Improvement Project (SCIP)
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Armstrong Institute for Patient Safety and Quality
No single SSI prevention bundle
• Deeper dive into SCIP measures to identify
local defects
• Emerging evidence
–
–
–
–
Abx redosing and weight based dosing
Maintenance of normogylcemia
Mechanical bowel preparation with oral abx
Standardization of skin preparation
• Capitalize on frontline wisdom
– CUSP/Staff Armstrong
Safety
Assessment
Institute for Patient Safety and Quality
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DEEPER DIVE INTO SCIP MEASURES
TO IDENTIFY LOCAL DEFECTS
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Armstrong Institute for Patient Safety and Quality
Deeper Dive: Auditing
www.visualthesaurus.com
“…to make an audit of (performance) to evaluate or
improve its safety, efficiency, or the like”
http://dictionary.reference.com
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Auditing Practice
• Evaluate a sample of patients
– (ie: the next 5-10 patients)
• Practical and feasible strategy to evaluate
performance and surface defects
• Needs to be adapted to local environment
• Empowers frontline staff
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Armstrong Institute for Patient Safety and Quality
Auditing tools
• Antibiotic
– Selection, dosing, redosing
•
•
•
•
Normothermia
Glucose Control
Skin Prep
Others?
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Armstrong Institute for Patient Safety and Quality
SCIP Measures
Quality Indicator
Numerator
Denominator
Appropriate antibiotic choice
Number of patients who received the
appropriate prophylactic antibiotic
All patients for whom prophylactic
antibiotics are indicated
Appropriate timing of prophylactic
antibiotics
Number of patients who received the
prophylactic antibiotic within 60 minutes
prior to incision
All patients for whom prophylactic
antibiotics are indicated
Appropriate discontinuation of antibiotics
Number of patients who received
prophylactic antibiotics and had them
discontinued in 24 hours
All patients who received prophylactic
antibiotics
Appropriate hair removal
Number of patients who did not have hair
removed or who had hair removed with
clippers
All surgical patients
Perioperative normothermia
Number of patients with postoperative
temperature ≥36.0oC
Patients undergoing surgery colorectal
surgery
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Armstrong Institute for Patient Safety and Quality
Perioperative Antibiotic Compliance:
Michigan Surgical Quality Collaborative
Antibiotics practices
All cases
(n = 3002)
number (%)
Was an SCIP-compliant antibiotic
2,431 (81.4%)
chosen?
Was antibiotic given within 1 h before
2,712 (90.8%)
incision?
Nonemergency Emergency
cases
(n = 2743)
(n = 248)
number (%)
number (%)
2,293 (83.6%)
130 (52.4%)
2,544 (92.7%)
159 (64.1%)
245 (8.9%)
24 (9.7%)
Antibiotics weight-adjusted (n = 972) 552 (56.8%)
Antibiotics redosed (n = 398)
24 (6.0%)
Total surgical site infection
269 (9.0%)
Hendren et al. Am. J Surg 2011
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SCIP measure performance
Johns Hopkins Hospital
May 2010 SCIP
Hospital Compare
www.medicare.gov
Johns Hopkins
Comparison
Hospitals
Surgery patients who were
given an antibiotic at the
right time (within one hour
before surgery) to help
prevent infection
98%
97%
Surgery patients who were
given the right kind of
antibiotic to help prevent
infection
98%
98%
Surgery patients whose
preventive antibiotics were
stopped at the right time
(within 24 hours after
surgery)
97%
96%
Surgery patients needing
hair removed from the
surgical area before
surgery, who had hair
removed using a safer
method (electric clippers
or hair removal cream –
not a razor)
100%
100%
Patients having surgery
who were actively warmed
in the operating room or
98%
whose body temperature
was near normal by the
Armstrong Institute
for Patient Safety and Quality
end of surgery.
99%
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SUSP Antibiotic
Audit Tool
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Antibiotic Compliance Project
Johns Hopkins
% of Patients Compliant
Correct Dose of
Gentamicin Received
100
92%
75
50
33%
Interventions:
• Increased amount of
gentamicin available in
the room
• Added dose calculator
in anesthesia record
25
0
Before
• Educated surgeons,
After
anesthesia and nursing,
anesthesia and nursing
Wick et al, JACS 2012 13
inandgrand
rounds
Armstrong Institute for Patient Safety
Quality
SCIP Measures
Quality Indicator
Numerator
Denominator
Appropriate antibiotic choice
Number of patients who received the
appropriate prophylactic antibiotic
All patients for whom prophylactic
antibiotics are indicated
Appropriate timing of prophylactic
antibiotics
Number of patients who received the
prophylactic antibiotic within 60 minutes
prior to incision
All patients for whom prophylactic
antibiotics are indicated
Appropriate discontinuation of antibiotics
Number of patients who received
prophylactic antibiotics and had them
discontinued in 24 hours
All patients who received prophylactic
antibiotics
Appropriate hair removal
Number of patients who did not have hair
removed or who had hair removed with
clippers
All surgical patients
Perioperative normothermia
Number of patients with postoperative
temperature ≥36.0oC
Patients undergoing surgery colorectal
surgery
14
Armstrong Institute for Patient Safety and Quality
SCIP measure performance
Johns Hopkins Hospital
May 2010 SCIP
Hospital Compare
www.medicare.gov
Johns Hopkins
Comparison
Hospitals
Surgery patients who were
given an antibiotic at the
right time (within one hour
before surgery) to help
prevent infection
98%
97%
Surgery patients who were
given the right kind of
antibiotic to help prevent
infection
98%
98%
Surgery patients whose
preventive antibiotics were
stopped at the right time
(within 24 hours after
surgery)
97%
96%
Surgery patients needing
hair removed from the
surgical area before
surgery, who had hair
removed using a safer
method (electric clippers
or hair removal cream –
not a razor)
100%
100%
Patients having surgery
who were actively warmed
in the operating room or
98%
whose body temperature
was near normal by the
Armstrong Institute
for Patient Safety and Quality
end of surgery.
99%
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SUSP
Normothermia
Audit Tool
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Armstrong Institute for Patient Safety and Quality
Normothermia Project
Johns Hopkins
% of Patients Compliant
Temperature > 36 °C
post-op
95%
100
83%
75
Interventions:
• Confirmed that
temperature probes
were accurate (trial
comparing foley and
esophageal sensors)
50
• Initiated forced air
warming in the preoperative area
25
0
Before
After
• Heightened awareness17
Armstrong Institute for Patient Safety and Quality
Use your
hospitals
glucose goal
SUSP Glucose
Control Audit
Tool
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Armstrong Institute for Patient Safety and Quality
How Do We Conduct Audits?
• Retrospective chart review
• Concurrent review
– Place audit tool on chart
– Complete over continuum of care
• We recommend auditing 5-10 patients
– Larger samples yield better estimates of
performance
• Your data does not need to be submitted
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Armstrong Institute for Patient Safety and Quality
Summary
• No single SSI prevention bundle
– Need to identify local defects
• Auditing is a practical and feasible strategy to
evaluate performance and surface defects
• Tools are adaptable to local environment
• Empowers frontline staff
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Armstrong Institute for Patient Safety and Quality
Action Items
• Pick 2-3 audit tools
– [Add website for tools]
• Audit 5-10 patients with each tool
• Be prepared to share your experience with
other teams on upcoming call
• Share your tools and ideas for new tools on
our next coaching call!
Armstrong Institute for Patient Safety and Quality
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