Surgical Site Infection
SUSP
Armstrong Institute for Patient Safety and Quality
Presented by: Elizabeth C. Wick, M.D. and Deborah B. Hobson, R.N.
Learning Objectives
• Understand pathogenesis, monitoring and
prevention of SSIs
• To explore how to implement evidence-based
behaviors to prevent SSIs
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Proportion of Adverse Events
Most Frequent Categories
25%
Non-surgical
20%
Surgical
15%
10%
5%
0%
Drugrelated
Wound
infect.
Tech.
comp.
Late
comp.
Diag.
mishap
Therap.
mishap
Nontech.
comp.
Proc.
related
Brennan. N Engl J Med. 1991;324:370-376
4
Background
• SSI is the most common nosocomial infection in the surgical
patient
• SSI is the most common complication after colorectal abdominal
surgery (3-30%)
• SSI is associated with increased mortality, length of stay and
readmission
• An SSI costs between $6,200 - $15,000/per patient (superficialorgan space)
Smith et al, Ann Surg, 2004
Wick et al, Arch Surg, 2011
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Pathogenesis of SSI
Host
Bacteria
Procedure
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SSI Definitions
• Superficial
–
–
–
–
purulent drainage from wound
positive wound culture
pain, redness swelling
diagnosis by surgeon
• Deep
– purulent drainage from deep aspect of wound
– dehiscence
– abscess on exam or CT scan
• Organ Space
– infection in surgical cavity (abdomen)
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Monitoring: NHSN
(CDC-National Healthcare Safety Network)
NEW MANDATORY Monitoring: colon and hysterectomy
• Rate will be risk adjusted based on age and ASA
• Deep incisional and organ space rates for colon and
hysterectomy will be reported to CMS (required for full payment)
• Data to be transmitted to CMS late 2012, 2013
• Hospital specific standardized infection ratios will be generated
for colon and hysterectomy
http://www.cdc.gov/nhsn/PDFs/FINAL-ACH-SSI-Guidance.pdf
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Monitoring: NSQIP
(National Surgical Quality Improvement
Program)
• Data
– Robust preoperative risk factors for risk adjustment
– 30-day postoperative mortality and morbidity
• Program
– Costs approximately $30K/year; infection only one of many
outcomes studied
– Requires full time RN dedicated to data collection AND surgeon
champion
– Includes annual audit by NSQIP and risk adjusted reports
– Option to collect all colon and rectal procedures vs. random sample
of surgical procedures
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SCIP PROCESSES TO PREVENT SSI
10
Does SCIP Give Us Enough
information?
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 whose body temperature
was near normal by the end of surgery.
98%
99%
SCIP Data
Johns Hopkins Hospital. May 2010 SCIP, Hospital Compare, www.medicare.gov
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Johns Hopkins CUSP Experience:
Room for Improvement in SCIP Compliance
Problem : Penicillin-allergic patients undergoing
colorectal surgery were not receiving proper
prophylactic antibiotics (Clindamycin and
Gentamycin).
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Antibiotic Compliance Project
Johns Hopkins
Correct Dose of
Gentamicin Received
75
• Increased amount of
gentamicin available in the
room
50
• Added dose calculator in
anesthesia record
100
% of Patients Compliant
Interventions
92%
33%
• Educated surgeons,
anesthesia, and nursing in
25
0
Before
After
Wick et al, JACS 2012 (in press)
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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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Johns Hopkins CUSP Experience:
Room for Improvement in SCIP Compliance
Problem: Patients arrive in the recovery room
with temperature < 36°C despite having a
forced air warmer during surgery
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Normothermia Project
Johns Hopkins
Temperature > 36 °C Post-Op
95%
% of Patients Compliant
100
83%
75
Interventions
• Confirmed that temperature
probes were accurate (trial
comparing foley and
esophageal sensors)
50
• Initiated forced air warming
in the pre-operative area
25
• Heightened awareness
0
Before
After
Wick et al, JACS 2012 (in press)
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EMERGING EVIDENCE FOR SSI
PREVENTION
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Emerging Evidence for SSI
Prevention
1. Antibiotic Usage
– Redosing
– Weight based dosing of cephalosporins
2. Maintenance of normogylcemia
3. Utilization of mechanical bowel preparation
with oral antibiotics
4. Standardization of skin preparation
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Additional Interventions to Improve
Antibiotic Efficacy
•
Antibiotic Redosing
– Maintain therapeutic antibiotic serum levels
during entire procedure
Medication
Dosing Interval
Cefazolin
q3hrs
Cefotetan
q6hrs
Cefoxitin
q2h
Clindamycin
q6h
Vancomycin
q12h
Consensus Guidelines, in press
IDSA/SIS/SHEA/AHPS
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Hyperglycemia and Infection
BACKGROUND:
•
Hyperglycemia is common in
hospitalized patients
•
38% of medical and surgical
patients had hyperglycemia (26%
diabetic and 12% non-diabetic
•
In cardiac surgery, degree of postoperative hyperglycemia
correlates with SSI; adopted as
SCIP measures
GOAL: Glucose <180mg/dl in all
hospitalized patients
Ramos. Ann Surg 2008
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Preparation of the Surgical
Site
BACKGROUND
•
•
1012 Bacteria reside on the skin
Staphlococcus and Streptococcus species among others
GOAL OF SKIN PREPARATION
•
Reduce bacterial burden on skin prior to incision
BEST PRACTICE
•
•
•
•
Dual-agent skin preparation (chlorhexidine + alcohol, providone-iodine
+alcohol)
Skin prep should include alcohol to increase durability of sterilization
Prep should be applied to specification (duration and amount)
Prep must dry before incision
Darouiche RO et al. N Engl J Med. 2010
Swenson BR et al. Infect Control Hosp Epidemiol. 2009
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Bowel Preparation:
A Brief History
• Oral antibiotics for prevention of SSI was first described in the
1940’s
• 1973 Nichols and Condon FAVORABLE
• 1974 Washington et al randomized trial FAVORABLE
• 1990’s-2000’s oral antibiotics fell out of favor in US
– Patients not tolerant of preparation (nausea, dehydration)
• 2002 Lewis et al
– Randomized controlled trial
– Oral neomycin and metronidazole plus systemic antibiotics vs
systemic antibiotics alone (5% neomycin and metronidazole vs
17% placebo)
Reviewed in Fry, 2011.
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Bowel Preparation:
A Brief History
• Rigorous studies of IV antibiotics did not include oral antibiotics
• 1990’s-2000’s oral antibiotics fell out of favor in US
– Patients not tolerant of preparation (nausea, dehydration)
– Patients no longer admitted to hospital pre-operatively
• Lewis et al (2002)
– Randomized controlled trial
– Oral neomycin and metronidazole plus systemic antibiotics vs systemic
antibiotics alone (5% neomycin and metronidazole vs 17% placebo)
• 2012
– AHPSA guidelines on antimicrobial prophylaxis endorse use of oral
antibiotics with mechanical bowel preparation plus IV antibiotics to prevent
SSIs
Reviewed in Fry, 2011.
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Cochrane Review:
Oral Antibiotics + Bowel Preparation is
Associated with Lowest SSI Rate
Guenaga Study2
SSI Rate
SSI Rate
Nelson Study1
MBP +
oral +
parenteral
MBP no oral +
parenteral
MBP +
+ parenteral
No MBP +
+ parenteral
MBP = Mechanical Bowel Preparation
Slide adapted from
Patch Dellinger, MD University of Washington
1Guenega,
2Nelson,
Cochrane Database Syst Rev,2009
Cochrane Database Syst Rev,2009
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Summary of SCIP and Emerging
Evidence to Prevent Colorectal SSIs
• Appropriate prophylactic antibiotics
–
–
–
–
–
Selection*
Weight-based dosing of cephalosporins
Timing*
Redosing
Discontinuation*
• Appropriate hair removal as close to time of surgery as
possible*
• Temperature management*
• Appropriate glycemic control
• Dual agent (with alcohol) surgical skin prep
• Mechanical bowel prep and oral antibiotics
*SCIP measures
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Next Steps
• Review current colorectal SSI bundles at your
hospital (policy and practice)
• Review hospital process measure data
• With assembled CUSP team, plan for
administration of staff safety assessment
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Poll
Who’s on the call?
30
Poll
Does your hospital have a colorectal SSI bundle
in place?
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Poll
If your hospital has a colorectal SSI bundle in
place, what’s in it?
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On-boarding Call Evaluation
We want to ensure that the on-boarding calls provide useful and
pertinent information for the SUSP teams. For this reason we
request that you complete a brief evaluation following each call.
The evaluation may be found at the following link:
• https://www.research.net/s/susp_cohort_3
If you are not able to reach the link from the slide, please cut & past
the URL into your browser.
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Armstrong Institute for Patient Safety and Quality