Impact of a Surgical Site Reduction Strategy after Colorectal Resection Lisa Wilbert RN, Assistant Director Quality Management & Analytics Stony

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1 Impact of a Surgical Site Reduction Strategy after Colorectal Resection Lisa Wilbert RN, Assistant Director Quality Management & Analytics Stony Brook Medicine July 19, 2016

2 No Disclosures

3 THE PROBLEM: High Surgical Site Infection SSI rates (5-26%) in Colorectal Surgery $10,443-$25,546 additional cost per infection Longer LOS and mortality

4 OUR LOCAL PROBLEM: In the NSQIP data from 2006 to 2009, Colorectal Surgery was a high outlier- Needs Improvement for SSI rates.

5 Who we are: Stony Brook Medicine University Hospital and Medical School Suffolk County s only tertiary care center and Level 1 Trauma Center 546 beds Dept of Surgery established in 1974 Division of Colorectal Surgery established in fulltime colorectal surgeons and 2 that divide time between hospitals

6 What did we do? We began with a SSI reduction strategy. The SSI reduction strategy consisted of pre hospital, preoperative, intraoperative, and postoperative components 6

7 Prehospital Bowel prep Shower from neck down Chlorhexidinescrub Preoperative Clipping hair from nipples to thighs (NOT in OR) Preopchecklist for compliance Blood glucose <200

8 Intraoperative Standardized procedures included all members of the operative team. Normothermia (>36.0 C) Prophylactic abxw/in 1 hr. of incision Standardized abx Control of Blood Glucose Wound protector (Alexis, Ioban) Re-prep and drape prior to closing Change gloves prior to closing Clean-unutilized instruments for closing Standardized wound closure 8

9 Before (n = 379) After (n = 311) Total 121 (31.92%) 58 (18.65%) <0.01 Superficial incisional 89 (23.48%) 25 (8.04%) <0.01 Deep incisional 9 (2.37%) 9 (2.89%) 0.66 Organ space 23 (6.07%) 24 (7.72%) 0.26 P Results The implementation of SSI reduction strategy resulted in a 41% decrease in SSI rates following colorectal resections. Mostly superficial SSI was affected Poster Presentation ASCRS, May 17-21, % 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% Colorectal SSI Rates 31.9% 23.5% 18.7% 8.0% Total SSI Superficial SSI Pre Implementation Post Implementation

10 More Than A Quick Fix 41% decrease in SSI rates following colorectal resection over a six year period Continuing improvement seen over an additional two years NYS DOH Colorectal SSI data showed similar improvement 10

11 Setbacks Most recent NSQIP results have demonstrated increased SSI rates for Colorectal Surgery A rapid cycle improvement team has been created A larger multidisciplinary group meets monthly Working to Hardwire processes utilizing our electronic medical record (EMR) 11

12 The War Room Our War Room is our rapid cycle improvement team Meets every Monday Morning at 8:15 Includes reps from Surgery, Information Technology (IT), Infection Control, Quality & Analytics, and Coding

13 Current War Room implementations include Inclusion of the Functional Status with our Anesthesia, Surgical and Nursing EMR Documentation Within a 30 day preoperative period, Patient s best functional status: Dependent Partially Dependent Independent

14 SURGICAL WOUND CLASSIFICATIONS included in the Postoperative Note I. Clean: Uninfected, no inflammation Resp, GI, GU tracts not entered Mandated Field 5/23/2016 Closed primarily Examples: Ex lap, mastectomy, neck dissection, thyroid, vascular, hernia, splenectomy II. Clean-contaminated: Resp, GI, GU tracts entered, controlled No unusual contamination Examples: Chole, SBR, Whipple, liver txp, gastric surgery, bronch, colon surgery III: Contaminated: Open, fresh, accidental wounds Major break in sterile technique Gross Spillage from GI tract Acute nonpurulent inflammation Examples: Inflamed appy, bile spillage in chole, diverticulitis, Rectal surgery, penetrating wounds IV: Dirty: Old traumatic wounds, devitalized tissue Existing infection or perforation Organisms present BEFORE procedure Examples: Abscess I&D, perforated bowel, peritonitis, wound debridement, positive cultures pre-op

15 An updated Pre-operative Surgical Powerplan - available for INPATIENTS Prechecked Clip & Prep and preoperative CHG Bath Redundancy efforts for patients arriving to the OR without having used their CHG wipes Expansion of CHG wipes to clinics for patients not passing through POS Bundle documentation for glove changes, double gloving and designated closure instruments

16 Creation of an OR DEBRIEFING GUIDEto include Infection Control checks & closure methods Wound Classification Invasive lines necessity Occurs as a 2 nd Time Out prior to closure and documented in the Intraoperative Note These additional DEBRIEF POINTS will be Incorporated into the current SIGN OUT section of our Safety Checklist for use in all and testified to within the EMR Intraoperative Note

17 Coming soon from the War Room Development of a Surgical Discharge Wound Care Powerplan within the Depart Process Pre-checked general wound care to include daily inspection, signs of infection, showering limitations - and pet precautions Specific options for duration and frequency of dressing changes, topical treatments, follow-up care and Special Instructions Covering both Closed & Open surgical wounds, multiple sites

18 Tips for Others 1. Convene a monthly SSI Committee 2. Implement data tracking for process measures; Bundle compliance, power plan use 3. Institute a Physician Root Cause Analysis (RCA) tool with a brief case summary and bundle compliance 4. Create a Surgical Service Pre-op Power plan and Comprehensive Wound Care discharge order-set 5. Review data as real time as possible, include both NHSN and NSQIP events as discovered 18

19 Conclusion Currently NSQIP Real time reporting tools show our rates are starting to improve again for Colorectal SSI More work needs to be done at our institution to address deep and organ space SSI reduction 19