Preventing Surgical Site Infections: Implementing a Multidisciplinary Evidence-Based Strategy

Transcription

1 Preventing Surgical Site Infections: Implementing a Multidisciplinary Evidence-Based Strategy Cindy Kildgore, RN, BSN, MSHA, CNOR Perioperative Services VOR Director Vanderbilt University Medical Center, Nashville, TN SPONSORED BY

2 FACULTY DISCLOSURE Cynthia L. Kildgore, MSHA, BSN, RN, CNOR- Eloquest Healthcare Speaker Bureau

3 Objectives Identify strategies to implement surgical site infection (SSI) care bundles Describe tactics for overcoming barriers to change in clinical process Describe future technologies to aid in SSI prevention

4 Clinical Case Study (1) SD 68 yo F c/o 30 lb. weight loss over 6 months and hematochezia; colonoscopy demonstrates constricting lesion in the proximal trasd 68 yo F c/o 30 lb. weight loss over 6 months and hematochezia; colonoscopy demonstrates constricting lesion in the proximal transverse colon No previous abdominal operations, no contributory medical history Preoperative instructions: Sage wipes after showering the morning of surgery Magnesium citrate one bottle at 5pm day before surgery Admitted for elective laparoscopic colectomy

5 Clinical Case Study Uneventful perioperative course Operative time 1:45p Cefoxitin 2 Gm infused 5 minutes prior to incision Lowest intraoperative temperature 36.3 C Wound Class 2: Clean-contaminated After PACU was taken to colorectal surgery unit POD 1-3 doing well except for ileus; await flatus POD 4-5 advancing diet slowly; activity, pain management POD 7: Abdominal pain, general malaise. CT and contrast enema demonstrate anastomotic leak.

6 Clinical Case Study Return to OR on POD 7; ex lap, washout, repair of leak, loop ileostomy Infected ascites, 2mm leak at anastomosis, abdominal sepsis Transferred to ICU after surgery Postoperative course complicated by sepsis, vein thrombosis Discharged on POD 21 (first operation)/14 (second operation)

7 Event Analysis No institutional guidelines regarding perioperative care of colorectal surgery patients Surgeon s routine practices were followed: Sage wipes x 1 Mag citrate prior to surgery NPO after midnight IV antibiotics prior to incision Intraoperative normothermia

8 2010

9 SSI Surveillance Programs Public reporting of data based on CDC-NHSN colon and abdominal hysterectomy outcomes Only deep and organ/space SSI are included Superficial is surveyed and reported, but not public Optional reporting of NSQIP Colectomy, LE Bypass, elderly (death, serious morbidity) Both are risk-adjusted, but with different models Surveillance methodology may differ in some hospitals

10 VUMC NHISN and NSQIP Coloectomy Surveillance Procedure Comparison

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12 The data is wrong We have more IBD patients, and they re more likely to have infections. We re a level 1 trauma center. We re a regional referral center for catastrophes. Surveillance over-counts clinical infection. XX Medical Center doesn t count infections the way you do.

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14 NSQIP Colorectal SSI Rates Compared to Academic Medical Centers

15 Improving Performance Review existing guidelines Literature review Identify gaps in current practice Reduce variability

16 Agreeing on the Evidence

17 The Challenge Move from Show me why I should do it to Show me why you should not Standardize practices

18 Standardization of Expected Practices Based in literature/guidelines Multidisciplinary Determine what should occur for any case Understand where variability necessary try to limit the degree of variability

19 Action Steps to Prevent Surgical Site Infections Standardization of surgical team members Prep standardization: Chlorhexidine + alcohol Bowel isolation prep and training Intra-operative handling of contaminated materials Antibiotic administration Temperature management Reduction of OR foot traffic Coaching hand hygiene and hand scrub practice

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21 Continued Pursuit of Zero SSI s The preceding slides detail the changes and progress we ve made in our journey from worst to best, but we re constantly evaluating ways and tools that can help us reach our goal of zero SSIs. One that I m excited about evaluating in 2018 is ReliaTect Post-Op Dressing with CHG.

22 Looking Ahead ReliaTect Post-Op Dressing with CHG a new product that has our interest because it supports the delivery of CHG (the same product used during prep) throughout the perioperative continuum of care to reduce post-op wound contamination, as well as providing the unique combination of transparency and absorbency to facilitate post-op assessment and monitoring of the incision site

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24 100% Case Review Identify signals Any practice lapses Multidisciplinary

25 The Grid

26 Work in Progress

27 Policy and Culture The best bundle doesn t work without a culture supporting it Encourage vigilance for all members of the team Create a culture where speaking up is expected

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30 Challenges: Physician Champion Must be involved and vested Helps with peers Understands the clinical practice Will be at frontline as advocate

31 Challenges: Physician Champion Initial champion was not a champion Disagreement with outcome measures Rationalization that our patients are sicker We see more folks with inflammatory bowel disease Other facilities have higher rates than CDC benchmark Other facilities don t look as hard for SSI as we do We re operating in a dirty space

32 The Value of the Champion Sought to understand the surveillance metrics Provides insight to improvement team Provides insight to clinicians (practices, documentation) New Colorectal Surgeon Champion s Case Review Spreadsheet

33 Lessons Learned: Target the Program Start focal, then broaden Early lesson: Attempted to addressing SSI prevention across all procedures (not just colorectal) Focus on early adopters/engaged champions

34 Services Performing Colorectal Surgery at VUMC All Surgical Procedures Performed on Colon CDC Colon Procedures (by ICD9 Proc Code) Surg Onc EGS CRS Service GNS GI Lap HEPBIL TRX GU GYN Two major services perform colorectal surgery (CRS Colorectal Surgery and EGS Emergency General Surgery) yet other services also involved Need to involve these groups to 1) raise awareness of bundle practice expectations and 2) identify unique aspects of practice that may need to be addressed

35 Lessons Learned: Capture Practices Across Transitions of Care Map out patient flow across clinical areas Standardize across transitions Anticipate varying entry points (e.g. admitted pt vs. elective admission vs. emergent case)

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37 Tracking Bundle Compliance Once standards developed how do you know they are being followed? Must Track compliance Understand variations in practice Feedback data to stakeholders Develop accountability

38 Colorectal Bundle Compliance Dashboard Provides breakout by bundle element Drill down to service, surgeon Challenges: Data availability How to share surgeon data Understand noncompliance PACU O 2

39 Infeciton Rate per 100 Procedures Expansion to Other Procedures Cesarean Section 10.0% 9.0% 8.0% 7.0% 6.0% 5.0% 4.79% 4.0% 3.0% 2.0% 1.0% 0.0% Standardized Bundle Implemented 1.01% 2012Q42013Q12013Q22013Q32013Q42014Q12014Q22014Q32014Q42015Q1

40 Qtr1 Qtr2 Qtr3 Qtr4 Qtr1 Qtr2 Qtr3 Qtr4 Qtr1 Qtr2 Qtr3 Qtr4 Qtr1 Qtr2 Qtr3 Qtr4 Qtr1 Qtr2 Qtr3 Qtr4 Qtr1 30% 25% 20% 15% 10% NSQIP NHSN 5% 0%

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44 CDC Prevention Guideline for the Prevention of SSI, 2017 Prior to surgery patient should shower or bathe with soap or antiseptic agent the night before Antimicrobial prophylaxis should be administered only when indicated based on published clinical practice guidelines and times such that a bacterial concentration of the agent is established in the serum and tissues when incision is made Skin preparation in the OR should be performed using an alcohol-based agent unless contraindicated For clean/contaminated procedures, additional prophylactic antimicrobial agent doses should not be administered after the surgical incision is closed, even in the presence of a drain Topical antimicrobial agents should not be applies to the surgical incision During surgery, glycemic control should be implemented using blood glucose target levels less than 200mg/dl Normothermia should be maintained in all patients Increased fraction of inspired O2 should be administered during surgery and after extubation in the immediate postoperative period for patients with normal pulmonary function Transfusion of blood products should not be withheld from surgical patients as means to prevent SSI

45 Future Challenges Maintaining vigilance Incorporating new clinicians Dealing with desire to identify which bundle elements matter in order to remove components New fellows began (errors in documentation and closure technique)

46 Clinical Case Study (2) OP 61yo M with rectal adenocarcinoma presented for low anterior resection s/p neoadjuvant therapy. PMH: PAD, lymphedema, chronic anticoagulation PSH includes lower extremity bypass, femoral aneurysm Preoperative instructions: Neomycin / metronidazole orally x 3 doses day prior to surgery Peg-electrolyte solution 4 liters until clear Chlorahexadine wipes night before and morning of surgery Uneventful perioperative course, discharged on POD 4. Last clinic visit (22 months postop); no new problems

47 Evidence-Based References 1. Bull A, Wilson J, Worth LJ, Stuart RL, Gillespie E, Waxman B, Shearer W, Richards M. A bundle of care to reduce colorectal surgical infections: an Australian experience. J Hosp Infect Aug;78(4): Epub 2011 Jun 12. PubMed PMID: Qadan M, Akça O, Mahid SS, Hornung CA, Polk HC Jr. Perioperative supplemental oxygen therapy and surgical site infection: a meta-analysis of randomized controlled trials. Arch Surg Apr;144(4):359-66; discussion Review. PubMed PMID: Kurz A, Sessler D, Lenhardt R Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. NEJM 334(19): /NEJM Akhtar S, Barash PG, Inzucchi SE Scientific Principles and Clinical Implications of Perioperative Glucose Regulation and Control. Anesthesia and Analgesia, 110(2): /ANE.0b013e3181c6be Englesbe MJ, Brooks L, Kubus J, Luchtefeld M, Lynch J, Senagor A, Eggenberger JC, Velanvich V, Campbell DA. A Statewide Assessment of Surgical Site Infection Following Colectomy: the Role of Oral Antibiotics. Ann Surg 2010; 252: Sehgal R, Berg A, Figueroa R, Proits LS, McKenna KJ, Stewart DB, Koltun WA. Risk factors for surgical site infections after colorectal resection in diabetic patients. J Am Coll Surg 2011;212: Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, Fish DN, Napolitano LM, Sawyer RG, Slain D, Steinbert JP, Weinstein RA. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm. 2013; 70:

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