Which Elements in a Wound Infection Prevention Process are Important? Aaron Chen, BS, Sebastian Perez, MSPH, John Sweeney, MD, Joe Sharma, MD

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1 Which Elements in a Wound Infection Prevention Process are Important? Aaron Chen, BS, Sebastian Perez, MSPH, John Sweeney, MD, Joe Sharma, MD

2 Disclosure Slide No COI and no disclosures.

3 SSI Surgical Site Infections 2 nd leading cause of health care associated infections 290,000 in USA 8207 attributed deaths Mortality rates 3-12x higher $3.34 $10.07 billion in direct costs

4 Wound Infection Group Preadmit OR Anesthesia General Surg Onc Vascular Urology Plastics Surgery WIG Nursing Periop OR Floor Office of Quality Admin Support Statistician Coordinator CDC Liason Facilities Coders

5 Wound Infection Prevention Process Pre-op Peri-op Intra-op Post-op Patient characteristics Nutrition Previous hospitalizations and transfers Culture nasal swabs Smoking cessation Patient Education Nasal Swab Chlorhexidene Wipes HgbA1c Bowel Prep Chlorhexidine Clippers Antibiotics -redosing Prep Technique Sterile Technique Foot Traffic Home Scrubs Attire Universal Drapes Wound Closure technique (Delayed) TO CLOSE OR NOT TO CLOSE Double Gloving Closing pan Change gown and gloves Gylcemic Control Oxygen Saturation Prevent Hypothermia Anitbiotic wound irrigation Drains (obese) Surveillance Patient hand hygiene Dressing Standardization and Changes GlycemicControl Prevent Hypothermia

6 WIG Goals Implement standardized protocols to reduce surgical site infections at Emory University Hospital by 40% and move to an O/E ratio of 1 in NSQIP. Develop a Wound Infection Prevention Process (W.I.P.P.) with colorectal surgery as test of change.

7 Compliance Audits May 2013, October 2013 and June 2014 Service lines : General, Gynecology, Urology, Vascular Colorectal Surgery May 2013 October 2013 June 2014 OR Cases Total Colorectal Cases # of OR s Wound class (Clean/C-C/Cont) 56/37/5 60/34/6 58/40/1

8 % Compliance Composite Compliance of Individual SSI Elements in May 2013 Good: 80% Fair: 30-79% Poor: 30% WIPP Bundle Elements

9 Compliance to Elements of the Colorectal Checklist May-13 Oct-13 Jun-14 * p-value < 0.05

10 SSI Trend at EUH in Colorectal Surgery 20 NSQIP SAR s SSI % WIG Colorectal WIPP Observed Expected

11 1.5 Reduction in SSI rates at EUH Overall SSI Rate at EUH O/E Ratio

12 Evaluation of Compliance Measures Compliance was measured in 698 patients (548 general/vascular and 150 colorectal) to the following elements in WIPP: antibiotics timing re-dosing appropriateness, skin prep; patient temperature in the operative room Patient temperature PACU.

13 Compliance change over time for each population Year Type n Skin Prep Antibiotics Full Appropriate OR Temp > 36 OR Temp > 35.5 PACU>36 Total SSI Superficial SSI Deep SSI Organ Space SSI 2013 Study % 82.35% 24.26% 54.41% 93.38% 6.62% 2.21% 1.47% 2.94% Colorectal % 63.64% 9.09% 54.55% % 9.09% 0.00% 4.55% 4.55% Sensitivity % 84.42% 33.77% 70.13% 97.40% 6.49% 2.60% 2.60% 1.30% 2014 Study % 84.17% 30.65% 62.81% 96.98% 6.53% 3.27% 1.01% 2.51% Colorectal % 83.95% 35.80% 69.14% 98.77% 12.35% 4.94% 2.47% 6.17% Sensitivity % 82.14% 19.64% 51.79% 92.86% 3.57% 3.57% 0.00% 0.00% 2015 Study % 78.05% 35.98% 64.02% 97.56% 6.10% 3.05% 1.22% 3.05% Colorectal % 74.47% 40.43% 61.70% % 2.13% 0.00% 0.00% 2.13% Sensitivity % 87.01% 42.86% 75.32% 97.40% 6.49% 1.30% 1.30% 3.90% Totals Study % Colorectal % Sensitivity %

14 Results in General and Vascular Cases Element Non-Chlorhexidine prep Non- Compliance Rate% OR for SSI 95% CI Fisher p- value 1.2% * InAppropriate Antibiotic Use Patient Temp in OR < 36C Patient Temp in OR < 35.5C Patient Temp in PACU < 36C 17.9% % % % *

15 Colorectal Population Subset Element OR for SSI 95% CI Fisher p-value Chlorhexidine prep NA NA NA Appropriate Antibiotic Use Patient Temp in OR > 36C Patient Temp in OR > C Patient Temp in PACU > 36C

16 What is the effect of non-compliance? *p-value = Not compliant Compliant 20 % SSI *p-value = Skin Prep AB Appr T > 36 in OR T > 35.5 in OR PACU Start Temp WIPP Bundle Elements

17 More Work to Do!!! Wound Infection Prevention Process Single element comparisons have minimal value WIPP reduces SSI rates

18 Acknowledgements John Sweeney (Chair, Department of Surgery ) Arnold Berry (Anesthesia) Colorectal Surgeons Anesthesia John Galloway, Charlie Staley, Jhanavi Srinivasan, Patrick Sullivan & Virginia Shaffer Operating Room Nursing Leadership Cheryl Castleberry, Kathy Galloway, Lou Bottoms Surge ry WIG Nursing Infectious Disease Jay Varkey, J. Steinberg Admin Support Quality Team Sebastian Perez, Amy Newell, Judy Lewis, Avina Goel, Aaron Chen