Combined SSI Bundles and ERAS in Colorectal Surgeries

Transcription

1 Combined SSI Bundles and ERAS in Colorectal Surgeries Joy Lanfranchi BSN, RN, CNOR, CMLSO Richard Bollin Jr. M.D. Kevin Kinzinger M.D. MBA, FACS, FASCRS Joanne Bonnot MSN, RN, BBA, NE-BC Claudia Skinner DNP, RN, CIC, CCRN-K Rita Thompson MSN, RN, CNOR, RN-BC Marysol Cacciata PhD(c), MSN, RN, CCRN-K Sil Kim Mishreki BSN, RN, CNOR, RNFA Amanda McCoy BSN, RN, CNOR Betty Petty BSN, RN, CNOR, CRNFA 1

2 Why an SSI Bundle + ERAS? In FY 16, St. Jude was experiencing an uptick in Colorectal SSI, higher than the National Health and Safety Network (NHSN) Top 25% Standardized Infection Ratio (SIR) of Infection Prevention Department involved Concurrently, the Anesthesia Department had been working to implement an Enhanced Recovery after Surgery (ERAS) for colorectal surgery Improve outcomes 2

3 Colorectal Infections Reviewed Cases Reviewed with Surgeons Multiple organisms, ASA and CDC Wound Class scores, across specialty Caused by anastomotic leak, perforations (existing or postoperative), or unknown All approaches including Robotic, open, and laparoscopic 3

4 Bundle Elements Decision to combine elements of a Universal bundle and modified NYSPFP Colorectal Bundles with ERAS Modified Duke/UVA University version of ERAS Decision team included surgeons, anesthesiologists, nursing, infection prevention, leadership, and other disciplines Initial implementation Perioperative phase higher level of control 4

5 Universal Bundle Supported by several articles including AORN Journal and other research/peer reviewed publications Translatable to all specialties - Universal Piloted in Colorectal surgeries in preparation for rollout to other surgical specialties 5

6 Universal Elements Skin prep with CHG/Alcohol (Chloraprep) or Povidone Iodine/Alcohol Nasal decolonization with 5% povidone iodine Better tolerated, higher compliance, and lower cost than mupirocin Use of antimicrobial-impregnated sutures as available Double gloving by all surgical team members 6

7 Universal Elements Changing sterile outer gloves at specific times Improved post-operative dressing products Antimicrobial-impregnated postoperative dressings if dressing is used, or Negative-pressure wound therapy (NPWT) for incisions/patients that meet specific criteria 7

8 Universal Elements Intraoperative removal of bioburden on surgical instrumentation by surgical scrub assistant using sterile water Discontinue use of triple antibiotic solution for irrigation in colorectal surgeries 8

9 NYSPFP Bundle Elements Modified version of NYS Colorectal Bundle Wound Management- Standardize wound management strategy for all types of colorectal surgeries Standardized Fascia Close Normothermia - maintain core temperature 36 C during the perioperative period 9

10 NYSPFP Bundle Elements Glucose control - maintain blood glucose level between mg/dl Antimicrobial prophylaxis Ertapenem Cipro/Flagyl (if allergic) Increased perioperative oxygenation 10

11 ERAS Elements Lung/Ventilation IV Fluid management Water and Gatorade, PO up to 4 hours prior to scheduled surgical time Use and reversal of neuromuscular agent for all colorectal surgery patients Anesthetic management Sevoflurane or combination with Propofol infusion or TIVA Minimize long-acting narcotics 11

12 ERAS Elements Multimodal analgesia PO or IV Tylenol 1000mg, PO Celebrex 200mg, PO Neurontin 400 (may give 600mg PO for younger more robust patients). 4 Quadrant TAP block/rectus Sheath Block (Ropivicaine) Intrathecal morphine as alternative mg Consider optional: 0.5mg/kg Ketamine 12

13 Implementation Crosswalk determining compatibility Share supporting evidence Requires ownership Staff and physician trust Proactive facilitation Visual management tools Reinforce compliance through audits Monitor and report data 13

14 Order sets in EMR Implementation Hospital and office based Education Office staff patient brochure/surgical instructions Hospital staff Champions Physician- surgeon & anesthesia Nursing Leadership 14

15 Visual Management Tool Property of St. Jude Medical Center, Fullerton, CA 15

16 Visual Management Tool Adapted from Duke University/University of Virginia 16

17 Visual Management Tool ERAS SSI NYSPFP-COLO 17

18 Results 18

19 Lessons Learned Input from stakeholders Provide education before implementation Pilot Flexibility Evaluate compliance by all team members, including the patient Persistence Barriers 19

20 Questions? 20

21 References See attached reference list. 21