IHI Expedition. Expedition Coordinator 12/18/2013

Transcription

1 Thursday, December 19, 2013 These presenters have nothing to disclose IHI Expedition Improving Safety and Reliability for Surgical Procedures Session 3 Deborah Yokoe, MD, MPH Kathy Duncan, RN Expedition Coordinator Chris Chue, Project Coordinator at the Institute for Healthcare Improvement. Chris has worked on organizing any care transition related activities through the STate Action on Avoidable Rehospitalizations (STAAR) Initiative. He has also supported several webinars such as the Primary Care Coach Program: Wave 3, IHI s Expedition on Reducing Readmissions, and many others. In addition, he is an avid Boston Celtics fan, go Celtics! 1

2 WebEx Quick Reference Welcome to today s session! Please use Chat to All Participants for questions For technology issues only, please Chat to Host WebEx Technical Support: Dial-in Info: Communicate / Join Teleconference (in menu) Raise your hand Select Chat recipient Enter Text When Chatting Please send your message to All Participants 2

3 Let s Practice Using Chat Please take a moment to chat in your organization name and the number of people on the call with you. Ex. Institute for Healthcare Improvement 2 Expedition Director Kathy D. Duncan, RN, Faculty, Institute for Healthcare Improvement (IHI), oversees multiple areas of content and is the clinical lead for IHI s National Learning Network. Ms. Duncan also directs content development and provides spread expertise for IHI s Project JOINTS as well as additional content direction for the Hospital Portfolio, directs a number of virtual learning webinar series, and manages IHI s work in rural settings. Previously, she co-led the 5 Million Lives Campaign National Field Team and was faculty for the Improving Outcomes for High Risk and Critically Ill Patients Innovation Community. In addition to her leadership on the field team during the Campaign, Ms. Duncan was the content lead for several interventions in IHI s 100,000 Lives and 5 Million Lives Campaigns. She also serves as a member of the Scientific Advisory Board for the American Heart Association s Get with the Guidelines Resuscitation, NQF s Coordination of Care Advisory Panel and NDNQI s Pressure Ulcer Advisory Committee. Prior to joining IHI, Ms. Duncan led initiatives to decrease ICU mortality and morbidity as the Director of Critical Care for a large community hospital. 3

4 Expedition Objectives By the end of this Expedition, participants will be able to: Identify specific opportunities to improve safety and reliability during the patient s surgical experience Improve reliability of key processes identified during each step of the surgical suite Identify and test strategies to decrease risk of surgical site infection Describe strategies to identify failures during the surgical process Expedition Schedule Session Date/Time Lead Faculty: Summary Session 4: Pre-Operative Processes Post-Admission Session 5: Perioperative Processes Session 6: Post-Operative Processes Thursday, 1:00 2:00 PM ET Thursday, 1:00 2:00 PM ET Thursday, 1:00 2:00 PM ET Gerald Healy, MD Harvard University Medical School Sheila Barnett, MD Beth Israel Deaconess Medical Center Standardize patient experience immediate pre-op BIDMC team discusses their best practices William Berry, MD Harvard School of Public Health Team work and communication Standardize immediate post-op process William Berry, MD Harvard School of Public Health Post-op procedures Standardizing the end of the surgical process 4

5 Today s Agenda Assignment #2 Strategies for Hip and Knee Surgery Q&A SAVE all questions for the end Homework from Session #2 Identify one clinic and one surgeon to use the Blood Sugar Control Checklist All Patient questions. Screen and Identify 5 patients who are either prediabetic or diabetic seen during one day of clinic. Follow through to check fasting blood sugar levels on the morning of surgery for indicated patients. What were the results? 5

6 Deborah Yokoe, MD, MPH Deborah Yokoe, MD, MPH, is a member of the Infectious Diseases division of the Brigham and Women s Hospital (BWH) Department of Medicine, the Hospital Epidemiologist and medical director of Infection Control at BWH and Dana-Farber Cancer Institute (DFCI), and is an Associate Professor of Medicine at Harvard Medical School. Her research has focused on the development and evaluation of streamlined and reliable methods for performing surveillance for healthcare-associated infections, particularly surgical site infections (SSI), and she is an investigator in the CDC s Prevention Epicenters research program. She is a member of the Department of Health and Human Services/CDC Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Massachusetts Department of Public Health Technical Advisory Group that provides oversight for the statewide mandatory reporting and healthcare-associated infection prevention program. She is an active member and has served on the Board of Directors of the Society for Healthcare Epidemiology of America (SHEA). Dr. Yokoe co-led the creation of the SHEA- and Infectious Disease Society of America (IDSA)- sponsored documents titled A compendium of strategies to prevent healthcare-associated infections in acute care facilities which were published in October of 2008 and have been promoted by the IDSA, SHEA, the CDC, The Joint Commission, IHI, and the American Hospital Association as a tool to assist acute care hospitals in translating evidence-based recommendations for prevention of healthcare-associated infections into practice. She continues in her role as SHEA co-lead to coordinate updating of this compendium. Background: Project JOINTS 12 Offer implementation support to participants on the recommended interventions to reduce hip and knee SSIs Build a network of facilities that are working together toward the same aim literally Joining Organizations IN Tackling SSIs Test IHI s ability to spread evidence-based practice 6

7 Why Focus on Hip and Knee Arthroplasty? Over 1.1 million hip and knee arthroplasty procedures per year in the U.S. Knee arthroplasty surgical site infection (SSI) rates range from 0.68% to 1.60% and hip arthroplasty SSI rates range from 0.67% to 2.4% depending on patient risk. At these rates, between 6,000 and 20,000 SSIs occur annually. Estimated hospital costs alone: hip arthroplasty $100,000 and knee arthroplasty $60,000 with 22 day increase in length of stay Substantial impact on patients Ask patients to bathe or shower with CHG soap at least 3 times before surgery 7

8 Why Consider Preoperative CHG Bathing or Showering to Prevent SSIs? Topical chlorhexidine significantly reduces bacterial counts on skin and has a residual antimicrobial effect Impacts a broad range of potential pathogens Low risk of skin reactions There is progressive reduction in counts when used serially up to 3 times preoperatively Hayek J Hosp Infect 1987 Kaiser Ann Thor Surg 1988 Garibaldi J Hosp Infect 1988, Paulson AJIC Effectiveness of CHG washes depends mainly on the residual antimicrobial effect, which is increasingly effective the more consecutive days it is used At least 3 consecutive washes are needed to keep skin flora lower than baseline through a 24-hour period Paulson DS. Efficacy evaluation of a 4% chlorhexidine gluconate as a full-body wash. Am J Infect Control 1993;21:

9 Why Is This Recommendation Controversial? 17 Cochrane Systematic Review 2011: no clear evidence based on RCTs that preop bathing with CHG reduces the incidence of SSI Studies had many limitations: Variable SSI definitions and follow-up No monitoring of compliance with CHG use Most used only 1 or 2 applications of CHG soap May need repeated applications (i.e., showering with CHG at least 3 times prior to surgery) 18 9

10 19 Impact of CHG Bathing on Other Hospital- Acquired Infections in ICUs 23% decrease in multidrugresistant organisms acquisition (p=0.03) 31% decrease in primary BSI (p=0.006) 53% decrease in CLABSI (p=0.004) 20 Climo MW, et al. NEJM 2013;368:533 10

11 21 Screen patients for Staphylococcus aureus (SA) carriage and decolonize SA carriers with 5 days of intranasal mupirocin and at least 3 days of CHG soap prior to surgery Why Worry about Staph Aureus Nasal Carriage? 22 Staphylococcus aureus nasal colonization predisposes patients to invasive S. aureus infections Nasal carriage of S. aureus is associated with a relative risk of 7.1 for developing SSI (Kluytmans J Infect Dis 1995) Most cases of invasive S. aureus infection are due to endogenous strains (Von Eiff NEJM 2001, Huang CID 2008) 11

12 Does Using Mupirocin Eradicate S. Aureus Nasal Carriage? 23 Systematic review (Ammerlaan HS, et al. CID 2009): 8 studies comparing mupirocin to placebo Short-term nasal mupirocin (4-7 days) was an effective method for S. aureus eradication 90% success at one week, 60% at longer ( days) follow-up 1% develop mupirocin resistance Does Using Mupirocin Prevent SSIs? 24 Systematic review (van Rijen JAC 2008): Included 4 randomized controlled studies Conclusion: Mupirocin use was associated with a significant reduction in S. aureus postoperative infection rates among S. aureus carriers (RR 0.55, 95% CI ) 12

13 25 Randomized, double-blinded, placebo-controlled multicenter study of 6,771 patients in the Netherlands (Bode NEJM 2010) Rapid screening for MSSA/MRSA on admission Carriers randomized to mupirocin/chg soap vs. placebo/bland soap x 5 days (Continued) Bode NEJM Results: CHG bathing + mupirocin group had significantly lower SSI rates than the placebo group Conclusion: Preoperative identification of S. aureus carriers followed by 5 days of intranasal mupirocin plus CHG bathing reduced S. aureus SSIs by ~60% Localization of infection Mupirocin + CHG Placebo Relative Risk (95% conf interval) Deep SSI 4 (0.9) 16 (4.4) 0.21 ( ) Superficial SSI 7 (1.6) 13 (3.5) 0.45 ( ) Bode LGM, et al. NEJM 2010;362:9 13

14 Impact of Nasal Decolonization: Systematic Review and Meta-analysis 27 Nasal decolonization was associated with lower risk of S. aureus SSI for cardiac and orthopedic surgery RR* Gram positive SSIs (95% CI) RR* MRSA SSIs (95% CI) RR* MSSA SSIs (95% CI) Cardiac surgery studies 0.46 (0.32 to 0.67) 0.69 (0.36 to 1.31) 0.46 (0.29 to 0.72) Orthopedic surgery studies 0.32 (0.21 to 0.47) 0.16 (0.09 to 0.28) 0.58 (0.31 to 1.01) All studies 0.41 (0.30 to 0.55) 0.30 (0.15 to 0.62) 0.50 (0.37 to 0.69) *RR = Pooled relative risk Schweizer M, et al. BMJ 2013;346:12743 Why Not Use Preoperative Mupirocin For All Orthopedic Patients? 28 Prevent S. aureus SSIs for some patients Mupirocin resistance Costs 14

15 Possible SA Decolonization Strategies 29 Target procedures where S. aureus SSIs are common and potentially devastating Orthopedic surgery involving implants Cardiac surgery Consider screening these patients for S. aureus nasal carriage (MSSA and MRSA) Decolonize with intranasal mupirocin +/- CHG bathing 30 15

16 31 Implementation Strategies.. Ask Patients to Bathe or Shower with Chlorehexidine Gluconate (CHG) for at Least 3 Days Prior to Surgery Behavioral Objective: Provide patients with chlorhexidine soap, and have them use the soap in bathing or showering for at least three days before surgery Assess your current process and potential barriers: Assess where most preoperative assessments take place Assess current preoperative communication between the hospital OR department and the offices of orthropaedic surgeons inside and outside the hospital Tailor the implementation process to your setting Develop a process flow diagram to define all components of the process 32 16

17 Key Concepts to Consider Patients must understand why CHG bathing is important Patients need to understand How to do CHG bathing Access to CHG for pre-op bathing How will we know if CHG baths were completed? 34 17

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19 37 Screen Patients and Decolonize SA Carriers w/5 Days Intranasal Mupirocin & 3 Days CHG Behavioral Objective: Screen all patients for Staphylococcus aureus prior to surgery, allowing enough time for those who screen positive to be decolonized with five days of intranasal mupirocin Assess your current process and potential barriers: Assess where most preoperative assessments take place Tailor the intervention to the setting in which preoperative assessment is done Work with Lab to assure screening includes both MRSA and MSSA Develop a process to assure info on screening and decolonization is available at the time of surgery Develop a process flow diagram to define components of the process 38 19

20 Key Concepts to Consider 39 Assess your current process and potential barriers Tailor the intervention to the setting in which the preoperative assessment is done Work with your laboratory to ensure screening includes MSSA and MRSA and notification process Understand culture/pcr process, possibilities and barriers (PDSA) follow one class thru notification process Key Concepts to Consider 40 Develop a process to ensure information on screening and decolonization is available prior to the time of surgery (PDSA) follow one class thru notification process Test processes to provide mupirocin prescription How do you assess compliance? Develop a process flow diagram Define components (from your tests) 20

21 Lessons Learned 41 Incorporate screening for SA and prescribing mupirocin into surgeons preoperative assessment orders Build on established preop assessment processes that require patient follow-up/treatment before surgery, such as positive urinalysis/urine culture requiring antibiotic treatment If PCR testing is available, assess the feasibility of providing screening results and prescription if needed, at the preop visit Create a flag system to be used during surgery for patients testing positive for MRSA to ensure Vancomycin is used preop Lessons Learned 42 Pre-Op class Weekly, same time, same place Discuss processes Multidisciplinary Education materials (Screening for MSSA and MRSA) Education Material What product to use, provide if possible How to use CHG Measure: How many patients completed the 3 baths prior to surgery How many patients completed the 3 baths prior to surgery Checklists Admit process/holding area 21

22 43 (Sparrow Hospital, Lansing, Michigan, USA) 44 22

23 45 UPMC 46 (Exempla Lutheran Medical Center, Wheat Ridge, Colorado, USA) 23

24 Resources Homework 1101, 1201, 1301 Happy Holidays!! Spoiler alert: Great time for testing- small, of course! New Process: If no pre op class: Ask one MD if you educate 3 of his scheduled pts Teach them who, what, when, where, how Find them on day of surgery Assess compliance, Noting any issues, asking about education was it clear, did they find CHG? Revise education Repeat As Education process reliable, add providers/practices Measure, measure, measure, Noting patient responses, issues Volunteer? 48 24

25 Next Steps (Homework) Pre- op class in place Test one class Ask providers if you can test they won t care Insert education in class Find them on day of surgery Assess compliance Noting any issues, asking about education was it clear, did they find CHG? Revise education Repeat As education process reliable, incorporate into standard work Measure, measure, measure! Noting patient responses, issues looking for improvement? Develop process to ensure compliance Volunteer? 49 Next Steps (Homework) Pre-op class in place and CHG Bathing in place Test one class Revise education in class patient education tools, checklist, etc? Follow the next class yes follow (verb, to go after somebody or something) Assess compliance (Did they do it? What went well, what did not?) Noting any issues, asking about education was it clear, did they find CHG? Revise education Repeat As education process reliable, incorporate into standard work Measure, measure, measure! Noting patient responses, issues looking for improvement? Develop process to ensure compliance Volunteer? 50 25

26 Questions? 51 Raise your hand Use the Chat Expedition Communications Listserv for session communications: To add colleagues, us at Pose questions, share resources, discuss barriers or successes 52 26

27 Next Session 53 Thursday, January 9, 1:00 PM 2:00 PM ET Session 4 Processes Post-Admission Gerald Healy, MD Harvard University Medical School Sheila Barnett, MD Beth Israel Deaconess Medical Center 27