SSI/OR Safety Introductory Webinar. A partnership of the Healthcare Association of New York State and the Greater New York Hospital Association

SSI/OR Safety Introductory Webinar A partnership of the Healthcare Association of New York State and the Greater New York Hospital Association

Agenda 2

Introduction to SSI/OR Safety Approach Zeynep Sumer Nancy Landor 3

Overview of SSI/OR Safety Initiative o Goals o Objectives o Measurement Strategy/Data collection o Alignment with IPRO 4

Goals o Reduce Surgical Site Infection by 40% across New York State by December 2013 o Reduce Surgical Site Infections in the following procedures: o Hip and Knee replacement o Coronary artery bypass graft o Colon surgery o Hysterectomy o Reduce all other procedural harm 5

Measurement o Monthly Data Collection o SSI rates per 100 operative procedures (hip, colon, CABG, hysterectomy) (NHSN) o Surgical Care Improvement Project (SCIP) infection measures o Scip-Inf-1; Scip-Inf-2; Scip-Inf-3; Scip-Inf-4; Scip-Inf-9; Scip-Inf- 10) o Baseline and follow-up assessment of current practices o Hospitals internal monitoring for compliance and improvement 6

Interventions Implement a surgical safety checklist containing the following essential elements: 7

Objectives 8

SSI is part of OR Safety 9

Milestones 10

Milestones (Continued) 11

The Interdisciplinary Team Approach to Achieve OR Safety David Feldman Loraine O Neil Mark Lema 12

Polling Question o Who is in the room with you today participating on this webinar, members of the: (select all that apply) o Anesthesia team o Surgical Team o PACU Team o Infection Preventionist/ Control Team o Quality Improvement/Patient safety o Other: Please specify 13

Polling Question o Who is accountable for administering the preoperative antibiotics in your hospital? o Anesthetist o Anesthesiologist o Nurse in pre-op area/pacu o Nurse in OR o Surgeon o Other 14

Polling Question o Do you currently have a debrief/sign-out at the end of the procedure and, if yes, who leads it? o No, we do not have debrief o Yes, led by surgical attending o Yes, led by anesthesiologist/anesthetist o Yes, led by OR nurses o Yes, depends who is in the room 15

Patient Safety & OR culture David L Feldman, MD MBA CPE FACS Senior Vice-President & Chief Medical Officer Hospitals Insurance Company/FOJP Professorial Lecturer, Department of Surgery Mount Sinai School of Medicine New York, NY

Patient Safety o Reliable teams o Communication o Mutual support/respect o Leadership skills o Reliable processes o Systems that are consistent o Human factors engineering o Just Culture o Encourages open/honest reporting of errors 17

Safety v. Quality v. Efficiency Performance Improvement Quality Safety Efficiency Operating Room Time Outs 18

Polling question o Does you hospital have a policy that deals with disruptive behavior? o Yes and it is used in practice for all providers o Yes but in practice but doesn t seem to apply to physicians o Yes but is not followed at all for anyone o No 19

Teamwork & Respect...the key success factors in a safety effort are teamwork and respect, two basic ideas that are too often lacking in medicine. People have to be trained to work in teams and to respect others on the team. 20 Interview with Lucian Leape, MD. Journal of Healthcare Management. Volume 53, Number 2. March/April 2008.

Teamwork & Respect Medical Schools should teach: 1. Safety Science 2. In Interdisciplinary teams 3. Respect for Colleagues, coworkers, patients 21 Q&A with Lucian Leape, MD. Physician Executive Journal. March/April 2012.

The Joint Commission Universal Protocol o Pre-procedure verification process o Best practice: a conversation between Attending Anesthesiologist and Attending Surgeon o Site Marking o NYS surgeon marking site, must be present for time-out and perform procedure o Time-Out o NYS immediately prior to incision o Best practice requires presence of: o Attending Surgeon o Attending Anesthesiologist o Circulating RN 22

World Health Organization Safe Surgery Saves Lives o Sign-in o In OR with patient awake o Time-out o Immediately prior to incision o Sign-out o At conclusion of procedure 23

WHO Checklist - 2009 24

Polling question o Do you use the WHO checklist in your hospital s Operating Rooms? o Yes and it is used frequently o Yes but it is used rarely o No but we are working on one o No 25

Checklists and Time-outs o WHO Checklist Study 1 o Reduction from 1.5% mortality to.8% o Reduction in inpatient complications from 11% to 7% o Canadian Study with team briefing structured by a checklist 2 o Reduction in communication failures from 3.95 to 1.31 o 34% of briefings demonstrated utility 1 Haynes AB, et al. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population NEJM Jan, 2009. 2 Lingard L, et al. Evaluation of a Preoperative Checklist and Team Briefing Among Surgeons, Nurses, and Anesthesiologist to Reduce Failures in Commincation Arch Surg Jan, 2008.

Value of Briefings Mayo Briefing Protocol 1 o Reduction in total surgical flow disruptions from 5.4/case to 2.8/case o Reduction in miscommunication events from 2.5/case to 1.17/case o Fewer trips outside the OR 10 v. 4.7 o Less time spent outside the OR 397 sec v. 172 sec o Trend towards less waste 30% v. 17% 27 1 Henrickson SE, et al. Development and Pilot Evaluation of a Preoperative Briefing Protocol for Cardiovascular Surgery JACS June, 2009.

The Surgeon s Role It is also helpful for the surgeon to empower people to speak up. Surgeons should explicitly request that members of the surgical team speak up if they re concerned about the process. We ve seen the reverse of this, where people have spoken up and surgeons have disregarded these concerns and performed wrong-site surgery. 28 John Clark, MD, FACS, Clinical Director of the Pennsylvania Patient Safety Reporting System

Patient Safety o Reliable teams o Communication o Mutual support/respect o Leadership skills o Reliable processes o Systems that are consistent o Human factors engineering o Just Culture o Encourages open/honest reporting of errors 29

Something Close to Home Which dial turns on the burner? Stove A Stove B 30

Visual Controls in the OR 31

Human Factors Engineering 32

Patient Safety o Reliable teams o Communication o Mutual support/respect o Leadership skills o Reliable processes o Systems that are consistent o Human factors engineering o Just Culture o Encourages open/honest reporting of errors 33

Accountability for our behaviors Human Error Manage through changes in: o Processes o Procedures o Training o Design o Environment At-Risk Behavior Manage through: Removing incentives Creating incentive for healthy behavior Increasing situational awareness Reckless Behavior Manage through: o Remedial action o Disciplinary action Console Coach Punish

Teamwork & Safety Loraine O Neill, RN MPH Director of Quality Initiatives, Department of Ob/Gyn & Reproductive Sciences Mount Sinai Medical Center New York, NY

Polling Question o Do you use critical language in your daily practice? o Yes o If yes what? CUS Special local phrase other o No o Do not know what you mean? 36

Polling Question o What is included in the debrief? (select all that apply) o What went well o Opportunity for improvement o Review of PACU orders o Review of post-pacu orders o Review and ordering of prevention protocols for HACS 37

Patient Safety o Reliable teams Communication Mutual support/respect Leadership skills o Reliable processes Systems that are consistent Human factors engineering o Just Culture Encourages open/honest reporting of errors 38

Root Causes of Sentinal Events 39 39

Teamwork Is All Around Us 40 40

What is Teamwork Cooperative effort by the members of a group or team to achieve a common goal. The process of working collaboratively with a group of people, in order to achieve a goal. The actions of individuals, brought together for a common purpose or goal, which subordinate the needs of the individual to the needs of the group Work done by several associates with each doing a part but all subordinating personal prominence to the efficiency of the whole 41

Crew Resource Management o 1979-80 - Aviation industry Teamwork failure - 70% of airline crashes Airlines develop training programs for cockpit personnel - Cockpit Resource Management Expanded to Crew Resource Management Entire flight crew Maintenance crews Air traffic controllers o No definitive study correlating CRM training with enhanced airline flight safety but aviation industry has accepted this practice on face validity 42

Crew Resource Management

TeamSTEPPS Team Strategies and Tools to Enhance Performance and Patient Safety Initiative based on evidence derived from team performance leveraging more than 25 years of research in military, aviation, nuclear power, business and industry to acquire team competencies 44

TeamSTEPPS 45

What Comprises Team Performance?

Outcomes of Team Competencies o Knowledge o Shared Mental Model o Attitudes o Mutual Trust o Team Orientation o Performance o Adaptability o Accuracy o Productivity o Efficiency o Safety 47

Impact of Impact Team of Team Training 48

Impact of Team Training Impact of Team Training 2 First case starts 69% to 81% SQIP antibiotic admin (p<0.05) 78% to 97% SQIP VTE Prophylaxis (p<0.05) 74% to 91% SQIP Beta Blocker (p<0.05) 19.7% to 100% NSQIP Morbidity (p<0.05) 20.2% to 11.0% NSQIP Surgical Mortality (p<0.05) 2.7 to 1% Note: Some results worsened 1 year after training, suggesting the need for continuous reinforcement. 49

Creating Highly Reliable Teams 50

The Nurses Role Nursing plays a central role in ensuring that patients consistently receive high-quality care and are protected from injury at all times. It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm. 51 Riley, et.al. A Model for developing high-reliability teams. Jnl of Nrsg Mgmt. July 2010: 556-563

Anesthetic Best Practices in Reducing SSIs Mark J. Lema, MD PhD Professor and Chair, Department of Anesthesiology, Critical Care & Pain Medicine Roswell Park Cancer Institute Buffalo, NY

Scope of the Problem o It has been estimated that surgical site infections (SSIs) occur in 2% to 5% of all patients who undergo surgery in the United States, resulting in 800,000 to 2 million surgical site infections annually. In addition, SSIs account for 38% of nosocomial infections in surgical patients and result in increased mortality, intensive care unit (ICU) admission, length of hospital stay, cost, and hospital readmission. 1-4 1. Boyce JM, Potter-Bynoe G, Dziobek L. Infect Control Hosp Epidemiol. 1990;11(2):89-93. 2. Poulsen KB, Bremmelgaard A, Sorensen AI, Raahave D, Petersen JV. Epidemiol Infect. 1994;113(2):283-295. 3. Martone WJ, Jarvis WR, Culver DH, Haley RW. In: Bennett JV, Brachman PS, eds. Hospital Infections. 3rd ed. Boston: Little, Brown & Co; 1992:577-596. 4. Vegas AA, Jodra VM, Garcia ML. Eur J Epidemiol. 1993;9(5):504-510. 53

American Society of Anesthesiologists Recommendations for Infection Control for the Practice of Anesthesiology (Third Ed.) 1 II C. Prevention of Surgical Site Infection o i. Preoperative considerations o o o 1. Hair removal o 2. Glucose control o 3. Nicotine use o 4. Transfusion o 5. Antiseptic shower o 6. Antimicrobial prophylaxis ii. Intraoperative considerations o 1. Ventilation o 2. Cleaning o 3. Surgical attire o 4. Asepsis and surgical technique o 5. Normothermia iii. Postoperative considerations o 1. Postoperative incision care o 2. Surveillance 54 1 - www.asahq.org

Glucose control ASA Recommendations 3ed Recommendation: Consider control serum blood glucose levels preoperatively in all diabetic patients and avoid perioperative hyperglycemia, to an extent that would not place the patient at risk of hypoglycemia. Rationale: data suggest that a significant relationship exists between increasing levels of hemoglobin (Hg) A1c and SSI rates. In addition, hyperglycemia (>200 mg/dl) has been associated with increased SSI risk in the immediate postoperative period 1,2. 55 1 - Zerr KJ et al. Ann Thoracic Surg. 1997;63(2):356-361 2 - Terranova A. Plast Surg Nurs.1991;11(1):20-25

Society of Ambulatory Anesthesia (SAMBA) Consensus Statement on Perioperative Blood Glucose Management in Diabetic Patients Undergoing Ambulatory Surgery (2010) 56

SAMBA Guidelines - 2010 57

Artlice on Perioperative Blood Glucose o Uncontrolled blood glucose (BG) results in poor outcomes in cardiac, neurosurgical, general surgical and critical care patients. o Tight glucose control (80-110 mg/dl) is related to increased mortality. o ADA and STS recommend: o Maintaining BG between 140-180 mg/dl o Using insulin infusions to maintain BG control o Minimizing BG variability during surgery 58

o o o o o o o Article Inadequate Blood Glucose 8727 patients analyzed. Stratified into good BG control (<200), moderate BG control (200-250) or poor BG control (>250) based on highest BG level over 60 hour period. 10% were in moderate control and 4% in poor control Diabetes was discovered in 8% of good, 31%of moderate and 52% of poor groups. Inadequate BGC and NOT diabetes was associated with in-hospital mortality. (1.8 vs. 4.2 vs. 9.6%). Inadequate BGC and NOT diabetes was associated with a 2.7x increase in MI and a 2.2x increase in pulmonary/renal complications. Conclusions: o More then 50% of moderate/poor BGC groups were previously undiagnosed for diabetes. o Inadequate postoperative BGC is a predictor of in-hospital morbidity and mortality. Ascione R et al.circulation 2008;118:113-123 59

Normothermia ASA Recommendations 3ed Recommendation: Maintain patient normothermia. Rationale: Hypothermia (core temperature <36 C) has been associated with an increased SSI risk 1,2. Mild hypothermia seems to increase SSI risk by causing vasoconstriction, decreased oxygen delivery to the wound space, and impaired phagocytic leukocyte function 3,4. 1 - Sessler DI. N Engl J Med 1997;336(24):1730-1737 2 - Kurz A et al. N Engl J Med 1996;334(19):1209-1215 3 - Wenisch C et al. Anesth Analg 1996;82:810-816 4 - Hunt TK, Hopf HW.Surg Clin North Am. 1997;77:587-606 60

Article on Perioperative Normothermia o 200 colorectal surgical patients were randomized in a doubleblind, controlled trial into Normothermia v. Hypothermia groups o Wounds evaluated daily until discharge and 2 weeks later in clinic o Wounds with culture positive pus were considered to be infected Results: o Mean temp: Hypo 34.7 C v. Normo 36.6 C, p<.001 o Infections: Hypo 18/96 (19%) v. Normo 6/104 (6%), p=.009 o Sutures were removed one day later (p=.002)and 20% of patients were discharged 2.6 days later (p=.01) in Hypo group. 61 Kurz A et al. New Engl J Med. 1996;334(19):1209-1215

Article on Hypothermia and Hyperoxia o Anesthesiologists have some control over six factors that can reduce surgical site infections 1. Hypothermia 2. Hyperoxia 3. Perioperative Fluid Management 4. Hyperglycemia 5. Blood Transfusion and the Risk of Infection 6. Antimicrobial Prophylaxis 62 Mauermann WJ, Nemergut EC. Anesthesiology 2006;105:413-421

Hypothermia/Hyperoxia - Anesthesiology 2006 o The major relationship between hypothermia and increased SSI is thought to be a decrease in subcutaneous tissue perfusion mediated by vasoconstriction. o Providing adequate oxygen delivery maintains oxidative killing by neutrophils. o Patients with subcutaneous oxygen tension (P t O 2 ) greater than 90 mmhg had no infections while those with P t O 2 of 40-50 mmhg had and infection rate of 43% 1. 63 Mauermann WJ, Nemergut EC. Anesthesiology 2006;105:413-421 1 Hopf HW et al. Arch Surg 1997, 132:997-1004.

Hypothermia and Hypovolemia Hypothermia and Hypovolemia Hypothermia causes vasoconstriction which produces inadequate tissue oxygen perfusion and reduced neutrophil (PMNs) migration to the site. Blood and fluid loss (hypovolemia) also leads to inadequate tissue oxygen perfusion. Less oxygen and lower PMN migration reduces bacteria killing effect by neutrophils. Bacterial infection occurs. 64 Mauermann WJ, Nemergut EC. Anesthesiology 2006;105:413-421

Normothermia, Euvolemia Normothermia, Euvolemia and Hyperoxia and Hyperoxia Benefits Normothermia maintains normal blood flow and oxygen delivery to tissue. Euvolemia maintains adequate tissue perfusion. Hyperoxia delivers sufficient oxygen for PMN cytotoxic and phagocytic activity. Bacterial growth is thwarted. Mauermann WJ, Nemergut EC. Anesthesiology 2006;105:413-421

Hyperglycemia - Anesthesiology 2006 o Diabetic patients are at increased risk for SSIs. o Diabetic patients PMNs have impaired chemotaxis, decreased phagocytosis, and lower bactericidal ability. o Glucose challenge in healthy volunteers showed a transient reduction in PMN and all lymphocyte subset counts. o Hyperglycemia deactivates immunoglobulins and blocks complement C action. o Insulin infusions work better than a sliding scale. A 66% reduction in sternal SSI seen in cardiac patients 1,2. 66 1 Furnary AP et al. Ann Thorac Surg.1999;67:352-360 2 Zerr KJ et al. Ann Thorac Surg. 1997;63:356-361

Normoglycemia Anesthesiology 2006 Normoglycemia promotes PMN bactericidal actions, immunoglobulin and complement functions. 67 Mauermann WJ, Nemergut EC. Anesthesiology 2006;105:413-421

Hyperglycemia Anesthesiology 2006 Hyperglycemia: Decreases PMN chemotaxis, phagocytosis and bacterial destruction Decreases IgG fixation of complement Decreases complement binding to bacteria 68 Mauermann WJ, Nemergut EC. Anesthesiology 2006;105:413-421

Summary o Anesthesia personnel can play a key role in the perioperative setting to help surgical patients and surgeons in reducing surgical site infections. o There are six ways where SSI reduction may be accomplished by prophylactic maneuvers. The evidence is so strong for some of these factors that implementation have become quality measures. As always, teamwork and effective communication among caregivers is essential for optimal patient outcomes. 69

Next Steps Zeynep Sumer Nancy Landor 70

Next Steps Ensure OR Safety Team in Place o o o o o o o o NYSPFP SSI lead Nursing (PAT, PACU, Surgical nurse) Physician (surgeon and anesthesiologist) champions Surgical Technicians, PAs, Anesthetist Infection prevention staff SSI/OR Safety Coordinator and Data lead Support Staff Executive sponsors and managers Attend In-Person Kick off Friday, February 15, 2013 Sign-in 6:30 a.m. 7:00 a.m. to 10:00 a.m. 13 Locations across the state Keynotes: Dr. Patchen Dellinger Ms. Caroline Jacobs 71

Questions and Answers Questions 72